Neck pain (approach)

The regional approach hub for neck pain. Most neck pain is non-specific (facet-joint) dysfunction; disc disorders are common in the lower cervical spine; spondylosis is very common after 55 (>25% on imaging, rising with age). For neck pain after an acceleration-deceleration mechanism (a car crash), see Whiplash-Associated Disorder.

Diagnostic strategy (Murtagh)

• Probability: non-specific/vertebral dysfunction, traumatic strain/sprain, cervical spondylosis.
• Serious, not to miss: ACS (referred), neoplasia, osteomyelitis, meningitis, fracture.
• Pitfalls: disc prolapse (cervical radiculopathy), myelopathy, cervical lymphadenopathy, fibromyalgia, PMR, ankylosing spondylitis, RA, Paget disease.
• Masquerades: depression, thyroid disease (thyroiditis).

Red flags: major trauma, age >50, constant day-and-night pain, fever, anterior neck pain, cancer/weight loss, neurological deficit, and RA or Down syndrome (atlantoaxial instability).

Down syndrome: atlantoaxial (C1–2) subluxation from odontoid hypoplasia can cause sudden death — flexion/extension lateral C-spine X-rays detect it.

A useful three-question framework for triaging non-specific neck pain: does the pain represent a medical emergency; does it need imaging or further investigation; and does it need specialist input? Emergency features include sudden-onset, unilateral “tearing” pain with headache and vertigo (vascular dissection); posterior neck rigidity with a rapidly declining conscious state (meningitis — a positive Kernig’s sign should prompt urgent lumbar puncture and antibiotics); acute limb weakness across more than one myotome (stroke); and, rarely, neck pain as an atypical presentation of myocardial ischaemia, almost always alongside more typical cardiac features. Fever with severe, acute posterior neck pain and restricted movement suggests an extradural abscess and needs MRI, not plain film. Early-morning stiffness improving through the day points to a rheumatological cause (RA, ankylosing spondylitis, polymyalgia rheumatica); an abnormal neck posture with tremor or autonomic symptoms should raise cervical dystonia or a movement disorder.

Management

For chronic non-specific neck pain, exercise therapy has moderate-quality evidence: cervico-scapulothoracic and upper-limb strengthening/endurance programs reduce pain and improve function, and combined strengthening/ stretching regimens help from immediate post-treatment through to long-term follow-up. Evidence specifically for acute neck pain is lacking, and stretching alone shows little benefit. Reassurance, activity modification rather than strict rest, and simple analgesia remain first-line for non-specific/facet- joint dysfunction while exercise-based management is arranged.

Examination

Look/feel/move the cervical spine and shoulders; assess ROM and neurology of the upper limbs. Spurling’s test for radiculopathy: extend and laterally flex the neck, then apply gentle axial compression — reproduction of radicular arm pain is positive (see Cervical radiculopathy).