Neck Pain Algorithm

Safety

Exclude emergencies & can't-miss diagnoses first

Done

The neck is anatomically dense — the spinal cord, great vessels, oesophagus, and thyroid all lie within centimetres of each other. Screen for vascular, neurological, and malignant emergencies before any further assessment.

Cervical myelopathy Bilateral hand symptoms or clumsiness, dropping objects, gait disturbance or imbalance, leg weakness or stiffness, brisk reflexes, extensor plantars, Hoffmann's sign in context, sensory level, Lhermitte's phenomenon, bladder/bowel disturbance → suspected cervical myelopathy: discuss with the on-call spinal team the same day; urgent specialist assessment and cervical MRI. Same-day emergency assessment for rapidly progressive neurological deterioration, significant weakness, gait failure, new bladder/bowel dysfunction, respiratory/bulbar symptoms or acute cord compression. Slowly progressive or stable myelopathic features still need same-day discussion and urgent referral — not routine mechanical neck pain

Vertebral artery dissection Sudden severe neck or occipital pain with vertigo, diplopia, ataxia, dysarthria, facial numbness, Horner syndrome, retinal/brain ischaemic symptoms or recent neck trauma/manipulation → immediate emergency assessment (999). Avoid neck manipulation until serious vascular and cervical-spine causes have been excluded

Epidural abscess / discitis Severe neck pain + fever ± neurological deficit → suspected spinal epidural abscess or discitis requires same-day hospital assessment, urgent inflammatory markers and MRI through the acute medical/spinal pathway. Blood cultures before antibiotics where this does not delay treatment. CRP/WCC may be only mildly raised or initially normal. Risk factors: recent spinal procedure or injection, bacteraemia, immunosuppression, diabetes, IV drug use, recent infection, endocarditis risk, vertebral instrumentation

Cervical fracture / instability Trauma (RTA, fall, contact sport, diving) → for alert and stable adults after blunt trauma, use the Canadian C-spine rule within the local trauma pathway. Maintain spinal precautions and arrange emergency assessment/imaging if high-risk features (age ≥65, dangerous mechanism, paraesthesia in the limbs), neurological symptoms or inability to assess safely (unstable, intoxicated, confused). CT is usually the first imaging test; MRI if neurological abnormalities. Do NOT examine ROM in acute post-trauma neck pain until fracture excluded

Carotid artery dissection Unilateral neck pain + Horner's syndrome (ptosis, miosis, anhidrosis) ± contralateral hemiplegia/facial droop → 999 stroke pathway. May follow minor trauma or sudden neck movement. Pulsatile tinnitus may occur but is non-specific

Meningitis / subarachnoid haemorrhage Neck stiffness + headache + photophobia + fever (meningitis) OR thunderclap headache + meningism (SAH) → 999. Suspected bacterial meningitis or meningococcal disease requires emergency transfer to hospital — do not delay transfer to give antibiotics. If meningococcal disease is strongly suspected, give IV/IM ceftriaxone or benzylpenicillin as soon as possible unless this delays transfer or there is severe allergy; for suspected bacterial meningitis, pre-hospital antibiotics are generally reserved for a clinically significant delay in transfer (NICE NG240). Do not rely on Kernig's or Brudzinski's signs — their absence does not exclude meningitis

Cervical malignancy / metastasis Age >50, known cancer, progressive unrelenting pain, night pain, weight loss, lymphadenopathy, bony tenderness → known or suspected cancer plus neurological symptoms/signs of cord compression (new gait disturbance, difficulty walking, limb weakness, sensory loss or paraesthesia, radicular pain, bladder or bowel dysfunction): contact the local MSCC coordinator immediately; oncological emergency; MRI whole spine as soon as possible and always within 24 hours. Spinal pain suggestive of metastases without neurological symptoms: contact the MSCC service/oncology pathway promptly; MRI whole spine within 1 week (NICE NG234). Not a routine GP MRI request. Do not routinely start corticosteroids without discussion with the MSCC/oncology pathway — follow the local MSCC protocol. Cervical spine is a common site for metastatic deposit (breast, prostate, lung, thyroid, kidney)

Retropharyngeal / peritonsillar abscess Neck pain + severe dysphagia + drooling + muffled voice + trismus + systemic sepsis → 999. Airway compromise can develop rapidly. Do NOT attempt to examine throat alone — senior review essential

Vertebral artery dissection is a dangerous missed diagnosis in neck pain — it is an important cause of stroke in younger adults and can follow seemingly minor neck trauma or manipulation. The posterior circulation stroke symptoms (vertigo, diplopia, dysphagia, ataxia) may be subtle and transient initially, making this a particularly hazardous diagnosis to miss. Cervical myelopathy is insidious — patients often attribute hand clumsiness and gait changes to age, and the diagnosis is often delayed. Any patient with bilateral upper limb symptoms or gait change with neck pain must be discussed with the on-call spinal team the same day and referred urgently. The Canadian C-spine rule applies to alert, stable adults after blunt trauma within the trauma pathway — it does not replace trauma-system assessment in an unstable, intoxicated, confused or otherwise unassessable patient.

