Is the current treatment plan sufficient for a adult patient with no significant past medical history, who was hit on the neck and presents with pain, limited neck movement, and tenderness to palpation, but no neurological deficits, and is being treated with ice compress, bed rest, limited neck movement, and celecoxib (celecoxib) 200mg once daily, and a cervical spine x-ray?

Management of Acute Neck Trauma with Pain and Limited Range of Motion

Direct Answer

The provider's current management plan is incomplete and requires immediate modification—specifically, a rigid cervical collar should be applied immediately, and the patient requires urgent evaluation to rule out cervical spine instability before any mobilization occurs. 1

Critical Gaps in Current Management

Missing Cervical Spine Precautions

• Cervical spine injury must be assumed in any patient with neck trauma until definitively cleared, particularly when there is midline tenderness on palpation and limitation of movement 1
• The current orders of "limit movement of neck" are inadequate—rigid cervical immobilization with a collar is mandatory until cervical spine injury is excluded 1
• Bed rest alone does not provide adequate cervical spine stabilization if an unstable injury exists 1

Inadequate Clinical Clearance Criteria

The patient fails multiple criteria for clinical clearance of the cervical spine 1:

• Presence of midline neck pain and tenderness on palpation (high-risk factor) 1
• Limited range of active movement in all planes 1
• Blunt trauma mechanism (assault with object) 1

Clinical clearance requires ALL of the following to be absent 1:

• No midline tenderness or pain
• Full range of active movement without pain
• No neurological deficits
• Alert and oriented (GCS = 15)
• No intoxicants
• No distracting injuries

Imaging Concerns

• Plain radiographs alone are insufficient for excluding cervical spine injury in symptomatic patients with tenderness and limited range of motion 1
• CT of the cervical spine is the appropriate initial imaging modality for patients who cannot be clinically cleared, with sensitivity of 94-100% compared to 49-82% for plain films 1
• If plain films are obtained and negative but clinical suspicion remains high, CT should follow 1
• MRI should be considered if ligamentous injury is suspected, particularly if pain persists despite negative CT 1, 2

Recommended Management Algorithm

Immediate Actions Required

1. Apply rigid cervical collar immediately 1
2. Upgrade imaging from plain x-ray to CT cervical spine (or obtain CT if x-ray is negative but symptoms persist) 1
3. Maintain cervical precautions until imaging definitively excludes injury 1

Pharmacologic Management Assessment

The celecoxib 200mg once daily is appropriate for pain management 3:

• FDA-approved dosing for acute pain is 400mg initially, followed by 200mg as needed, then 200mg twice daily on subsequent days 3
• Current dosing of 200mg once daily is suboptimal—should be increased to 200mg twice daily for acute pain management 3
• Celecoxib has demonstrated efficacy for acute pain with onset within 60 minutes 3, 4

Follow-Up Imaging Strategy

If initial imaging (CT) is negative but symptoms persist 1:

• Consider flexion-extension radiographs after acute pain subsides (typically not in first 48-72 hours due to muscle spasm limiting adequate motion) 1
• MRI is indicated if pain persists beyond 2 weeks despite negative CT, to evaluate for ligamentous injury 1, 2

Additional Conservative Measures

Once cervical spine injury is excluded 1:

• Ice compress is appropriate for first 48-72 hours 1
• Manual therapy (mobilization/manipulation) should be considered after acute phase if pain persists beyond 4 weeks 1
• Graded physical exercise and cervical range of motion exercises should begin once cleared, to prevent chronic symptoms 1

Critical Pitfalls to Avoid

• Never assume the cervical spine is stable based on absence of neurological deficits alone—up to 4.3% of cervical fractures may be missed, with 67% developing neurological deterioration 1
• Do not rely on "limiting movement" without rigid immobilization—collars may not fully prevent movement but are standard of care until clearance 1
• Prolonged immobilization beyond 48-72 hours increases morbidity (pressure sores, respiratory complications, thromboembolism), so expedite definitive imaging 1
• Plain films miss 18-51% of cervical spine fractures depending on location—CT is superior 1

Summary of Required Additions

The provider must add 1, 3:

1. Rigid cervical collar application immediately
2. CT cervical spine (upgrade from or in addition to plain films)
3. Increase celecoxib to 200mg twice daily for adequate acute pain control
4. Maintain strict cervical precautions until imaging excludes injury
5. Plan for MRI if symptoms persist despite negative CT