What are the likely causes and recommended evaluation and management for right‑sided neck and supraclavicular pain that worsens with inspiration?

Right-Sided Neck and Supraclavicular Pain Worsening with Inspiration

You must immediately rule out pulmonary embolism (PE) and pneumothorax as life-threatening causes, then systematically screen for red-flag features that mandate urgent MRI before considering benign mechanical etiologies.

Immediate Life-Threatening Differential Diagnosis

The pleuritic nature of this pain (worsening with inspiration) places PE and pneumothorax at the top of your differential, both of which can present with neck and supraclavicular pain rather than classic chest pain.

Pulmonary Embolism

• PE is found in 5-21% of patients presenting to emergency departments with pleuritic chest pain and is the most common serious cause 1
• Tachycardia and dyspnea occur in >90% of PE patients; pain with inspiration is characteristic 2
• PE can present as referred neck-to-shoulder pain, particularly in the right supraclavicular region, even without classic chest symptoms 3
• Apply a validated clinical decision rule (Wells' criteria or PERC rule) immediately to guide d-dimer testing, with d-dimer >0.5 mg/mL warranting CT pulmonary angiography 1, 3

Pneumothorax

• Pneumothorax presents with dyspnea and pain on inspiration, with unilateral absence of breath sounds on examination 2
• Right-sided pneumothorax can manifest as pleuritic neck and supraclavicular pain 4, 5
• Obtain immediate chest radiography; if clinical suspicion is high and radiograph is negative, proceed to chest CT 1

Other Cardiopulmonary Emergencies

• Aortic dissection presents with severe pain of abrupt onset, pulse differential (30% of patients), and widened mediastinum on chest X-ray 2
• Acute coronary syndrome (ACS) should be considered when accompanying symptoms such as shortness of breath are present, though chest tenderness or pain with inspiration markedly reduces ACS probability 2

Mandatory Initial Workup

Obtain ECG within 10 minutes and chest radiography immediately 2—the ECG may show right axis deviation or precordial changes with pneumothorax 5, and chest X-ray will identify pneumothorax, widened mediastinum (dissection), or infiltrates (pneumonia).

Perform focused cardiovascular examination to identify tachycardia, hypotension, unilateral decreased breath sounds, pulse differentials, or friction rub 2

Red-Flag Screening for Cervical Spine Pathology

If cardiopulmonary emergencies are excluded, systematically screen for red flags that mandate urgent cervical spine MRI without contrast:

Constitutional and Infectious Red Flags

• Fever, unexplained weight loss, or night sweats require urgent MRI 2, 6, 7
• Elevated inflammatory markers (ESR, CRP, leukocytosis) warrant urgent imaging to exclude infection or malignancy 2, 6, 7
• History of IV drug use or immunosuppression signals high risk for vertebral osteomyelitis or epidural abscess and requires immediate MRI 2, 6

Neurological Red Flags

• Progressive weakness, sensory changes, gait disturbance, or bowel/bladder dysfunction indicate possible myelopathy and demand MRI within 12-24 hours 2, 6
• Vertebral body tenderness on palpation suggests metastatic disease or infection 2, 6

Oncologic Red Flags

• History of prior malignancy necessitates prompt MRI to assess for metastatic disease 2, 6
• Intractable pain despite 6-8 weeks of appropriate conservative therapy is a red flag for serious underlying pathology 2, 6

Benign Mechanical Causes (Only After Excluding Above)

Cervical Radiculopathy

• Nerve root compression from herniated disc or osteophyte is the primary neuropathic cause of mechanical neck pain 6, 8
• Spurling's test (axial compression with lateral flexion toward the painful side) is highly specific for nerve root compression 6
• 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy 6, 8

Pleuritic Musculoskeletal Pain

• Reduced thoracic spine and chest mobility in chronic neck pain patients can cause respiratory dysfunction and pleuritic-type pain 9
• Costochondritis presents with tenderness of costochondral joints on palpation 2

Pneumonia

• Pneumonia causes localized pleuritic chest pain, fever, regional dullness to percussion, and egophony 2
• Viruses (Coxsackie, RSV, influenza) are common causative agents of pleuritic chest pain 1

Algorithmic Management Pathway

1. Immediate assessment (<10 minutes):

   • Vital signs, focused cardiopulmonary examination
   • ECG and chest radiography
   • If tachycardia, dyspnea, or unilateral decreased breath sounds → pursue PE/pneumothorax workup urgently

2. If cardiopulmonary causes excluded:

   • Systematic red-flag screening (constitutional symptoms, neurological deficits, malignancy history, immunosuppression, elevated inflammatory markers)
   • If ANY red flag present → urgent MRI cervical spine without contrast 2, 6

3. If no red flags and acute presentation (<6 weeks):

   • Defer imaging and initiate conservative management: NSAIDs, activity modification, physical therapy 2, 6
   • Approximately 50% will have residual or recurrent symptoms at 1 year, but this does not change initial management 2, 6

4. If symptoms persist beyond 6-8 weeks despite conservative therapy:

   • Obtain MRI cervical spine without contrast to evaluate for nerve root compression or other structural pathology 2, 6

Critical Pitfalls to Avoid

• Do not attribute pleuritic neck pain to "muscle strain" without first excluding PE and pneumothorax—these can present atypically with referred supraclavicular pain 3
• Do not order plain radiographs of the cervical spine in the absence of red flags—they rarely change management and degenerative changes are present in 85% of asymptomatic adults over 30 2, 6
• Do not delay MRI while trialing conservative therapy if red flags are present—early imaging prevents missed serious pathology 6
• Do not interpret degenerative changes on MRI as causative without clinical correlation—spondylotic changes correlate poorly with symptoms 2, 6