Diagnose

Structured history — mechanism, radiation pattern, and neurological symptoms

Done

Radiation pattern and neurological symptoms are the most powerful history discriminators. Non-specific neck pain (by far the most common) is a diagnosis of exclusion — confirm absence of serious features first.

Onset & mechanism

Acute (trauma, whiplash, disc prolapse, infection): immediate referral considerations. Insidious gradual (cervical spondylosis, OA, posture-related, inflammatory arthritis). Episodic (cervicogenic headache, facet joint pain, muscle tension). Sudden severe = vascular emergency until proven otherwise

Pain location & radiation

Axial neck only: mechanical (muscle, facet joint, discogenic). Neck → shoulder/scapula: C4–C5 referral pattern, supraspinatus pathology overlap. Neck → arm in dermatomal pattern: cervical radiculopathy (C5–C8 most common). Neck → occipital head: C2/C3 referral, cervicogenic headache. Neck → bilateral arms + legs: myelopathy — same-day spinal discussion, urgent referral

Dermatomal pattern

C5: lateral upper arm, shoulder abduction weakness, biceps reflex ↓. C6: lateral forearm, thumb/index, biceps reflex ↓, wrist extension weakness. C7: middle finger, triceps reflex ↓, wrist flexion/finger extension weakness. C8: medial forearm, ring/little finger, grip weakness. T1: medial upper arm, intrinsic hand weakness

Neurological symptoms

Unilateral arm numbness/tingling (radiculopathy — C5–C8). Bilateral hand clumsiness / dropping objects (myelopathy — same-day spinal discussion). Gait disturbance / leg weakness (myelopathy — same-day spinal discussion). Bladder/bowel dysfunction (myelopathy / cord compression — emergency). Lhermitte's sign (electric shock on flexion — cord involvement)

Aggravating / relieving

Worse with neck extension/rotation (facet joint, foraminal stenosis). Worse with sustained posture (muscle tension, discogenic). Worse with Valsalva/cough/sneeze (discogenic — raised intradiscal pressure). Relieved by traction (radiculopathy — shoulder abduction relief sign positive). Night pain worse = inflammatory / malignancy (alarm)

Headache pattern

Occipital headache starting in neck, unilateral, triggered by neck movement = cervicogenic headache (C2/C3). Distinguish from migraine (aura, nausea, photophobia) and tension-type. Do not confuse with posterior circulation stroke symptoms

Whiplash specific

Mechanism (RTA — direction of impact, head restraint position, airbag deployment). Quebec Classification (descriptive only — does not by itself determine treatment): Grade 1 (complaint only), Grade 2 (MSK signs), Grade 3 (neurological signs), Grade 4 (fracture/dislocation). Psychosocial yellow flags: catastrophising, fear-avoidance, passive coping — predict chronic pain and disability

Systemic features

Fever / rigors (infection — epidural abscess, discitis, meningitis). Weight loss (malignancy). Night sweats (lymphoma, malignancy). Prior malignancy (metastasis). Inflammatory arthritis history (RA atlantoaxial instability — significant risk). Steroid use (epidural abscess risk ↑, osteoporotic fracture). Spinal infection risk factors: recent spinal procedure/injection, bacteraemia, immunosuppression, diabetes, IV drug use, recent infection, endocarditis risk, vertebral instrumentation

Occupation & lifestyle

Prolonged screen use (postural). Heavy manual work (cervical spondylosis, disc disease). Contact sports (acute injury). Occupation as key yellow flag: work dissatisfaction and poor social support predict chronicity more reliably than physical findings

Yellow flags (psychosocial)

Fear-avoidance beliefs (pain with activity = damage). Catastrophising ("this will never get better"). Depression / anxiety. Passive coping strategies. Job dissatisfaction. Poor social support. Litigation / compensation claims. Screen with Keele STarT MSK tool (also validated for neck pain)

