How should I treat a stiff neck in an adult without trauma or red‑flag symptoms?

Treatment of Non-Traumatic Neck Stiffness in Adults

For an adult with a stiff neck without trauma or red-flag symptoms, conservative management with NSAIDs, physical therapy focused on cervical proprioception and muscle coordination, and activity modification is the appropriate first-line approach—imaging is not indicated and most cases resolve spontaneously within 6-8 weeks. 1, 2

Initial Red-Flag Screening (Mandatory)

Before proceeding with conservative care, you must systematically screen for red flags that would mandate immediate MRI cervical spine without contrast:

• Constitutional symptoms: fever, unexplained weight loss, night sweats 1, 3
• Elevated inflammatory markers: ESR, CRP, or leukocytosis 4, 1
• History of malignancy or immunosuppression 1, 3
• Current or past IV drug use (high risk for spinal infection/epidural abscess) 1
• Progressive neurological deficits: weakness, sensory changes, gait disturbance, bowel/bladder dysfunction 1, 3
• Intractable pain despite appropriate conservative therapy 1, 3
• Vertebral body tenderness on palpation 1, 3
• Coagulopathy or recent trauma 1

If any red flag is present, do not delay MRI imaging or definitive treatment while awaiting specialist consultation. 1

Conservative Management Protocol (When No Red Flags Present)

Pharmacologic Treatment

• NSAIDs provide symptomatic relief and are appropriate first-line therapy 4, 1
• Muscle relaxants may be considered in acute neck pain associated with muscle spasm 2

Physical Therapy and Exercise

• Exercise treatment targeting cervical proprioception and muscle coordination is beneficial for patients with neck pain 5, 2
• Cervical proprioceptive impairment is a main problem in patients with neck pain, leading to sensorimotor control disturbances 5
• Retraining aimed at improving cervical proprioception and muscle coordination is supported by current evidence 5
• The cervical joint position error (JPE) test is the most commonly used assessment for cervical sensorimotor control 5

Expected Natural History

• Most acute neck pain (< 6 weeks duration) resolves spontaneously or with conservative treatment 1, 2
• Approximately 50% of patients will have residual or recurrent symptoms at 1-year follow-up, but this does not alter the initial conservative approach 1, 3, 2
• 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy 3

When to Consider Imaging

MRI cervical spine without contrast should be considered only if:

• Persistent symptoms beyond 6-8 weeks of appropriate conservative therapy 1, 3
• Progressive neurological deficits develop during treatment 1
• Severe pain unresponsive to treatment 1
• Any red-flag symptoms emerge during the course of treatment 1

Critical Pitfalls to Avoid

• Do not order imaging immediately in the absence of red flags—this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 1
• Do not interpret degenerative changes on imaging as causative without clinical correlation—spondylotic changes are present in 85% of asymptomatic individuals over 30 years, and 53.9% of individuals aged 18-97 show cervical degeneration 1, 3
• Plain radiographs rarely change therapeutic decisions in the absence of red flags and are not routinely indicated 1
• Imaging has limited value in whiplash-associated disorders, as diagnosis primarily relies on clinical factors 6

Alternative Treatment Considerations

• Fu's subcutaneous needling (FSN) has been shown to relieve pain, improve neck disability and mobility, and enhance sleep quality in chronic neck pain 7
• Cervical facet joint radiofrequency ablation may provide long-term analgesia exceeding 6 months for facet-mediated pain, but requires controlled diagnostic blocks first 3
• There is conflicting evidence for epidural corticosteroid injections for radiculopathy 2