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Evaluation and Treatment of Posterior Neck Pain in Family Practice

Family Practice Residency Program, Middlesex Hospital, Middletown, CT (ABD)
Riverside Family Practice Residency Program, Riverside Methodist Hospital, Columbus, OH (ETB)

Correspondence: Address correspondence to Alan B. Douglass, MD, FAAFP, Family Practice Residency Program, Middlesex Hospital, 90 South Main Street, Middletown, CT 06457 (e-mail: alan_douglass_md{at}midhosp.org)

Neck pain is almost universal and is a common patient complaint. Although the differential diagnosis is extensive, most symptoms are from biomechanical sources, such as axial neck pain, whiplash-associated disorder (WAD), and radiculopathy. Most symptoms abate quickly with little intervention. There is relatively little high-quality treatment evidence available, and no consensus on management of axial neck pain or radiculopathy. A number of general pain management guidelines are applicable to neck pain, and specific guidelines are available on the management of WAD. The goal of diagnosis is to identify the anatomic pain generator(s). Patient history and examination are important in distinguishing potential causes and identifying red flags. Diagnostic imaging should be ordered only when necessary because of the high incidence of asymptomatic radiographic abnormalities. First-line drug treatments include acetaminophen, cyclo-oxygenase 2–specific inhibitors, or nonsteroidal anti-inflammatory drugs. Short-term use of muscle relaxants may be considered. Opioids should be used if other treatments are ineffective and continued if improved function outweighs impairment. Adjuvant antidepressants and anticonvulsants should be considered in chronic or neuropathic pain and coincident depression. Epidural steroids should be considered only in radiculopathy. Physical modalities supported by evidence should be used. If symptoms have not resolved in 4 to 6 weeks, re-evaluation and additional workup should be considered.