Psychosocial yellow flags are better predictors of chronic disability from neck pain than any physical examination finding or imaging result. The STarT MSK tool risk-stratifies patients into low/medium/high psychosocial risk — high-risk patients need early psychology/pain management input, not just physiotherapy, to prevent the transition to chronic pain. Dermatomal pattern recognition is a core GP SCA competency: C7 is the most commonly affected root (C6/C7 disc = C7 radiculopathy), followed by C6 (C5/C6 disc) (Radhakrishnan et al., Brain 1994). The shoulder abduction relief sign (patient abducts arm to rest hand on head and pain improves) may support cervical radiculopathy, but no single bedside test is diagnostic; imaging decisions depend on the whole clinical picture, severity, progression and referral pathway. RA atlantoaxial instability is a critical and often forgotten hazard: RA erodes the transverse ligament of C1, causing C1–C2 instability that can cause sudden death with minor neck trauma — it must be screened in any RA patient with new neck symptoms.

Diagnose

Classify by presentation type — mechanical vs radicular vs myelopathic vs inflammatory

Done

Use this four-category classification to direct investigation and management. Most neck pain is non-specific mechanical — do not over-investigate or over-treat. Infection, malignancy/MSCC and vascular/intracranial emergencies are covered in Step 1.

🟢 Non-specific mechanical neck pain

The commonest diagnosis. Axial neck pain ± referred shoulder/scapular ache (non-dermatomal). No neurological deficit. Normal reflexes. Causes: muscle strain, facet joint dysfunction, poor posture, psychological tension. Duration: acute (<6 weeks), subacute (6–12 weeks), chronic (>12 weeks). Generally favourable prognosis

🟡 Cervical radiculopathy

Dermatomal arm pain (usually > neck pain), paraesthesia, ± weakness in myotomal distribution. C5–C8 nerve roots. Most common: C7 (C6/C7 disc), then C6 (C5/C6 disc). Spurling's test, shoulder abduction relief sign or upper limb tension test (ULTT) may support the diagnosis but none is diagnostic alone. Stable radiculopathy is generally managed conservatively; refer if pain is uncontrolled, symptoms are disabling or there are gait disturbance, clumsy/weak hands or legs, brisk reflexes, extensor plantars or new bladder/bowel disturbance (NICE NG127)

🔴 Cervical myelopathy

Same-day discussion with the on-call spinal team; urgent specialist assessment + MRI; same-day emergency assessment if rapidly progressive, gait failure, new bladder/bowel or respiratory/bulbar symptoms. Bilateral upper limb symptoms + lower limb signs. Gait disturbance, clumsy hands, Lhermitte's sign, hyperreflexia (lower limbs), Hoffmann's sign, upgoing plantars. Caused by cervical cord compression (spondylotic stenosis, OPLL, disc herniation). Onset often insidious — high index of suspicion required. MRI confirms. Management is specialist-led

🟠 Cervicogenic headache

Unilateral headache starting in occipital region radiating frontally, triggered by neck movement / sustained posture, associated neck stiffness. C2/C3 referral. Cervicogenic headache is a clinical diagnosis after excluding primary headache and secondary causes. Consider physiotherapy-based exercise and manual therapy where appropriate, but do not use treatment response to establish the diagnosis. Manage headache according to the presenting phenotype and local headache guidance

🔵 Whiplash-associated disorder

Following acceleration-deceleration trauma (typically RTA). Assess within the trauma pathway first (Canadian C-spine rule in alert, stable adults). Uncomplicated whiplash without fracture, instability or neurological deficit: reassurance, normal activity as tolerated, analgesia and gentle range-of-motion exercises. Neurological symptoms or signs, fracture or instability → emergency/specialist assessment (Quebec grade is descriptive, not a treatment rule). Yellow flags predict chronicity: catastrophising, fear-avoidance, early sick certification. Active engagement and early return to normal activities is the evidence-based management goal

🟣 Inflammatory / systemic neck pain

RA: atlantoaxial instability (odontoid erosion) — subluxation risk with trauma/anaesthesia. Symptoms or signs suggestive of cervical myelopathy → urgent MRI and specialist surgical opinion (NICE NG100). Imaging is symptom-led and specialist-directed; avoid flexion/extension views where instability is a concern without specialist advice. Axial spondyloarthritis / ankylosing spondylitis: can affect all sexes and ages (often missed in women), inflammatory back/neck pain, SI involvement. PMR: bilateral shoulder girdle + neck, age >50, dramatic steroid response. Malignancy: constant unremitting pain, worse at night, known primary, weight loss

The most dangerous misclassification is labelling early myelopathy as non-specific neck pain. Myelopathy has an insidious onset, and patients do not volunteer symptoms of hand clumsiness or gait change unless specifically asked — these symptoms must be actively sought at every neck pain consultation. The natural history of untreated myelopathy is stepwise deterioration punctuated by sudden neurological deterioration events (often triggered by minor trauma such as a fall or motor vehicle accident). Early specialist assessment aims to prevent these events. Cervicogenic headache is a clinical diagnosis after excluding primary and secondary headache causes; physiotherapy-based exercise and manual therapy may help where appropriate, and analgesic overuse should be avoided. Atlantoaxial instability in RA is a surgical/anaesthetic emergency hiding in plain sight — every RA patient with new neck pain must be assessed for this complication before any neck manipulation or elective anaesthesia.

