Signs or Symptoms of Pathology (Red Flags)

 

Clinical Cornerstone: Consider asking additional questions that help evaluate for the presence of red flags in neck pain. Red flags are symptoms or signs that may indicate a serious pathology and should be deliberated in the clinician’s differential diagnosis.

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• Spinal fracture

  • Red flags: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, paresthesias in extremities, inability to actively rotate the neck 45 degrees to the left and right (Canadian C-Spine Rule).

  • Action: Refer to appropriate provider for imaging especially if pain is sudden in onset and pain is severe.

 

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• Spinal malignancy

  • Red flags: history of cancer, unexplained weight loss, unexplained significant night sweats, pains worse at night, progressive headaches worse with exertion.

  • Action: Refer to an appropriate provider.

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• Spinal infection

  • Red flags: intravenous drug use, poor living conditions, immunosuppression, recent surgery/invasive interventions, history of TB/born in TB-endemic country, recent infection, unexplained constitutional symptoms (e.g. fever/chills).

  • Action: Immediate emergency referral.

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• Cervical myelopathy

  • Red flags: gait disturbances, hand clumsiness, non-dermatomal numbness, weakness or numbness and weakness involving  lower extremity / bowel / bladder, coordination problems.

  • Action: Immediate emergency referral.

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• Meningitis

  • Red flags: neck stiffness, severe generalized headache that is worse with flexion, neck pain or headache with fever or  vomiting or rash,  altered mental status, photophobia.

  • Action: Immediate emergency referral.

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• Vertebral / Carotid Artery Dissection

  • Red flags: severe neck pain and/or headache (described as the worst pain ever), double vision, difficulty initiating swallowing, dizziness, drop attacks,facial numbness, difficulty walking, nausea, nystagmus.

  • Action: Immediate emergency referral.

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• Intracranial / Brain Lesion

  • Red flags: sudden and intense onset headache (thunderclap headache).

  • Action: Immediate emergency referral.

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• Neurological disorders (e.g., MS, ALS, neurodegenerative disorders)

  • Red flags: upper/lower motor neuron findings, clonus.

  • Action: Refer to appropriate provider.

Orange Flags

 

Clinical Cornerstone: Orange Flags are symptoms or signs that may represent the presence of serious psychiatric disorder (e.g., major depression, major personality disorders, post-traumatic stress disorders [PTSD], substance addiction and abuse). In the event such disorders are present, referral to a psychiatric specialist would be indicated over usual care in the presence of non-major disorders such as anxiety. Screening can include:

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• High level of distress, Substance addiction or abuse

• PHQ-9 for depression

• GAD-7 for PTSD