Neck Pain

  1. In patients with non-traumatic neck pain, use a focused history, physical examination and appropriate investigations to distinguish serious, non-musculoskeletal causes (e.g., lymphoma, carotid dissection), including those referred to the neck (e.g., myocardial infarction, pseudotumour cerebri) from other non-serious causes.
  2. In patients with non-traumatic neck pain, distinguish by history and physical examination, those attributable to nerve or spinal cord compression from those due to other mechanical causes (e.g., muscular).
  3. Use a multi-modal (e.g., physiotherapy, chiropractic, acupuncture, massage) approach to treatment of patients with chronic neck pain (e.g., degenerative disc disease +/- soft neuro signs).
  4. In patients with neck pain following injury, distinguish by history and physical examination, those requiring an X-ray to rule out a fracture from those who do not require an X-ray (e.g., current guideline/C-spine rules).
  5. When reviewing neck X-rays of patients with traumatic neck pain, be sure all vertebrae are visualized adequately.

General Overview

  • Temporal
    • Acute <6w
    • Subacute 6w-6mo
    • Chronic >6mo
  • Origin
    • Axial Neck Pain Syndromes
      • Cervical strain
      • Cervical spondylosis
      • Cervical discogenic pain
      • Cervical facet syndrome
        • Whiplash injury
      • Cervical myofascial pain
      • Diffuse skeletal hyperostosis
    • Extremity pain/neurological deficit
      • Cervical spondylotic myelopathy
      • Cervical radiculopathy
      • Brachial plexus injury (eg. burner/stinger)
    • Non-spinal
      • Thoracic outlet syndrome
      • Herpes Zoster
      • Diabetic neuropathy
      • Other (Malignancy, vascular, cardiovascular -MI, carotid/basilar artery dissection, infection, visceral, referred, rheumatologic, neurologic)

Red Flags

  • Trauma
  • Cancer or constitutional symptoms
  • Infectious symptoms, Immunosuppression or IVDU (Epidural abscess, discitis)
  • Neurological signs/symptoms (cord compression, demyelinating process)
  • Severe ripping neck pain, unstable (carotid/vertebral dissection)
  • Chest pain, SOB, diaphoresis (MI)
  • History of rheumatoid arthritis (atlanto-axial disruption)

Physical Exam

  • Neck
    • Observation - posture, symmetry, muscle bulk, scars
    • ROM in all planes
    • Palpation of cervical spine, r/o focal tenderness
      • Palpation of trapezius and paraspinal muscles
      • Lymphadenopathy
    • Neurological examination of upper limbs (strength, sensory, reflex)
      • C1, C2 - Neck flexion
      • C3 - Neck lateral flexion
      • C4 - Shoulder elevation (Trapezius)
      • C5 - Shoulder abduction/external rotation, bicep reflex
      • C6 - Biceps/brachioradialis reflex
      • C7 - Triceps reflex
      • C8 - Finger abduction, grip
      • T1 - Hand intrinsics
    • Provocative manoeuvres (not sensitive)
      • Spurling (cervical root compression)
        • Head flexed, ipsilaterally rotated and tilted, with axial loading
      • Upper limb tension test (equivalent of straight leg raise for arm)
        • Wrist supinated, shouder abducted, elbow extended, and neck lat flexion to contralateral side
      • Manual neck distraction test
        • Vertical traction on head - and pain relieved
  • Examine shoulder

Clear C-spine Injury

  • Consider NEXUS criteria (caution using criteria in <2yo, and>65yo)
    • Neuro deficit (focal)
    • Spinal (midline) tenderness
    • Altered LOC
    • Intoxication
    • Distracting injury
      • There is some data showing that you may consider clearing C-spine even in distracting injury
  • Consider Canadian C-Spine Rule in alert, stable trauma patients (excluded known spine disease/surgery, non-trauma, GCS<15, age <16 years - consider NEXUS)
    • Can clear C-spine if no high risk factor:
      • Age ≥ 65 years
      • Extremity paresthesias
      • Dangerous mechanism (Fall ≥3 ft/5 stairs, axial load to head [eg. diving], MVC >100km/h or rollover or ejection, motorized recreational vehicles, bicycle crash)
    • One low risk factor present AND able to actively rotate neck 45° left and right:
      • Sitting position in the ED
      • Ambulatory at any time
      • Delayed (not immediate onset) neck pain
      • No mid-line tenderness
      • Simple rear-end motor vehicle collision


  • Blunt Trauma
    • Lateral, AP, odontoid X-ray
      • High risk mechanism
      • Multiple system trauma with comorbid injuries to head, face, torso
      • Conditions that predispose C-spine injury (Down syndrome)
      • AMS (GCS 14)
      • Neck pain, tenderness, deformity, limited ROM
    • Flexion-extension X-ray
      • Normal C-spine X-ray and no neuro deficit, continued pain/tenderness, and able to flex and extend neck
    • CT C-spine
      • Acute neuro deficit
      • GCS 3-13
      • Abnormal/suspicious C-spine X-ray
    • MRI if abnormal neurological exam and if requires spinal cord imaging
  • Consider initial five-view X-ray (odontoid, lateral, PA, and both oblique views) in non-traumatic neck pain if
    • Age >50yo with new symptoms
    • Constitutional symptoms
    • History of malignancy
    • Moderate-severe pain >6w
    • Progressive neurological findings
    • Infectious risk
  • Not required in cervical radiculopathy (motor/sensory/reflex deficits) UNLESS (consider MRI)
    • Trauma
    • Persistent symptoms >4-6w of treatment
    • Red flag (malignancy, myelopathy, abscess)
  • MRI in all progressive neurological deficits, suspicion of infection/malignancy, or significant pain >6w
  • Consider EMG if pain and dysesthesia in extremities


  • Early return to usual activities
    • Home exercises
    • Soft collar not recommended (unless few days)
  • Tylenol, NSAIDs, muscle relaxant for initial 4 days
  • Second-line
    • Manual Physiotherapy
      • Consider multimodal (physiotherapy, chiropractic, acupuncture, massage) for chronic neck pain
    • Augment pain control
      • Tramadol
      • TCA, Venlafaxine
  • Refer Physiotherapy / Neurosurgery / Neurology

Pre-vertebral soft tissue

  • Above C4 ≤ 1/3rd vertebral body width
  • Below C4 ≤ 100% vertebral body width

Consider CT scan if abnormal swelling and no obvious fracture on X-ray