Diagnose

Targeted cervical spine examination — neurological assessment is mandatory

Done

Always perform a neurological examination of the upper limbs in neck pain. Missing myelopathy signs is a serious patient safety failure.

Inspection & posture

Forward head posture (chin protruded). Torticollis (muscle spasm / atlanto-axial rotatory subluxation in children). Muscle wasting (trapezius, deltoid, intrinsic hand — suggests chronic radiculopathy). Skin: rash (meningococcal, herpes zoster — Ramsay Hunt variant)

Range of movement

Document functional limitation, restriction and pain direction rather than numerical ranges. Do NOT assess ROM in acute post-trauma neck pain until fracture excluded. Painful limitation of rotation in one direction → facet joint / spondylosis. Globally restricted ROM → severe OA, inflammatory arthritis, myelopathy, malignancy

Spurling's test (foraminal compression)

Extend and rotate neck toward affected side, apply gentle axial compression — reproduction of arm symptoms = positive. Can help reproduce radicular symptoms; perform gently. Not a required primary-care test and a negative test does not exclude radiculopathy. Do NOT perform after trauma or where instability is possible

Shoulder abduction relief sign

Ask patient to place hand of symptomatic arm on top of head — relief of arm pain = positive. May support cervical radiculopathy, but no single bedside test is diagnostic. Base imaging on the whole clinical picture, severity, progression and referral pathway

Upper limb neurology (mandatory)

Power: shoulder abduction (C5), elbow flexion (C5/6), wrist extension (C6), elbow extension (C7), finger extension (C7), grip strength (C8/T1), intrinsics (T1). Sensation: dermatomal testing with light touch / pinprick — C5 (lateral upper arm), C6 (thumb/index), C7 (middle finger), C8 (ring/little), T1 (medial upper arm). Reflexes: biceps (C5/6), supinator (C6), triceps (C7)

Myelopathy signs (mandatory)

Hoffmann's sign: flick terminal phalanx of middle finger — thumb flexion = positive (upper motor neurone sign). Hyperreflexia lower limbs: brisk knee and ankle jerks. Upgoing plantars (Babinski): UMN lesion. Clonus: sustained clonus at ankle = significant cord compression. Gait: observe walking — wide-based, spastic gait = myelopathy. Any objective upper motor-neurone sign should prompt same-day discussion with the on-call spinal team and urgent neurological/spinal referral; same-day assessment when symptoms are progressive, severe or associated with bladder/bowel, gait or respiratory dysfunction. A positive Hoffmann's sign alone is not diagnostic and needs corroborating findings

Upper limb tension test (ULTT)

Shoulder depression + abduction + elbow extension + wrist/finger extension — reproduction of arm symptoms = nerve root tension (equivalent of SLR for cervical). Most sensitive for C5/C6 radiculopathy. Useful when Spurling's negative but clinical suspicion remains

Lymph nodes

Palpate: anterior/posterior cervical chains, supraclavicular fossae. Unexplained or persistent neck lump → assess against NICE NG12 criteria (age, site, persistence, associated symptoms) for suspected cancer pathway referral (head/neck cancer, lymphoma). Tender mobile nodes = reactive (infection)

Thyroid & carotids

Palpate thyroid (goitre, nodule — if causing neck pain/dysphagia). Auscultate carotids (bruit — TIA risk). Check temporal arteries in >50 yrs with new headache + neck pain (GCA)

⚠ Canadian C-Spine Rule — alert, stable adults after blunt trauma only, within the local trauma pathway: High-risk features (age ≥65, dangerous mechanism, paraesthesia in the limbs) → maintain spinal precautions and arrange emergency assessment/imaging according to the clinical situation. Low-risk features (simple rear-end collision, ambulatory at scene, no midline tenderness) → assess ROM safely. If cannot rotate 45° bilaterally → imaging required (CT is usually first-line; MRI if neurological abnormalities or suspected cord/ligamentous injury). Not for unstable, intoxicated, confused or unassessable patients.

