The incidence of neck pain in US primary care settings ranges from 10% to 21% per year. A key component in evaluation of patients with neck pain is identification of red flag signs or symptoms that indicate the need for urgent evaluation for possible serious conditions. These include fever, unexplained weight loss, trauma, vision changes, new or severe headache, and altered mental status, among others. Patients with acute onset or worsening chronic neck pain without trauma or red flag signs or symptoms should be assessed initially with x-ray. Magnetic resonance imaging study is recommended for patients with progressive neurologic symptoms, neurologic compromise, suspected infection, or other red flag signs or symptoms. Common conditions and injuries associated with neck pain in the primary care setting include cervical strains and sprains, cervical spondylosis, cervical discogenic pain, cervical radiculopathy and myelopathy, whiplash, cervical fracture, and postural pain. Most patients with neck pain without red flag signs or symptoms recover with conservative management, however, there is little evidence to support these treatments. Pharmacotherapy includes nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants. Small benefits have been shown for combination exercise programs, mind-body programs, and acupuncture. Referral for surgical management is indicated for patients with progressive neurologic deficits.

Case 3. HH is a 60-year-old patient who comes to your office reporting neck pain and stiffness. He says he has experienced mild neck stiffness and discomfort for years, but his symptoms have worsened in the past 2 months. He reports no recent injury or trauma but notes that he was in two motor vehicle crashes 30 to 40 years ago. He now is experiencing increased neck pain as well as discomfort in his right shoulder and arm. His right hand occasionally feels numb. He has not noticed overt weakness. He reports no fever, chills, or weight loss.