Although neck pain is often poorly defined and vague in presentation, it is important to avoid missing serious pathology.
It is worth mentioning that red flags in this scenario have a high negative predictive value (so if they are absent, the chances of a serious cause being present are quite low) but their positive predictive value for diagnosing serious pathology is low.
Red flag symptoms
- Significant preceding trauma or neck surgery
- Systemic upset (unintentional weight loss, night sweats, fevers)
- Severe pain
- Nocturnal pain
- Relatively young (<20 years) or old (>55 years)
- Signs of spinal cord compression
- Significant vertebral body tenderness
- History of TB, HIV, cancer or inflammatory arthritis
- Severe headache +/– fever +/– non-blanching rash
History
Establish the characteristics of the pain (use the SOCRATES acronym, below). Consider whether there has been any preceding injury, trauma or neck surgery.
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating symptoms
Severity
Older patients tend to have a narrower cervical canal and are more likely to have osteoporosis, which may result in fractures with only minor trauma. Younger patients may have congenital abnormalities of the spine.
Severe pain
Severe pain that is unremitting should ring alarm bells, particularly if it is worse at night. Night sweats, fevers and weight loss may indicate malignancy, or an infective process (for example, TB, osteomyelitis or even simpler pathology such as glandular fever).
A history of recent significant trauma, even to the head, should make you consider fracture, particularly if it was a hyperextension injury.
A severe headache associated with neck pain may represent meningeal irritation from a bleed or infection and requires an emergency admission.
Neurological symptoms
Neurological symptoms (such as clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function) should prompt a neurological examination to exclude spinal cord compression or cervical myelopathy. A background of inflammatory arthritis or Down's syndrome increases the chances of a more serious problem.
Drop attacks or dizziness, especially on upward gaze, may indicate vascular insufficiency, which is more common in older patients. This may occur, for example, when the patient is at the hairdressers and leans back at the sink.
Specific causes
It is important to consider specific causes of neck pain such as neck pain with acute spasm but no underlying obvious cause (torticollis).
There may be altered sensation or numbness associated with myeloradiculopathy but this can sometimes be present in patients with non-specific neck pain. The paraesthesia or tingling may occur down one arm or both arms.
Examination: face to face
For face-to-face examinations, ensure you wear appropriate PPE.
Examine with adequate exposure of the neck and shoulders. Look out for shingles. Feel for severe tenderness over the vertebrae, which may indicate a fracture from trauma or malignancy. Also, feel laterally in the supraclavicular region for cervical rib, and anteriorly for cervical lymph nodes, which may indicate infection or cancer.
Specific exquisite tenderness over one vertebral body can sometimes be a sign of infection, inflammation or malignancy.
Gently check neck movements. Lhermitte's phenomenon (symptoms of an electric shock or burning radiating downwards) may occur with neck flexion and can suggest an underlying serious cause such as myelopathy or demyelination.
Neurological examination of the limbs is important. Disc prolapse commonly affects C5/6 and C6/7. Rarely, inverted reflexes may be found in cervical myeloradiculopathy, indicated by absent reflexes at the level of the lesion and enhanced below (for example, a C5/6 lesion would give absent biceps reflex but the triceps, C7, may be exaggerated).
Cord compression can present with upper motor neurone signs in the lower limbs (upper going plantars, hyperreflexia, spasticity and clonus) and lower motor neurone signs in the upper limbs (atrophy and hyporeflexia).
Rarely, a pulsatile mass may indicate carotid artery aneurysm, especially after neck manipulation or trauma. This should be referred urgently.
Examination: remote
If you are assessing a patient remotely via video you can consider the following points.
- Observe the patient's gait. How do they look?
- Can the patient show you their neck? If so, look for rashes or swelling
- Ask the patient to do some movements such as flexion extension and lateral flexion
These remote examinations may help guide you on a management plan. But if you are unable to make a successful assessment then a face-to-face appointment will be needed.
Investigations
Consider blood work if infection is suspected, for instance, FBC, CRP. If inflammatory arthropathy is a possibility then consider an ESR. If glandular fever is suspected then consider performing a mono spot test.
X-ray may be useful. You might also wish to consider nerve conduction studies if you have direct access, and MRI neck may be requested, depending on your local access.
Possible causes
- Postural or muscular
- ENT pathology, such as glandular fever, tonsillar abscess
- Subarachnoid haemorrhage
- Cervical spondylosis/degenerative
- Vertebral disc prolapse
- Rheumatoid arthritis or seronegative arthropathies
- Malignancy (metastatic disease)
- Infection (TB, meningitis)
- Cervical rib
- Neck artery dissection or aneurysm
- Vertebral fracture
Management
A history of substantial preceding trauma and cervical spine tenderness should prompt consideration for immediate immobilisation, A&E referral and imaging to exclude fracture or instability.
Immediate referral may also be needed if spinal cord compression is suspected. This may require discussion with on-call neurosurgery.
Consider urgent referral, imaging or specialist opinion if any of the red flags are present. However, in the absence of red flags, x-rays are usually unhelpful and can often lead to false positive findings. For example, most patients over the age of 30 have some degree of osteoarthritis radiologically and it is often difficult to correlate this clinically.
Key learning points
- Red flags in neck pain have a high negative predictive value (so if they are absent, the chances of a serious cause being present are quite low).
- Older patients tend to have a narrower cervical canal and are more likely to have osteoporosis, which may result in fractures with only minor trauma.
- Severe pain that is unremitting should ring alarm bells, particularly if it is worse at night.
- A severe headache associated with neck pain may represent meningeal irritation.
- Cord compression can present with upper motor neurone signs in the lower limbs and lower motor neurone signs in the upper limbs.
- Rarely, a pulsatile mass may indicate carotid artery aneurysm.
- X-rays are usually unhelpful and can often lead to false positive findings.
Dr Baluch is a GP in London. This article was reviewed and updated in August 2021 by Dr Pipin Singh and Dr Ravi Ramanthan
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This is an updated version of an article that was first published in September 2012.