Hoffmann's sign is quick to check and can support a suspicion of cervical myelopathy, but alone it is not diagnostic. Combined with hyperreflexia, upgoing plantars or gait disturbance, objective upper motor-neurone signs should prompt same-day discussion with the on-call spinal team and urgent neurological/spinal referral, and same-day assessment when progressive, severe or associated with bladder/bowel, gait or respiratory dysfunction. The ULTT (upper limb tension test) is the upper limb equivalent of the SLR and can add information when Spurling's is inconclusive. Supraclavicular lymphadenopathy with neck pain is a trigger for the relevant suspected cancer pathway — the supraclavicular fossa drains thoracic and abdominal viscera, making firm nodes there a potential metastatic signal even when the primary is not in the head/neck. Temporal artery palpation takes 10 seconds but catches giant cell arteritis, which causes sudden permanent visual loss if missed.

Diagnose

Targeted investigations — most neck pain needs no imaging

Done

Non-specific mechanical neck pain does not require imaging. Degenerative changes on cervical X-ray / MRI are common with age and are not diagnostic. Image when the result will change management.

X-ray cervical spine Selective

Limited role in primary care. Acute trauma: CT is usually the first-line test when the Canadian C-spine rule indicates imaging (NICE NG41). Suspected RA cervical instability: imaging and urgent spinal review via local rheumatology/spinal pathways. Do NOT request for acute non-specific neck pain — degenerative changes correlate poorly with symptoms and increase anxiety.

MRI cervical spine Primary imaging

First-choice imaging when indicated: suspected myelopathy (urgent), progressive neurological deficit, persistent/disabling radiculopathy where specialist intervention is being considered, suspected infection (via acute pathway), suspected malignancy/MSCC (via MSCC pathway). Do not routinely request MRI for every radiculopathy at 4–6 weeks — stable radiculopathy can generally be managed conservatively (NICE NG127). MRI superior to CT for soft tissue, disc, cord pathology

CT cervical spine

Usually the initial imaging for suspected cervical spine injury in adults (NICE NG41). Alternative when MRI is unsuitable — many modern cardiac devices are MRI-conditional, so suitability requires radiology/cardiology/device-team assessment. CT myelography is a specialist decision. Do not use CT as first-line for soft tissue/disc pathology

Bloods — red flags

CRP, ESR, FBC + differential if: fever (infection — discitis/abscess; normal results do not exclude spinal infection), suspected inflammatory arthritis, malignancy screen. Raised ESR or CRP + new bilateral shoulder/neck girdle stiffness aged >50 → consider PMR (pre-steroid bloods per the PMR protocol). PSA (male >50 with bony neck pain — prostate metastasis). ALP, Ca (bone metastases, Paget's). LDH. Myeloma (may present with spinal pain): aged 60 and over with persistent bone pain or unexplained fracture → FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis and serum free light chains (NICE NG12)

Inflammatory markers — GCA

In a patient aged ≥50 with suspected GCA, take FBC, CRP and ESR if this does not delay treatment. Start glucocorticoids immediately when clinical suspicion is significant. New visual loss, transient visual symptoms or diplopia require same-day specialist/ophthalmology assessment. Use the local GCA fast-track pathway; steroid dose, taper and biopsy/imaging timing depend on the clinical phenotype and specialist pathway

Nerve conduction studies / EMG

Not first-line in primary care. Indicated by neurology if: atypical distribution, suspected peripheral neuropathy mimicking radiculopathy, suspected motor neurone disease, diagnostic uncertainty after MRI. Arrange via neurology referral

Thyroid function

TSH + T4 if goitre palpable or thyroid nodule causing neck pain/dysphagia. Urgent ultrasound thyroid for new neck mass / rapidly growing nodule. Fine needle aspiration arranged via endocrine/head and neck surgery if suspicious

Do NOT routinely order

X-ray for acute non-specific neck pain (<6 weeks, no red flags). MRI for acute whiplash grade 1–2. CT for suspected soft tissue/disc pathology (MRI preferred). Plain X-ray instead of MRI for suspected myelopathy or cord compression

Imaging paradox: Cervical MRI commonly shows "degenerative changes" in asymptomatic adults, increasingly with age. A finding on MRI is not automatically the cause of pain. Imaging should confirm a clinical hypothesis, not generate one. Over-imaging increases catastrophising, reduces return to activity, and leads to unnecessary surgery.

