What is the differential diagnosis, initial evaluation, and first‑line management for an adult presenting with cervical (neck) pain of unspecified duration?

Differential Diagnosis, Initial Evaluation, and First-Line Management of Cervical Pain

For adults presenting with cervical pain without "red flag" symptoms, imaging is not indicated and conservative management with reassurance, activity modification, NSAIDs, and physical therapy is the appropriate initial approach, as most cases resolve spontaneously within 6-8 weeks. 1

Differential Diagnosis Framework

Mechanical Causes (Most Common)

• Cervical radiculopathy from disc herniation or osteophyte formation represents the primary neuropathic mechanical pain etiology, presenting with dermatomal arm pain, sensory dysfunction, and motor weakness 1, 2
• Facet joint arthropathy causes localized mechanical pain that may be unilateral 3
• Cervical disc degeneration is extremely common but correlates poorly with symptoms—85% of asymptomatic individuals over 30 show spondylotic changes on imaging 3, 4
• Myofascial pain from cervical muscles and supporting structures accounts for the majority of nontraumatic cervical pain 1

Serious Etiologies Requiring Urgent Evaluation

• Vertebral osteomyelitis or discitis presents with fever, night sweats, elevated ESR/CRP/WBC, and risk factors including IV drug use or immunosuppression 1, 3, 5
• Metastatic disease to cervical vertebrae presents with intractable pain, constitutional symptoms, history of malignancy, and vertebral body tenderness on palpation 1, 3
• Primary spinal tumors cause progressive symptoms refractory to conservative treatment 3
• Cervical myelopathy from spinal cord compression requires differentiation through examination for myelopathic signs including gait disturbance, bowel/bladder dysfunction, and hyperreflexia 1, 3
• Inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis) causes persistent pain with elevated inflammatory markers 1, 3

Vascular and Referred Pain Etiologies

• Cervical arterial dissection presents with unilateral headache and neck pain, requiring urgent vascular imaging 1
• Cardiac ischemia can present as isolated neck pain, particularly with exertion—a critical diagnostic pitfall 6
• Cervicogenic headache presents as unilateral headache with accompanying neck pain, provoked by neck movement or awkward positions 1, 7, 8

Critical "Red Flag" Screening (Mandatory for All Patients)

The presence of ANY red flag symptom mandates urgent MRI cervical spine without contrast rather than conservative management. 1, 3, 5

Constitutional Symptoms

• Fever, unexplained weight loss, or night sweats require immediate MRI evaluation 1, 3, 5
• These symptoms suggest infection, malignancy, or inflammatory conditions 1, 3

Laboratory Abnormalities

• Elevated ESR, CRP, or leukocytosis warrant urgent imaging to exclude infection or malignancy 1, 3, 5
• Document specific values and trend over time 5

High-Risk Patient Factors

• History of malignancy requires immediate investigation for metastatic disease 1, 3
• Current or past IV drug use signals high risk for spinal infection or epidural abscess, even if currently denied 3, 5
• Immunosuppression (HIV, chronic steroids, chemotherapy) increases infection risk 1, 3
• Coagulopathy requires urgent evaluation for epidural hematoma 3, 5

Neurological Red Flags

• Progressive weakness, sensory changes, or gait disturbance indicate possible myelopathy requiring urgent MRI 1, 3
• Bowel or bladder dysfunction represents a surgical emergency 9
• Hyperreflexia, positive Hoffman's sign, or clonus suggest spinal cord compression 3, 2

Pain Characteristics

• Intractable pain despite appropriate conservative therapy for 6-8 weeks warrants MRI evaluation 1, 3
• Vertebral body tenderness on palpation suggests metastatic disease or infection 1, 3
• Pain reproduced by exertion that resolves with rest should prompt cardiac evaluation 6

Initial Evaluation Algorithm

For Acute Cervical Pain (<6 Weeks) WITHOUT Red Flags

Step 1: Clinical History

• Duration of symptoms (acute <6 weeks, subacute 6-12 weeks, chronic >12 weeks) 1
• Mechanism of onset (traumatic versus atraumatic) 1
• Pain characteristics: location, radiation pattern, aggravating/relieving factors 1, 2
• Presence of radicular symptoms: dermatomal pain, paresthesias, weakness 2
• Impact on function: sleep disturbance, inability to perform activities of daily living 9
• Prior episodes and response to previous treatments 1

Step 2: Physical Examination

• Cervical range of motion assessment 2, 8
• Palpation for vertebral body tenderness, muscle spasm, and trigger points 1, 3
• Spurling's test (cervical extension with lateral rotation and axial compression) is highly specific for nerve root compression from disc herniation or foraminal stenosis 3, 9
• Dermatomal sensory testing for C5-T1 distributions 2
• Myotomal motor testing: shoulder abduction (C5), elbow flexion (C6), elbow/wrist extension (C7), finger flexion (C8), finger abduction (T1) 2
• Deep tendon reflexes: biceps (C5-C6), brachioradialis (C6), triceps (C7) 2
• Screen for myelopathy: gait assessment, Hoffman's sign, clonus, hyperreflexia 3, 2

