Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic neck pain localized to the posterior cervical region, radiating to the trapezius and interscapular area. Symptoms are exacerbated by prolonged neck flexion and axial loading. No focal neurological deficits, gait instability, or bowel/bladder dysfunction reported. Pain is described as a dull ache with intermittent sharp exacerbations.
Clinical Examination Findings
Cervical spine examination reveals restricted range of motion, particularly in extension and lateral rotation. Palpation demonstrates tenderness over the C3-C4 paraspinal musculature. Spurlingโs test is negative bilaterally. Neurological examination of the upper extremities shows intact motor strength (5/5), symmetric deep tendon reflexes (2+), and no sensory deficits in the C3-C4 dermatomal distribution.
Treatment Protocol
Initiate conservative management including physical therapy focusing on cervical stabilization and postural correction. Prescribe NSAIDs for inflammation and muscle relaxants as needed for nocturnal spasms. Recommend ergonomic modifications for workstation setup. Follow-up in 6 weeks to assess response to therapy; consider cervical spine MRI if symptoms persist or neurological status changes.