Neck Pain: Initial Evaluation and Management

Marc A. Childress; Samantha Jayne Stuek

Aug 1, 2020 Issue

Neck Pain: Initial Evaluation and Management

MARC A. CHILDRESS, MD, and SAMANTHA JAYNE STUEK, MD, Virginia Commonwealth University Fairfax Family Practice, Fairfax, Virginia

Am Fam Physician. 2020 Aug 1;102(3):150-156.

Author disclosure: No relevant financial affiliations.

Neck pain is a common presenting symptom in the primary care setting and causes significant disability. The broad differential diagnosis requires an efficient but global assessment; therefore, emphasis is typically placed on red flags that can assist in the early recognition and treatment of more concerning diagnoses, such as traumatic injuries, infection, malignancy, vascular emergencies, and other inflammatory conditions. The critical element in appropriate diagnosis and management of these conditions is an accurate patient history. Physical examination findings complement and refine diagnostic cues from the history but often lack the specificity to be of value independently. Diagnostic tools such as imaging and electrodiagnostic tests have variable utility, especially in chronic or degenerative conditions. Treatment of mechanical or nonneuropathic neck pain includes short-term use of medications and possibly injections. However, long-term data for these interventions are limited. Acupuncture and other complementary and alternative therapies may be helpful in some cases. Advanced imaging and surgical evaluation may be warranted for patients with worsening neurologic function or persistent pain.

Neck pain is a common presenting symptom in primary care, with an incidence of 10.4% to 21.3% per year.1 It is the fourth leading cause of disability worldwide.1 The prevalence of neck pain is higher in older adults because of degenerative changes in facet joints and the collapse of intervertebral disks.2 It is estimated that only one in five people with neck pain seeks medical care.3 The differential diagnosis is broad and includes common conditions such as muscular strains and arthritis, as well as more dire conditions such as fractures, spinal cord and nerve injuries, neoplastic disorders, infections, and inflammatory conditions. Family physicians must be able to recognize when neck pain signals a potentially serious condition and should be able to generate an accurate diagnosis through findings from the patient's history, physical examination, and appropriate testing.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Myelopathic signs and symptoms such as lower extremity weakness, balance problems, and bowel and bladder irregularities should be evaluated and treated urgently.⁵	C	Expert consensus
Patients with neck pain should be assessed for comorbidities because underlying inflammatory or rheumatologic conditions increase the risk of cervical spine injury.^6,8	C	Consensus, usual practice, expert opinion, disease-oriented evidence, and case series
Electrodiagnostic studies should not be used routinely in the evaluation of isolated neck pain without peripheral neuropathic symptoms.²⁰	C	Consensus guideline, expert opinion, and disease-oriented evidence
Narcotic pain medications have no benefit for cervical pain and should be used with caution.²⁶	B	Systematic review

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Myelopathic signs and symptoms such as lower extremity weakness, balance problems, and bowel and bladder irregularities should be evaluated and treated urgently.⁵	C	Expert consensus
Patients with neck pain should be assessed for comorbidities because underlying inflammatory or rheumatologic conditions increase the risk of cervical spine injury.^6,8	C	Consensus, usual practice, expert opinion, disease-oriented evidence, and case series
Electrodiagnostic studies should not be used routinely in the evaluation of isolated neck pain without peripheral neuropathic symptoms.²⁰	C	Consensus guideline, expert opinion, and disease-oriented evidence
Narcotic pain medications have no benefit for cervical pain and should be used with caution.²⁶	B	Systematic review

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BEST PRACTICES IN NEUROLOGY

Recommendations from the Choosing Wisely Campaign

Recommendation	Sponsoring organization
Do not do nerve conduction studies without also doing a needle electromyogram for testing for radiculopathy, a pinched nerve in the neck or back.	American Association of Neuromuscular & Electrodiagnostic Medicine

Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For s

The Authors

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MARC A. CHILDRESS, MD, is chair of the Department of Family Medicine at Inova Fairfax (Va.) Hospital and associate director of the Primary Care Sports Medicine Fellowship at Virginia Commonwealth University Fairfax Family Practice....

SAMANTHA JAYNE STUEK, MD, is a second-year resident at Virginia Commonwealth University Fairfax Family Practice.

Address correspondence to Marc A. Childress, MD, Virginia Commonwealth University Fairfax Family Practice, 3650 Joseph Siewick Dr., Ste. 400, Fairfax, VA 22033 (email: mchildress@ffpcs.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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