Step 3: Imaging Decision

• No imaging is indicated for acute cervical pain without red flags 1
• Plain radiographs do not improve clinical outcomes or alter management decisions in the absence of red flags 1, 9
• Approximately 50% of patients will have persistent or recurrent symptoms at 1 year, but this does not change the initial decision to defer imaging 1, 3

For Acute Cervical Pain WITH Red Flags

Immediate MRI cervical spine without contrast is the imaging modality of choice 1, 3, 5

• MRI provides optimal soft tissue contrast to visualize disc herniations, nerve root impingement, spinal cord compression, infection, malignancy, and inflammatory conditions 3, 5, 9
• MRI has 88% accuracy in predicting nerve root lesions compared to 81% for CT myelography 9
• Do not delay MRI or definitive treatment while awaiting specialist consultation when red flags are present 3

For Chronic or Subacute Cervical Pain (>6-8 Weeks) Despite Conservative Management

MRI cervical spine without contrast is indicated when symptoms persist beyond 6-8 weeks of appropriate conservative therapy 3, 9

• Progressive neurological deficits warrant immediate MRI regardless of symptom duration 3, 9
• Severe pain unresponsive to multimodal conservative treatment requires MRI evaluation 3, 9

First-Line Management for Cervical Pain Without Red Flags

Conservative Treatment Protocol (6-8 Week Trial)

Multimodal conservative therapy achieves 75-90% symptomatic improvement in cervical radiculopathy and should be the initial approach 9, 2

Pharmacological Management

• NSAIDs (ibuprofen, naproxen) for anti-inflammatory effect and pain control 1, 9
• Acetaminophen for additional analgesia if NSAIDs contraindicated 1
• Short-term muscle relaxants for severe muscle spasm (use cautiously due to sedation) 1
• Avoid opioids for acute mechanical neck pain due to poor risk-benefit ratio 1

Physical Therapy

• Structured physical therapy demonstrates statistically significant clinical improvement in cervical radiculopathy 9
• At 12 months, physical therapy achieves comparable outcomes to surgical intervention, though surgery provides more rapid relief within 3-4 months 9, 2
• Focus on cervical range of motion, postural correction, and strengthening exercises 9

Activity Modification

• Avoid prolonged static neck positions and overhead activities 1, 9
• Ergonomic workplace adjustments 1
• Gradual return to normal activities as tolerated 1, 9

Cervical Collar Immobilization

• Consider short-term use (days to 1-2 weeks maximum) for severe acute pain 9, 2
• Prolonged immobilization leads to muscle deconditioning and should be avoided 9

Indications for Specialist Referral

Refer to spine specialist (neurosurgery or orthopedic spine) when:

• Symptoms persist beyond 6-8 weeks of appropriate conservative therapy 9, 2
• Progressive neurological deficits develop at any time 3, 9, 2
• Severe or intractable pain despite multimodal conservative management 3, 9
• MRI reveals significant pathology requiring surgical consideration (moderate-to-severe foraminal stenosis, disc herniation with nerve root compression, spinal cord compression) 9, 2

Critical Pitfalls to Avoid

Imaging Pitfalls

• Do not order MRI immediately for acute cervical pain without red flags—this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 3, 9
• 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 65% of asymptomatic patients aged 50-59 show significant cervical degeneration on X-ray 3, 9
• Abnormal MRI findings must always be interpreted in the context of the clinical picture because incidental degenerative changes are extremely common in asymptomatic individuals 3, 9

Diagnostic Pitfalls

• Do not assume all neck pain is musculoskeletal—cardiac ischemia can present as isolated neck pain, particularly with exertion 6
• If neck pain is reproduced by exercise and resolves with rest, consider cardiac evaluation with ECG and echocardiogram 6
• Do not miss cervical myelopathy—carefully examine for myelopathic signs (gait disturbance, hyperreflexia, Hoffman's sign, clonus) as this requires urgent surgical evaluation 3, 2
• Cervicogenic headache lacks definitive imaging diagnostic criteria, and imaging findings correlate poorly with symptoms—diagnosis is primarily clinical 1, 7

Treatment Pitfalls

• Do not proceed to surgery without documented 6-8 weeks of conservative therapy unless progressive neurological deficits or red flags are present 9, 2
• 90% of acute cervical radiculopathy patients improve with conservative management, making premature surgical intervention inappropriate 9
• Do not delay urgent MRI when red flags are present—waiting for "failed conservative therapy" is inappropriate when infection, malignancy, or myelopathy is suspected 3, 5