Routine imaging of neck pain is actively harmful. Imaging results in non-specific neck pain can increase pain catastrophising and fear-avoidance without improving clinical outcomes. "Moderate spondylosis at C5/C6" on an MRI report creates a diagnostic label that prevents recovery. The correct management for non-specific neck pain is early active rehabilitation, not passive imaging. However, the MRI paradox cuts both ways: myelopathy on clinical examination needs urgent specialist assessment and MRI (same-day if rapidly progressive or with bladder/bowel, gait or respiratory dysfunction) — delay in this direction is equally dangerous. The skill is knowing which patients to image and which not to, based on clinical findings rather than patient or clinician anxiety.

Refer

Referral criteria — right pathway, right urgency

Done

Most neck pain is managed entirely in primary care with physiotherapy and analgesia. Know the thresholds for urgent neurological and surgical escalation.

999 Emergency

999 Suspected vertebral or carotid artery dissection (posterior neck pain + stroke symptoms). Suspected meningitis / meningococcal disease (do not delay transfer; IV/IM ceftriaxone or benzylpenicillin if meningococcal disease strongly suspected and this does not delay transfer — NICE NG240). SAH (thunderclap headache + meningism). Unstable cervical fracture, spinal cord injury or airway compromise. Acute severe neurological deterioration. Suspected MSCC with rapidly progressive paralysis or sphincter dysfunction. Retropharyngeal/peritonsillar abscess with airway compromise. Sepsis or haemodynamic instability

Same-day urgent

Same-day New or progressive myelopathic signs; gait disturbance with bilateral hand symptoms → discuss with the on-call spinal team the same day (urgent specialist assessment + MRI; same-day emergency assessment if rapidly progressive or gait failure). New bladder/bowel dysfunction with cervical myelopathic signs suggests significant spinal cord dysfunction → emergency spinal assessment. Fever/systemic illness with severe neck pain; suspected epidural abscess / discitis → same-day hospital assessment + MRI via acute pathway. Known cancer + new neurological symptoms suggestive of MSCC → MSCC coordinator immediately, MRI within 24 hours. Suspected GCA with visual symptoms → same-day ophthalmology/specialist; start glucocorticoids immediately

Suspected cancer pathway

Suspected cancer Per NICE NG12 (updated April 2026): unexplained neck lump aged ≥45; persistent unexplained neck lump; persistent unexplained hoarseness aged ≥45; persistent unexplained oral ulceration; unexplained thyroid lump; unexplained lymphadenopathy, particularly generalised, persistent, supraclavicular or with systemic symptoms — consider age, site, persistence, associated symptoms and local triage. Known/suspected cancer with spinal pain suggestive of metastases but no neurological symptoms → MSCC/oncology pathway promptly; MRI whole spine within 1 week (NICE NG234). Unexplained progressive bony cervical pain + weight loss + night sweats → urgent investigation. Aged 60 and over with persistent bone pain or unexplained fracture → myeloma tests: FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis and serum free light chains (NICE NG12)

Urgent / prompt referral

Persistent or disabling cervical radiculopathy, uncontrolled pain, progressive focal weakness, or radiculopathy with brisk reflexes, gait disturbance or clumsy hands → spinal/neurosurgical referral (NICE NG127). Suspected myelopathy, even if stable → discuss with the on-call spinal team the same day; urgent specialist assessment + MRI. Suspected persistent synovitis of the small joints of the hands or feet, more than one joint, or ≥3 months since onset → urgent rheumatology referral, ideally within 3 working days (NICE NG100, QS33). PMR → start prednisolone 15 mg OD in primary care after the pre-steroid bloods; refer to rheumatology if atypical features, suspected GCA or relapse (BSR). RA with symptoms or signs suggestive of cervical myelopathy → urgent MRI + specialist surgical opinion (NICE NG100). Suspected inflammatory arthritis with cervical symptoms → rheumatology

Routine neurosurgery / spinal

Radiculopathy with persistent pain or neurological symptoms despite conservative management where specialist intervention is being considered. Recurrent severe disc prolapse. Cervical stenosis causing quality-of-life impairment

Physiotherapy First-line

All non-specific neck pain, whiplash grade 1–2, cervical radiculopathy (while awaiting / instead of surgery), cervicogenic headache, cervical spondylosis. Self-refer where NHS self-referral available. Emphasise: active exercise is first-line, not passive treatment only

Pain management / psychology

Chronic neck pain (>3 months) with high psychosocial yellow flag burden (STarT MSK high risk). Chronic pain programme via NHS Talking Therapies / pain clinic. CBT/psychological support for chronic pain (NICE NG193 applies to chronic primary pain only). Do not continue escalating analgesia without addressing psychological factors

Neurology

Diagnostic uncertainty (atypical presentation, suspected MND, peripheral neuropathy vs radiculopathy). Nerve conduction studies needed. Complex headache differential. Suspected central demyelination (multiple sclerosis — Lhermitte's sign in young patient)

