What is the appropriate management for a 12-year-old with acute neck pain and limited left rotation after a possible minor strain, who has been using ice and took over‑the‑counter ibuprofen?

Management of Acute Neck Pain with Limited Range of Motion in a 12-Year-Old

Continue the current regimen of ice application and ibuprofen, reassure the family that this is likely a benign muscular strain that will resolve within 3-5 days, and instruct them to return immediately if any red-flag symptoms develop.

Immediate Assessment for Red Flags

Before proceeding with conservative management, you must systematically exclude serious pathology by screening for:

• Constitutional symptoms (fever, unexplained weight loss, night sweats) that would indicate infection or malignancy and mandate urgent MRI 1
• Neurological deficits including progressive weakness, sensory changes, gait disturbance, or bowel/bladder dysfunction suggesting myelopathy 1
• History of trauma beyond the minor possible strain mentioned—any significant mechanism of injury requires imaging 1
• Vertebral body tenderness on palpation, which suggests metastatic disease or infection 1
• Intractable pain that does not respond to appropriate conservative therapy 1

In this case, the absence of these red flags allows you to proceed with conservative management without imaging. 2

Why Imaging Is Not Indicated

• Routine imaging is not recommended for acute pediatric neck pain (<6 weeks duration) without red-flag features because most cases resolve spontaneously within days to weeks 3, 2
• Plain radiographs rarely change management decisions in the absence of red flags and frequently reveal incidental degenerative changes that are present in asymptomatic individuals 1
• In pediatric spine trauma evaluation, imaging is only indicated when risk factors are present based on validated clinical decision rules 3
• Approximately 50% of acute neck pain cases may have residual or recurrent symptoms up to 1 year, but this does not alter the initial decision to defer imaging 2

Optimal Conservative Management Protocol

Pharmacologic Therapy

• Continue ibuprofen at age-appropriate dosing (typically 10 mg/kg every 6-8 hours, maximum 40 mg/kg/day or 2400 mg/day) for its anti-inflammatory and analgesic effects 2, 4
• Ibuprofen has been shown to provide effective pain relief in acute musculoskeletal neck pain 5, 4
• Avoid muscle relaxants (including benzodiazepines like diazepam) in pediatric patients, as they are associated with delayed recovery and excessive sedation 2

Thermal Therapy

• Either heat or ice may be used based on patient preference, as both provide similar mild symptomatic relief when combined with ibuprofen 5
• The choice between heat and cold should be based on what the child finds most comfortable, as a randomized controlled trial found no significant difference in pain relief between the two modalities 5
• Apply for 20-30 minutes at a time, several times daily 5
• Low-level continuous heat has been shown to improve pain relief and range of motion when used as an adjunct to therapy 6

Activity Modification

• Avoid prolonged static neck positions and activities that exacerbate pain 1
• Encourage gradual return to normal activities as tolerated 2
• The child should avoid overhead activities and positions that worsen the pain 1

Expected Clinical Course and Follow-Up

• Improvement should be evident within 3-5 days of conservative management 2
• Most acute neck pain in children resolves within 2 months without intervention 7
• Schedule follow-up in 2-4 weeks if symptoms persist beyond the expected timeframe 2

Critical Red Flags Requiring Immediate Re-Evaluation

Instruct the family to return immediately or seek emergency care if any of the following develop:

• Fever or constitutional symptoms (night sweats, unexplained weight loss) suggesting infection or malignancy 1, 2
• New neurological deficits including weakness, numbness, tingling, or changes in gait 1, 2
• Progressive worsening of pain despite appropriate conservative therapy 1
• Development of severe, intractable pain that is not relieved by over-the-counter medications 1
• Inability to move the neck in any direction or complete loss of range of motion 2

When to Consider MRI

MRI cervical spine without contrast should be obtained if 3, 1:

• Symptoms persist beyond 6-8 weeks of appropriate conservative therapy
• Any red-flag symptoms develop during the observation period
• New neurological deficits appear
• Pain becomes intractable despite adequate analgesia

Common Pitfall to Avoid

Do not order imaging at this initial presentation in the absence of red flags, as it rarely changes management in acute uncomplicated pediatric neck pain and frequently reveals incidental findings that do not correlate with symptoms 3, 1, 2. The high sensitivity of clinical examination combined with the benign natural history of most pediatric neck strains makes imaging unnecessary and potentially harmful through radiation exposure and overdiagnosis of clinically insignificant findings.