In a 67‑year‑old woman with neck pain, what are the most likely causes, red‑flag conditions to exclude, and recommended evaluation and initial management?

Evaluation and Management of Neck Pain in a 67-Year-Old Woman

Most Likely Causes

In a 67-year-old woman with neck pain, cervical spondylosis with degenerative disc disease is the most common etiology, though this diagnosis should only be made after systematically excluding serious red-flag conditions that require urgent intervention. 1

Common Mechanical Causes

• Cervical radiculopathy from nerve root compression by herniated discs or osteophytes is the primary neuropathic cause, occurring in approximately 83 per 100,000 persons annually 2, 3
• Facet joint arthropathy causes localized mechanical pain that may radiate to the trapezius region, with cervical spondylosis affecting 53.9% of adults across all ages 3
• Degenerative disc disease is extremely common but correlates poorly with symptoms in isolation, as degenerative changes appear in 53.9% of asymptomatic individuals 2, 3
• Cervical proprioceptive impairment from chronic neck pain can cause sensorimotor control disturbances 4

Prognostic Factors

• Female gender, older age, and coexisting psychosocial pathology are associated with poor prognosis 1
• Approximately 50% of patients will have residual or recurrent pain up to 1 year after initial presentation 1, 3
• Most cases (75-90%) of cervical radiculopathy resolve with conservative nonoperative therapy 3

Critical Red-Flag Conditions to Exclude Immediately

Every patient must undergo systematic red-flag screening because the presence of any single red flag mandates urgent MRI of the cervical spine without contrast. 2

Constitutional Symptoms

• Fever, unexplained weight loss, or night sweats indicate possible infection or malignancy and require urgent MRI 1, 2
• Intractable pain despite appropriate conservative therapy is a red flag for serious underlying pathology 1, 2

Infection Risk Factors

• History of intravenous drug use (even if currently denied) signals high risk for spinal infection or epidural abscess and requires immediate MRI 1, 2
• Immunosuppression increases risk of vertebral osteomyelitis or discitis 2

Inflammatory Markers

• Elevated ESR, CRP, or white blood cell count require urgent evaluation with MRI to exclude infection or inflammatory arthritis 1, 2, 5

Neurological Red Flags

• Progressive weakness, sensory changes, or gait disturbance require urgent evaluation for cervical myelopathy 1, 2
• Bowel or bladder dysfunction or myelopathic signs constitute neurological emergencies requiring immediate MRI 2

Malignancy Indicators

• History of malignancy or risk factors for metastatic disease warrant immediate investigation 1, 2
• Vertebral body tenderness on palpation suggests possible metastatic disease or infection and warrants immediate MRI 1, 2

Age-Related Considerations

• In patients over 50 years, concomitant vascular disease raises suspicion for vascular etiology and should lead to urgent MRI 1, 2

Other Red Flags

• Prior neck surgery or history of trauma 1
• Systemic diseases including ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, or inflammatory arthritis 1

Recommended Evaluation Algorithm

Initial Clinical Assessment

Step 1: Perform systematic red-flag screening using the checklist above 1, 2

Step 2: If ANY red flags are present → Order MRI cervical spine without contrast immediately 2, 5

• MRI is superior for evaluating soft tissue abnormalities, inflammatory processes, infection, tumor, and vascular pathology 2, 5
• Do not delay imaging when red flags are present 2

Step 3: If NO red flags are present and pain is acute (<6 weeks) → Defer imaging and pursue conservative management 1, 2

• Most acute cervical neck pain resolves spontaneously without imaging 1, 2
• Plain radiographs rarely change therapeutic decisions in the absence of red flags 1

Step 4: If NO red flags but symptoms persist beyond 6-8 weeks of conservative therapy → Consider MRI cervical spine without contrast 2, 3

Physical Examination Specifics

• Document specific dermatomal distribution of pain and any associated sensory or motor deficits to localize the affected nerve root level 2
• Assess deep tendon reflexes, particularly triceps reflex, as diminished reflexes are the most common neurologic finding 6
• Perform Spurling's test (axial compression with lateral flexion toward symptomatic side), which is highly specific for nerve root compression from herniated cervical disc 2, 3, 6
• Shoulder abduction test and upper limb tension test can confirm cervical radiculopathy 6
• Assess for myelopathic signs including hyperreflexia, Hoffman's sign, clonus, or gait disturbance that would indicate spinal cord compression requiring urgent surgical evaluation 2
• Palpate for vertebral body tenderness as a red flag for metastatic disease or infection 1, 2

Initial Management

Conservative Management (When No Red Flags Present)

For acute neck pain without red flags, reassure the patient that most cases resolve spontaneously and initiate multimodal conservative therapy. 1, 6

Pharmacologic Management

• NSAIDs as first-line medication 6
• Muscle relaxants for associated muscle spasm 6

Physical Therapy

• Strengthening and stretching exercises 6
• Interrupted traction may be beneficial 7
• Exercises targeting cervical proprioception and muscle coordination for chronic neck pain 4

Activity Modification

• Neck immobilization for short periods during acute exacerbations 8
• Activity modification to avoid provocative movements 8

Duration of Conservative Trial

• Continue conservative management for 4-6 weeks before considering advanced imaging in the absence of red flags 6
• If symptoms persist beyond 6-8 weeks, obtain MRI to identify pathology amenable to epidural steroid injections or surgery 2, 6

When to Consider Interventional Treatment

• Epidural steroid injections may be helpful for persistent radicular symptoms but have higher risks of serious complications 6
• Radiofrequency ablation of medial branches for confirmed facet joint pain provides long-term analgesia exceeding 6 months 3

Surgical Referral Indications

• Severe or progressive neurological deficits 2
• Persistent symptoms after 4-6 weeks of conservative treatment with MRI confirmation of nerve root compression 2, 6
• Cervical spondylotic myelopathy with severe or progressive neurologic deficits 8

Critical Pitfalls to Avoid

Imaging Pitfalls

• Do not order imaging immediately in the absence of red flags, as this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 2
• Do not interpret degenerative changes on imaging as causative without clinical correlation, as spondylotic changes are present in 85% of asymptomatic individuals over 30 years and 53.9% across all ages 2, 3
• MRI abnormalities must always be interpreted in clinical context because a high prevalence of incidental degenerative changes exists in asymptomatic people 2

Diagnostic Pitfalls

• Electrodiagnostic testing (EMG/NCS) is not routinely necessary for diagnosis of cervical radiculopathy, as the diagnosis is primarily clinical 2
• Consider EMG/NCS only if diagnosis remains unclear after clinical evaluation and MRI, or need to differentiate between cervical radiculopathy and peripheral nerve entrapment 2
• Cervical provocative discography and anesthetic facet/nerve blocks have no evidence supporting their use for diagnosis 2

Management Pitfalls

• Do not assume benign course when elevated inflammatory markers are present – this warrants MRI even if other red flags are absent 5
• Do not delay MRI when red flags are present, even if symptoms seem mild 2
• Flexion/extension radiographs have limited value in degenerative disease 1