Neck pain
History of trauma or whiplash?
High risk factors?
Age 65 years or older?
Dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head (eg diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, an accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)?
Paraesthesia in the upper or lower limbs?
- > Spinal immobilisation and refer for imaging
Low-risk factors:
- Involved in a minor rear-end motor vehicle collision?
- Comfortable in a sitting position?
- Ambulatory at any time since the injury?
- No midline cervical spine tenderness?
- Delayed onset of neck pain?
If at least one low-risk factor, assess range of neck rotation:
Can actively rotate neck 45 degrees to the left and right?
Advised:
Reassured, C-spine is 'cleared'
Early return to normal activities
To consider physio and acupuncture
If patient cannot achieve 45 degrees of rotation on either side?
-> Spinal immobilisation and refer
Cervical radiculopathy?
(Note: Commonly due to a combination of cervical disc herniation and degenerative changes with compression of the dorsal sensory or ventral motor roots of cervical spine, prognosis not as good as axial pain)
Pain radiating down arm in a dermatomal distribution?
Occipital headache?
Inter-scapular pain?
Motor symptoms (less common but have myotomal distribution)?
C5-T1 (most commonly affected, although > 50% will have multiple nerve roots involved and there is considerable dermatomal overlap)?
-> C-spine X-rays and other imaging modalities not routinely required for diagnosis
< 4-6 weeks and no objective neurological signs:
Reassured, encouraged normal activities and work, advised the use of a firm pillow
Simple analgesics; avoid the use of cervical collars; consider physio and home exercises
>4-6 weeks or objective neurological signs:
Refer for further assessment and MRI
Weak evidence for epidural steroid injection but overall no clear evidence to support surgical vs non-operative measures
Consider neuropathic drug
Non-specific/simple neck pain including acute torticollis?
Advised:
Reassurance
Normal activities and work
Firm pillow
Advise neck exercises (leaflet or video)
Simple analgesics, topical NSAIDs
Referral to physiotherapy +/or psychology if pain persists beyond 6 weeks
Pain clinic referral if pain persists beyond 12 weeks
Red flag syndromes/pathologies?
Cervical myelopathy (a clinical syndrome indicating spinal cord compression)?
(Note: most common causes are metastatic spinal cord compression, disc herniation and spondylosis (often in combination with congenital stenosis))
Clumsy/weak hands and feet?
Decreased dexterity?
Unsteady gait?
Difficulty with daily tasks?
Disturbance of bladder or bowel function (late presentation)?
UMN signs in all limbs (particularly in legs)?- Spastic weakness?
- Clonus (> 3 beats)?
- Bisk reflexes?
- +ve Babinski reflex?
Romberg’s sign (may be positive)?
Toe/heel walking (may be difficult)?
(Note: most common causes are metastatic spinal cord compression, disc herniation and spondylosis (often in combination with congenital stenosis))
-> Urgent referral for same-day imaging
Cancer?
(Note: Spinal malignancy without cord compression - often metastatic)
History of, or suspected cancer?
Intractable, unremitting or increasing pain or night pain?
Weight loss?
Exquisite local tenderness over vertebral body?
History of, or suspected cancer?
Infection?
(Note: Meningitis, discitis, osteomyelitis, spinal or epidural abscess)
Recent infection (eg TB, immunosuppression or IV drug use)?
Intractable, unremitting or increasing pain or night pain?
Exquisite local tenderness over vertebral body?
Fever, malaise, weight loss?
Spinal fracture?
History of trauma?
(Note: Beware the elderly patient with osteoporosis (or risk factors for OP) who presents with severe pain and a history of very mild trauma eg. missing a step)
Cervical radiculopathy?
(Note: Commonly due to a combination of cervical disc herniation and degenerative changes, prognosis not as good as axial pain
Pain radiating down arm in a dermatomal distribution?
Occipital headache?
Inter-scapular pain?
Motor symptoms (less common but have myotomal distribution)?
C5-T1 (most commonly affected, although > 50% will have multiple nerve roots involved and there is considerable dermatomal overlap)?
-> C-spine X-rays and other imaging modalities not routinely required for diagnosis
< 4-6 weeks and no objective neurological signs:
Reassured, encouraged normal activities and work, advised the use of a firm pillow
Simple analgesics; avoid the use of cervical collars; consider physio and home exercises
>4-6 weeks or objective neurological signs:
Refer for further assessment and MRI
Weak evidence for epidural steroid injection but overall no clear evidence to support surgical vs non-operative measures
Consider neuropathic drug
Non-specific/simple neck pain including acute torticollis?
Advised:
Reassurance
Normal activities and work
Firm pillow
Advise neck exercises (leaflet or video)
Simple analgesics, topical NSAIDs
Referral to physiotherapy +/or psychology if pain persists beyond 6 weeks
Pain clinic referral if pain persists beyond 12 weeks
Resource(s):
NICE CKS 2018 (cervical radiculopathy)NICE CKS 2018 (whiplash) (torticollis)