Differential Diagnosis for Acute Left-Sided Neck Pain After Self-Neck Manipulation

Life-Threatening Diagnoses Requiring Urgent Evaluation

• The American Heart Association and American Stroke Association recommend immediate evaluation for vertebral artery dissection, which can present with isolated unilateral neck pain without neurologic symptoms initially, but cerebral or retinal ischemia develops in 50-95% of cases after warning symptoms 2, 3
• Vertebral artery dissection can occur after minor trauma such as neck manipulation, hyperflexion, or hyperextension, and may cause devastating neurologic complications including stroke 1, 2, 3
• The American College of Cardiology recommends considering carotid and vertebral artery dissection in patients with neck pain and Horner syndrome (ptosis, miosis, anhidrosis) 2, 3

Serious Diagnoses Requiring Prompt Evaluation

• The American College of Radiology recommends considering cervical ligamentous injury in patients with persistent pain and potential delayed instability after self-manipulation 5
• Cervical ligamentous injury can present with mechanical pain from ligamentous disruption without obvious fracture, and flexion-extension radiographs may be inadequate in the acute setting due to muscle spasm 5

Common Mechanical Diagnoses

• The American College of Radiology recommends considering facet joint injury/arthropathy in patients with localized, often unilateral pain that may radiate to the trapezius region 6, 7, 8
• Facet joint injury/arthropathy typically presents with pain that worsens with extension and rotation 6

Diagnostic Approach

• The American College of Radiology recommends immediate emergency department evaluation and CTA or MRA of the neck if red flags are present, such as neurological deficits, severe headache, or visual disturbances 2, 3, 4, 6
• The American Heart Association and American Stroke Association recommend considering MRI cervical spine without contrast if vascular imaging is negative but suspicion remains high 6, 4