Neck Pain Care Pathway

4. Differential Diagnosis Requiring Medical Attention

 

Red Flags: Immediate Referral to Emergency Care:

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1. Cervical Myelopathy

• Pain Location: Neck pain may or may not be present.

• Signs/Symptoms/Red Flags: Wide-based disturbances, hand clumsiness, non-dermatomal numbness or weakness in upper and lower extremities, bowel/bladder dysfunction.

• Physical and Neurological Examination: Hyperreflexia, hypertonia, pathological reflexes, finger escape sign, lower extremity weakness, positive L’Hermitte sign.

• Action: Immediate referral to emergency care.

 

2. Meningitis

• Pain Location: Neck stiffness, generalized headache.

• Signs/Symptoms/Red Flags: Severe headache worse with neck flexion, fever, vomiting, rash, altered mental status, lethargy or drowsiness, photophobia, flexed hip and knee posturing.

• Physical and Neurological Examination: Positive Brudzinski sign, positive Kernig sign.

• Action: Immediate referral to emergency care.

 

3. Spinal Infection

• Pain Location: Neck pain and stiffness.

• Signs/Symptoms/Red Flags: Progressive or constant pain, pain worse at night, unexplained constitutional symptoms (e.g. fever/chills), immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

• Physical and Neurological Examination: Tenderness on palpation or tap test, possible redness or heat.

• Action: Immediate referral to emergency care.

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4. Intracranial/Brain Lesion

• Pain Location: Headache, may or may not be accompanied by neck pain.

• Signs/Symptoms/Red Flags: Sudden intense generalized headache (thunderclap); unexplained headache, dizziness, or visual changes; aggravated by coughing or straining; worse in the morning or after prolonged recumbency; possible vomiting or focal neurological signs.

• Physical and Neurological Examination: Headache provoked by forward bending; possible cranial nerve abnormalities, papilledema, motor and sensory deficits in limbs, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad – hypertension, bradycardia, irregular respirations).

• Action: Immediate referral to emergency care.

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5. Vertebral/Carotid Artery Dissection

• Pain Location: Neck pain, may or may not be accompanied by headache.

• Signs/Symptoms/Red Flags: Severe neck pain or headache (“worst pain ever”); double vision, difficulty swallowing, speaking, walking; dizziness, drop attacks, facial numbness, nausea, nystagmus.

• Physical and Neurological Examination: Facial sensory deficits, contralateral trunk sensory deficits, focal neurological signs.

• Action: Immediate referral to emergency care.

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6. Traumatic Fracture

• Pain Location: Localized pain in the neck.

• Signs/Symptoms/Red Flags: Sudden onset of severe pain following trauma, age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed collision), extremity weakness/tingling/burning, inability to rotate neck 45° left and right, midline cervical spine tenderness.

• Physical and Neurological Examination: Point tenderness over the affected vertebra, extremity neurological signs (weakness/tingling/burning).

• Action: Immediate referral to emergency care.

 

Refer to Medical Provider:

 

1. Non-traumatic Spinal Fracture

• Pain Location: Localized pain in the neck.

• Signs/Symptoms: Sudden onset, severe pain, osteoporosis, corticosteroid use, female sex, age >60 years, history of spinal fracture or cancer.

• Physical and Neurological Examination: Point tenderness over the affected vertebra, inability to rotate neck 45° left and right, possible extremity neurological signs (weakness/tingling/burning).

• Action: Referral to appropriate medical provider.

 

2. Spinal Malignancy

• Pain Location: Severe, progressive, localized neck pain.

• Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, fever).

• Physical and Neurological Examination: Localized tenderness, possible neurological deficits.

• Action: Referral to appropriate medical provider.

 

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis):

• Pain Location: Neck pain, may radiate to shoulders and upper back.

• Signs/Symptoms: Morning stiffness >1 hour, pain improves with activity, pain worse at night, presence of other inflammatory signs (e.g., uveitis, psoriasis), systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Possible reduced neck mobility, tenderness over cervical spine and other joints.

• Action: Referral to appropriate medical provider.

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2. Rheumatoid Arthritis

• Pain Location: Diffuse joint pain including the neck.

• Signs/Symptoms: Symmetrical joint pain, morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Joint swelling, tenderness, and deformity.

• Action: Referral to appropriate medical provider.

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3. Systematic Lupus Erythematosus (SLE)

• Pain Location: Can include neck and other joints.

• Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.

• Action: Referral to appropriate medical provider.