What is the recommended initial management for a 45‑year‑old woman with chronic neck pain radiating to the left shoulder and cervical X‑ray showing loss of lordosis with minimal C4‑C6 uncovertebral osteophytes?

Management of Chronic Neck Pain with Degenerative Changes

For this 45-year-old woman with chronic neck pain radiating to the left shoulder and X-ray showing loss of lordosis with minimal C4-C6 uncovertebral osteophytes, proceed with conservative management including NSAIDs and physical therapy for 4-6 weeks, followed by MRI cervical spine without contrast if symptoms persist or worsen. 1, 2

Initial Conservative Management (First-Line Treatment)

The presence of degenerative changes on X-ray does not automatically warrant advanced imaging or intervention, as these findings correlate poorly with symptoms and are common in asymptomatic individuals. 1, 3

Start with a 4-6 week trial of:

• NSAIDs (e.g., naproxen 500 mg twice daily) for pain control 2, 4
• Physical therapy focused on cervical spine mobilization, strengthening exercises, and posture correction 2, 5
• Activity modification to avoid positions that exacerbate pain 2

The rationale: 75-90% of patients with cervical radiculopathy achieve symptomatic relief with nonoperative conservative therapy. 1

Assessment for Red Flags

Before proceeding with conservative management, systematically evaluate for red flags that would warrant immediate MRI: 2, 3

• Progressive neurological deficits (weakness, numbness, gait disturbance)
• Constitutional symptoms (fever, unexplained weight loss)
• Known malignancy or immunosuppression
• Recent infection with elevated inflammatory markers
• Intractable pain despite appropriate analgesia

If any red flags are present, skip conservative management and proceed directly to MRI cervical spine without contrast. 2, 3

When to Obtain MRI

MRI cervical spine without contrast is indicated if: 1

• Symptoms persist beyond 4-6 weeks despite appropriate conservative therapy
• Symptoms worsen during the conservative trial
• New neurological symptoms develop (weakness, sensory changes, balance difficulty)

The 2025 ACR guidelines specifically state that for chronic neck pain with degenerative changes on radiographs, MRI without contrast is the appropriate next imaging study. 1

Critical Clinical Pitfalls to Avoid

Do not over-interpret degenerative findings on imaging. Loss of cervical lordosis and minimal uncovertebral osteophytes are extremely common in asymptomatic individuals and do not necessarily correlate with the patient's pain. 1, 3 The key is clinical correlation—treat the patient, not the X-ray.

Do not rush to advanced imaging in the absence of red flags or neurological deficits. The ACR guidelines emphasize that for chronic neck pain without neurological findings, plain radiographs are sufficient initially, with MRI reserved for persistent cases. 1

Recognize that shoulder pathology can present as neck pain. Given the left shoulder pain component, consider shoulder impingement syndrome in the differential diagnosis, which can be evaluated with shoulder examination and responds to subacromial injection if present. 6

Pharmacological Management Details

NSAIDs (First-Line): 4, 5

• Naproxen 500 mg twice daily (or 250 mg every 6-8 hours)
• Use the lowest effective dose for the shortest duration
• Consider dose reduction in elderly patients or those with renal/hepatic impairment

Muscle Relaxants (Adjunctive): 7, 5

• Cyclobenzaprine 5-10 mg three times daily may be added for muscle spasm
• Start with 5 mg in elderly patients and titrate slowly
• Note: drowsiness is common; warn patients about sedation

Combination therapy with NSAIDs and muscle relaxants is associated with more side effects (primarily drowsiness) but may be necessary for severe pain. 7

Physical Therapy Specifics

Physical therapy should focus on: 2, 8

• Cervical spine mobilization and manipulation
• Progressive strengthening of cervical-scapular musculature
• Postural correction exercises
• Range of motion exercises

Manual therapy combined with motor control exercises represents the most effective intervention for cervicogenic pain patterns. 8

Follow-Up Timeline

Reassess at 2-4 weeks: 3

• Evaluate response to conservative management
• Screen for new red flag symptoms
• Adjust medications as needed

If no improvement by 4-6 weeks, obtain MRI cervical spine without contrast. 1, 2

Role of Interventional Procedures

Cervical medial branch blocks or facet injections should be reserved for patients who fail both conservative management and have MRI correlation of their symptoms. 2, 9 These are not first-line treatments and should only be considered after appropriate conservative therapy has been exhausted.

Prognosis Considerations

Patients with straight or sigmoid lateral cervical curvature (loss of lordosis) may be more difficult to manage with oral medications alone and may require interventional procedures. 9 However, this does not change the initial conservative approach—it simply helps set realistic expectations for treatment response.