Management of Acute Cervicalgia with Muscle Spasm
For this 24-year-old with recurrent right-sided neck pain and muscle spasm of the SCM and posterior scalenes, continue conservative nonoperative management with physical therapy, NSAIDs, and muscle relaxants, as 75-90% of cervical pain cases resolve with this approach. 1, 2
Immediate Assessment Priorities
Rule out red flags before proceeding with conservative care:
- No myelopathy signs (gait disturbance, hand clumsiness, balance difficulties) - these would require urgent surgical evaluation 3
- No radiculopathy (dermatomal arm pain, motor weakness in myotomes, sensory deficits) - already documented as absent in PT notes 1, 2
- No constitutional symptoms (fever, weight loss, night sweats) that could indicate infection or malignancy 1
- No history of trauma, malignancy, or immunosuppression 1
- No elevated inflammatory markers - if CRP is elevated, this represents a red flag requiring MRI 4
Conservative Treatment Protocol
Physical therapy remains first-line treatment:
- Muscle energy techniques for SCM and scalene spasm - shown to significantly improve cervical ROM and reduce pain (p=0.001 for all planes of motion) 5
- Dynamic shoulder/scapular strengthening to address postural contributors 6
- Cervical stabilization exercises 6
- Stretching program targeting affected muscle groups 6, 5
- Posture training to prevent recurrence 6
Pharmacologic management:
- NSAIDs for pain control - standard first-line therapy 2, 7
- Muscle relaxants for acute muscle spasm - evidence supports use in acute neck pain with spasm 7
- Nerve-stabilizing agents (gabapentin, pregabalin) if pain persists or has neuropathic features 1
Imaging Decision Algorithm
Do NOT order imaging at this time - imaging is not indicated in the absence of red flags, as most acute cervical neck pain resolves with conservative treatment 1, 7
Consider MRI cervical spine without contrast only if:
- Symptoms persist beyond 6-8 weeks of conservative therapy 1
- New red flags develop (neurological deficits, constitutional symptoms, intractable pain) 1
- Focal neurologic symptoms emerge 7
Important caveat: Degenerative changes on imaging are present in 53.9% of asymptomatic individuals and correlate poorly with symptoms - abnormal imaging does not change management in the absence of red flags 1
Expected Outcomes and Follow-up
Reassure the patient that prognosis is favorable:
- 75-90% of cervical radiculopathy/neck pain cases resolve with conservative therapy 1, 2
- Most acute neck pain resolves spontaneously or with conservative treatment 1
- However, approximately 50% will have residual or recurrent pain up to 1 year after initial presentation 1, 7
Follow-up timeline:
- Reassess in 4-6 weeks to evaluate response to conservative management 2
- If no improvement after 4-6 weeks, consider MRI to identify pathology amenable to interventional treatment 2
- Continue PT for 8-13 weeks as needed - case studies show complete resolution of neck pain and headaches with this duration 6
Common Pitfalls to Avoid
Do not order premature imaging - the high prevalence of abnormal findings in asymptomatic individuals (53.9%) leads to unnecessary interventions and patient anxiety 1, 7
Do not assume recurrence indicates treatment failure - recurrent episodes are common and do not necessarily indicate need for escalation of care 7
Do not overlook medication options - muscle relaxants are underutilized despite evidence supporting their use in acute neck pain with muscle spasm 7