II. Causes: Serious and Neck Pain Red Flags

  1. See Low Back Pain Red Flag
  2. General higher risks for non-musculoskeletal cause
    1. Patient under age 20 years or over age 50 years
    2. Systemic disease signs or symptoms
  3. Cervical Spine Trauma
    1. See Cervical Spine Injury
    2. See Pediatric Cervical Spine Injury
    3. Vertebral Fracture
    4. Spinal Cord Syndrome
    5. For those at risk, minor Trauma may cause significant Spinal Injury (Vertebral Fractures, ligamentous instability)
      1. Rheumatoid Arthritis
      2. Trisomy 21 (Atlantoaxial Instability)
      3. Marfan Syndrome
      4. Elderly patient with fall from standing
      5. C-Spine Trauma with MRI demonstrating Ligamentous Injury (e.g. children with SCIWORA)
  4. Spinal Infection (e.g. Spinal Osteomyelitis, Spinal Epidural Abscess, Discitis) or Meningitis
    1. Fever
    2. Meningismus
    3. Nuchal Rigidity without neck injury
    4. Risk Factors (e.g. Intravenous Drug Abuse, AIDS, Hemodialysis, Alcoholism, Parapharyngeal Abscess)
  5. Rheumatologic Conditions
    1. Polyarthritis
    2. Morning stiffness
    3. Rheumatoid Arthritis
    4. Spondyloarthropathy (e.g. Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, Inflammatory Bowel Disease)
  6. Tumors of the Spine (e.g. Spine Metastases, Multiple Myeloma, chordoma)
    1. Malignancy History
    2. Anorexia or weight loss
    3. Fever
    4. Night pain
    5. Intractable pain not relieved with rest
  7. Myelopathy (spinal tract related neurologic defects)
    1. See Transverse Myelitis
    2. See Spinal Cord Syndrome
    3. See Central Cord Syndrome
    4. See Amyotrophic Lateral Sclerosis
    5. See Upper Motor Neuron Deficit (hyperreflexia, Clasp-knife spasticity, positive babinski reflex)
    6. Deep aching Neck Pain (with or without radicular pain)
    7. Muscle Weakness
    8. Ataxia or other Abnormal Gait
    9. Bowel or Bladder dysfunction
    10. Tremor
  8. Vascular Neck Pain (or associated CNS symptoms)
    1. See Vertebral Artery Injury in Blunt Neck Trauma
    2. See Traumatic Carotid Dissection
    3. Vertebrobasilar dissection (e.g. following Chiropractic Manipulation)
    4. Carotid Stenosis
    5. Neck sensation of ripping or tearing pain
    6. Diplopia
    7. Headache
    8. Syncope
    9. Vertigo
    10. Tranisent Ischemic Attack Symptoms
    11. Cognitive changes (e.g. Altered Level of Consciousness)
  9. Thoracic Outlet Syndrome
    1. Paresthesias or pain worse with use
    2. Unilateral symptoms in most cases
    3. Vascular involvement is uncommon (<5%), but may be associated
  10. Referred Neck Pain
    1. Coronary Artery Disease
    2. Biliary Colic or Cholecystitis (typically pain radiates to right Shoulder)
    3. Herpes Zoster (Shingles)
    4. Pneumothorax
    5. Pulmonary Embolism
      1. Lee (2017) Medicine 96(42): e8288 +PMID:29049229 [PubMed]

III. Causes: Musculoskeletal Neck Pain

  1. Cervical Disc Disease
    1. Neck tight or stiff
    2. Radicular pain, Paresthesias or weakness into Shoulder and arm
    3. Worse with activity, on awakening, with neck extension and with coughing, sneezing, or straining
  2. Cervical Spondylosis
    1. Older patients with disc Degeneration, disc space narrowing with osteophytes and nerve root compression
    2. Disc pain is worse with Cervical Spine flexion, while facet pain is worse with extension
  3. Cervical Neck Strain (or Whiplash)
  4. Vertebral Compression Fracture
  5. Cervical Spine Fracture (see above)

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