From the Guidelines
For a patient with pain at the base of the neck for 10 days, worse with right rotation and looking down, with occasional left arm and upper back pain and history of AC separation, I recommend initial evaluation with a thorough physical examination focusing on cervical range of motion, neurological assessment, and palpation of the cervical spine and surrounding musculature. Imaging should include cervical spine X-rays in AP, lateral, and oblique views to assess for degenerative changes, alignment issues, or residual AC joint abnormalities, as suggested by the American College of Radiology Appropriateness Criteria for cervical neck pain or cervical radiculopathy 1. Initial treatment should include NSAIDs such as ibuprofen 400-600mg three times daily with food for 7-10 days to reduce inflammation. Physical therapy focusing on gentle cervical stretching, postural correction, and strengthening exercises should be prescribed for 4-6 weeks. A muscle relaxant like cyclobenzaprine 5-10mg at bedtime may be added for muscle spasm. Application of moist heat for 15-20 minutes several times daily can help relieve muscle tension. If neurological symptoms worsen or fail to improve within 2 weeks, consider advanced imaging such as MRI to evaluate for cervical disc pathology or nerve impingement, as recommended for cases of new or increasing nontraumatic cervical radiculopathy without red flags 1. This approach addresses both the inflammatory component and mechanical factors that may be contributing to the pain, particularly given the history of AC separation which may have altered biomechanics in the neck and shoulder region. Key considerations in managing this patient include:
- Thorough physical examination to guide initial treatment and assess for red flags
- Appropriate use of imaging studies, such as X-rays and potentially MRI, based on clinical presentation and response to initial treatment
- Multimodal treatment approach including NSAIDs, physical therapy, and muscle relaxants as needed
- Close monitoring for worsening neurological symptoms or failure to improve with initial treatment, prompting consideration of advanced imaging or referral to a specialist.
From the Research
Initial Assessment and Testing
- The patient presents with pain at the base of the neck, increased pain when turning to the right and looking down, and occasional pain to the left arm and upper back, with a history of AC separation 2.
- Initial tests may include cervical spine radiographs, as the patient's symptoms suggest a potential cervical spine injury 2.
- Computed tomography (CT) may be used for initial osseous and basic soft tissue evaluation, followed by magnetic resonance imaging (MRI) for complementary evaluation of the neural structures and soft tissues 3.
Imaging Techniques
- Standard MRI of the cervical spine is typically performed in a supine position, but imaging with the neck extended may provide additional information in selected patients 4.
- CT and MRI are effective in detecting cervical spine injuries, with CT being effective in detecting clinically significant injuries and MRI providing complementary information on neural structures and soft tissues 3, 5.
Treatment and Management
- The patient's treatment and management plan will depend on the results of the initial tests and imaging studies, as well as the severity of the injury 3, 5.
- Clinically significant cervical spine injuries may require surgical stabilization or halo placement, while less severe injuries may be managed conservatively 5.
- The patient's history of AC separation and current symptoms suggest the need for careful evaluation and management to prevent further injury or complications 2.