Neck pain - red flag symptoms

The signs and symptoms of potentially serious pathology in patients presenting with neck pain.

Red flag symptoms

  • Significant preceding trauma or neck surgery
  • Systemic upset (weight loss, night sweats, fevers)
  • Severe pain
  • Nocturnal pain
  • Relatively young (<20) or old (>55)
  • Signs of spinal cord compression
  • Significant vertebral body tenderness
  • History of TB, HIV, cancer or inflammatory arthritis

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.


Establish the characteristics of the pain, such as its site, onset, nature and radiation, and whether there was any preceding injury, trauma or neck surgery.

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 that is unremitting should ring alarm bells, particularly if worse at night. Night sweats, fevers and weight loss may indicate malignancy, or an infective process (for example, TB or osteomyelitis). A history of recent significant trauma, even to head, should make one consider fracture.

Neurological symptoms should prompt a neurological examination to exclude spinal cord compression or cervical myelopathy (such as clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function). 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.

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.


Examine with adequate exposure of the neck and shoulders. 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 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, hyper reflexia, 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.


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.

Consider urgent referral, imaging or specialist opinion if any of these red flags are present however in the absence of red flags, x-rays are often unhelpful and can often lead to false positive findings. For example, most patients over 30 have some degree of osteoarthritis radiologically and it is often difficult to correlate this clinically.

Possible causes

  • Whiplash
  • Cervical spondylosis/degenerative
  • Vertebral disc prolapse
  • Rheumatoid arthritis or seronegative arthropathies
  • Malignancy
  • Infection (TB, meningitis)
  • Cervical rib
  • Neck artery dissection or aneurysm
  • Vertebral fracture

Dr Baluch is a GP in London

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This is an updated version of an article that was first published in September 2012.

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