Primary-care management

Uncomplicated mechanical neck pain. Stable cervical radiculopathy without objective progression. Uncomplicated whiplash after appropriate trauma assessment. Chronic neck pain with appropriate rehabilitation and psychosocial support

GCA with visual symptoms is a same-day ophthalmological emergency. Untreated GCA can cause sudden permanent visual loss, and the fellow eye is at risk. Start glucocorticoids immediately when clinical suspicion is significant, without waiting for results or biopsy, and use the local GCA fast-track pathway. For cervical radiculopathy, NICE NG127 supports conservative management initially, with referral if pain is uncontrolled, symptoms are disabling or there are myelopathic features. For whiplash, prolonged rest, collars and early long-term sick certification are associated with poorer recovery; refer for physiotherapy if symptoms persist or are disabling.

Treat

Condition-specific treatment pathways

Done

Active rehabilitation is the evidence-based foundation for all mechanical neck pain. Analgesia facilitates activity — it is not a standalone treatment. Address yellow flags early to prevent chronicity.

① Non-Specific Mechanical Neck Pain (Blanpied et al., JOSPT 2017 — international)

Step 1Reassurance + early active mobilisation: Advise: mechanical neck pain is not dangerous, continuing normal activities is the best treatment, avoiding movement makes it worse. Provide NHS patient information. Do NOT recommend collar immobilisation — prolongs disability. Return to normal activities as quickly as possible

Step 2Analgesia to facilitate movement: Paracetamol within the maximum daily dose — lower doses in low body weight, liver disease, chronic alcohol use or malnutrition; avoid duplicate paracetamol-containing products. Oral NSAID (e.g. ibuprofen with food) at the lowest effective dose for the shortest duration, with gastroprotection where indicated — caution in renal impairment, heart failure/cardiovascular disease, hypertension, peptic ulcer/GI bleeding, anticoagulants/antiplatelets, asthma sensitivity and pregnancy. Topical NSAIDs for localised muscle pain

Step 3Physiotherapy — structured exercise programme: Refer for neck-specific exercises (deep cervical flexor strengthening, ROM exercises, postural correction). Manual therapy (manipulation or mobilisation) by trained physiotherapist for acute/subacute — supported by the JOSPT 2017 neck pain guideline (Blanpied et al.). Combined exercise + manual therapy may be more helpful than either alone

Step 4Persistent pain (>6 weeks, subacute): Review yellow flags — address fear-avoidance and catastrophising directly. Do not prescribe benzodiazepines (e.g. diazepam) for mechanical neck pain — dependence, falls, sedation and driving risks. If neuropathic features, use the local neuropathic-pain pathway

Step 5Chronic neck pain (>12 weeks): Multidisciplinary pain programme. NHS Talking Therapies / CBT for pain — address central sensitisation and psychological contributors. Acupuncture: NICE NG193 (2021) — consider a single course for chronic primary pain (no more than 5 hours of healthcare professional time). Avoid escalating opioids — no evidence for chronic MSK neck pain, significant harm risk. Spinal injection (facet joint / medial branch block) via pain clinic if mechanical facet pain confirmed

② Cervical Radiculopathy

Acute radiculopathy

Analgesia + activity/physiotherapy

Use a short course of appropriate analgesia (NSAID with cautions and gastroprotection where indicated) and encourage activity/exercise. Consider specialist advice if severe or disabling radicular pain persists. Do not routinely prescribe oral corticosteroids. Physiotherapy: neural mobilisation, exercise

Neuropathic component

Local neuropathic-pain pathway

Do not routinely initiate gabapentin or pregabalin solely for cervical radiculopathy. If a neuropathic pain medicine is considered, use the local neuropathic-pain pathway (local: amitriptyline first line, gabapentin second line, pregabalin later), assess renal function, sedation, driving, drug interactions (including opioids and respiratory disease) and dependence risk, and review benefit early

Persistent / disabling

Specialist referral if criteria met

Refer for spinal/neurosurgical assessment if pain is uncontrolled, symptoms are disabling, weakness is progressive or myelopathic features develop (NICE NG127). MRI is arranged where specialist intervention is being considered. Surgical options are specialist decisions

③ Whiplash-Associated Disorder (Grades 1–2)

Acute phase (0–72h)

For uncomplicated whiplash-associated disorder without fracture, instability or neurological deficit: provide reassurance, advice to maintain normal activity as tolerated, analgesia (paracetamol/NSAID with the cautions above) and gentle range-of-motion exercises. Avoid prolonged soft-collar use and prolonged rest.

