Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic cervicalgia characterized by a dull, aching sensation, radiating into the trapezius and interscapular regions. Symptoms are exacerbated by prolonged neck flexion and axial loading. Denies acute trauma, bowel/bladder dysfunction, or progressive distal motor weakness. Pain intensity is [X]/10, intermittent, and associated with morning stiffness.
Clinical Examination Findings
Cervical spine inspection reveals normal alignment without deformity. Palpation demonstrates tenderness over the paraspinal musculature and spinous processes at [C-level]. Range of motion is restricted in extension and lateral rotation. Neurological exam: Sensation intact to light touch in C5-T1 dermatomes. Motor strength 5/5 in upper extremities. Deep tendon reflexes 2+ and symmetric. Spurlingโs test is [positive/negative].
Treatment Protocol
Initiate conservative management including physical therapy for cervical stabilization and postural correction. Prescribe NSAIDs for inflammatory control and muscle relaxants as needed for nocturnal spasms. Recommend ergonomic modifications at workstation. Consider cervical traction or epidural steroid injections if symptoms persist. Follow-up in [X] weeks to assess response.