What are the next steps for a patient with neck pain possibly involving a nerve, who has been advised to follow up with the Emergency Room (ER)?

Emergency Evaluation of Neck Pain with Possible Nerve Involvement

If you have neck pain with possible nerve involvement and have been advised to follow up in the ER, you should go immediately if you have any "red flag" symptoms including fever, unexplained weight loss, severe progressive weakness, difficulty walking, loss of bowel/bladder control, or history of cancer—otherwise, most neck pain with radiculopathy can be managed conservatively without emergency imaging. 1, 2

Immediate ER Evaluation is Required For:

Critical Red Flags Requiring Urgent Assessment

• Constitutional symptoms: Fever, unexplained weight loss, night sweats, or chills suggesting infection or malignancy 1, 2
• Progressive neurological deficits: Worsening weakness in arms/hands, difficulty with fine motor tasks, or gait disturbance 1, 2, 3
• Myelopathic signs: Difficulty walking, balance problems, bowel/bladder dysfunction, or bilateral arm/leg symptoms indicating spinal cord compression 1, 2
• History of malignancy: Previous cancer diagnosis increases risk of metastatic disease to cervical spine 1, 2
• Immunosuppression or IV drug use: Elevated risk for vertebral osteomyelitis or discitis 2, 3
• Intractable pain: Severe pain unresponsive to appropriate conservative therapy 2, 3
• Vertebral body tenderness: Point tenderness over spine on palpation suggests infection or metastatic disease 2

What the ER Will Do:

Initial Clinical Assessment

• Document specific nerve distribution: The ER physician will identify which dermatomal pattern your pain and numbness follow to localize the affected nerve root level 2
• Screen for myelopathy: Testing for hyperreflexia, positive Hoffman's sign, clonus, or gait abnormalities that indicate spinal cord compression requiring urgent surgical evaluation 2
• Check inflammatory markers: If red flags present, blood tests including ESR, CRP, and WBC count will be ordered 2, 3

Imaging Strategy in the ER

• MRI cervical spine without contrast is the preferred imaging if any red flags are present, as it is most sensitive for detecting disc herniation, nerve root impingement, infection, tumor, and inflammatory processes 1, 2, 3
• CT cervical spine with IV contrast may be used if MRI is contraindicated or unavailable, particularly for evaluating bony structures and when rapid assessment is needed 1
• No imaging is typically needed in the absence of red flags, as 75-90% of cervical radiculopathy cases resolve with conservative treatment 3, 4

If No Red Flags Are Present:

Conservative Management is Appropriate

• Most acute neck pain resolves spontaneously within 6-8 weeks without imaging or intervention 1, 2, 4
• The ER may discharge you with pain management recommendations including NSAIDs, muscle relaxants for acute muscle spasm, and instructions for conservative care 5, 4
• Follow-up imaging consideration: MRI should only be obtained if symptoms persist beyond 6-8 weeks of conservative therapy, progressive neurological deficits develop, or severe pain becomes unresponsive to treatment 1, 2

Critical Pitfalls to Avoid:

• Do not assume imaging is always necessary: Immediate imaging in the absence of red flags leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms, as 85% of asymptomatic individuals over 30 have spondylotic changes on MRI 2, 3
• Do not delay ER evaluation if red flags develop: Constitutional symptoms, progressive weakness, or myelopathic signs require urgent evaluation to rule out serious pathology such as epidural abscess, metastatic disease, or severe spinal cord compression 1, 2, 3
• Positive Spurling's test is highly specific: If neck pain worsens with head rotation and compression toward the affected side, this strongly suggests nerve root compression from herniated disc, but does not necessarily require emergency intervention unless accompanied by red flags 2

Expected Outcomes:

• 75-90% of cervical radiculopathy resolves with conservative nonoperative therapy 3, 4
• Nearly 50% may have residual symptoms: Some degree of pain or frequent recurrences can persist up to 1 year after initial presentation 3, 4
• Surgery is rarely needed emergently: Surgical decompression is reserved for severe stenosis, cord compression, tumor, or progressive neurological deficits despite conservative treatment 5, 6