Active management (1–6 wks)

Refer for physiotherapy or further assessment if symptoms persist, are disabling or neurological symptoms develop. ROM exercises, strengthening, postural correction. Address yellow flags at first assessment — catastrophising predicts chronic disability more reliably than injury severity

Sick certification

Avoid long-term sick certification — return to work is therapeutic and reduces chronicity. Use fit note with "may be fit for work with modifications" rather than "not fit for work." Short-term certification may be appropriate for severe symptoms, based on function rather than Quebec grade. DVLA: can drive once pain and medication allow safe driving (patient's responsibility)

Neurological signs after whiplash

Emergency/specialist assessment within the trauma pathway; imaging per NICE NG41 (MRI when there are neurological abnormalities or suspected cord/ligamentous injury). Ongoing management specialist-guided

④ Giant Cell Arteritis (neck pain variant)

Visual symptoms present

Start glucocorticoids immediately when clinical suspicion is significant — take FBC, CRP and ESR if this does not delay treatment. New visual loss, transient visual symptoms or diplopia → same-day specialist/ophthalmology assessment via the local GCA fast-track pathway. Dose, biopsy/imaging timing and taper are specialist-directed. Bone protection based on glucocorticoid dose, expected duration and fracture risk (local osteoporosis guidance)

No visual symptoms

Aged ≥50 with suspected GCA: FBC, CRP and ESR if this does not delay treatment; start glucocorticoids immediately when clinical suspicion is significant; refer urgently to the local GCA fast-track pathway. Steroid dose and taper depend on the clinical phenotype and specialist pathway. Monitor for steroid side effects — BP, HbA1c, weight, fractures

Next steps: see Giant cell arteritis · Polymyalgia rheumatica · Metastatic spinal cord compression

Soft collar prescription for whiplash or acute neck pain is one of the most persistently harmful interventions in musculoskeletal medicine. Prolonged collar use and prolonged rest can increase disability, deconditioning and fear-avoidance; advise maintaining normal activity as tolerated with gentle range-of-motion exercises. For neuropathic pain, follow the local neuropathic-pain pathway (amitriptyline first line locally); evidence for radicular pain is limited, and gabapentinoids carry renal-dose, sedation, driving, misuse/dependence and respiratory-depression risks (pregabalin and gabapentin are Schedule 3 Controlled Drugs since April 2019). Oral corticosteroids are not supported as routine treatment — NICE NG59 advises against them for sciatica, and there is insufficient justification for routine use in cervical radiculopathy.

Lifestyle

Non-pharmacological interventions — address posture, sleep, and work ergonomics

Done

Ergonomic and lifestyle advice can be offered as pragmatic self-management, but should not be presented as proven disease-modifying treatment.

Workstation ergonomics Screen at eye level (top of monitor = eye height). Keyboard at elbow height with forearms supported. Chair height: feet flat on floor, hips/knees at 90°. Screen distance: arm's length. Avoid laptop on lap for prolonged use. Refer to occupational health for formal DSE assessment in office workers (employer duty under Display Screen Equipment Regulations 1992)

Exercise prescription Deep cervical flexor (DCF) strengthening: chin tucks (craniocervical flexion). Scapular retraction exercises (rhomboid/lower trapezius). General aerobic exercise for overall health. Avoid high-impact neck-loading sports during acute episodes

Sleep posture One pillow aligned to maintain neutral cervical spine (fill shoulder gap in side-lying). Some people find sleeping prone or on a sofa/armchair aggravates symptoms. Pillow and mattress choice is a matter of personal comfort — no specific product is proven

Screen time & phone use Pragmatic advice: raise phone/screen towards eye level for sustained use and take regular movement breaks

Stress management Psychological stress → trapezius hypertonicity → chronic neck tension. Neck pain is the musculoskeletal symptom most strongly associated with work-related stress and anxiety. Mindfulness-based approaches may help some people. Refer to NHS Talking Therapies for anxiety/depression contributing to pain. Progressive muscle relaxation techniques — can be self-taught via NHS apps

Driving ergonomics Adjust the head restraint correctly and the seat for comfort. Take regular breaks on long journeys

Weight management & smoking cessation Weight management and smoking cessation benefit general health and may support recovery and surgical outcomes. Refer to NHS Stop Smoking Service + NRT/varenicline

Return to normal activity — key message The most important lifestyle prescription is avoiding activity restriction. Fear of movement (kinesiophobia) is the primary driver of chronic neck disability, not structural damage. Active message: "Your neck is safe to move. Activity nourishes the discs and muscles. Rest causes weakness and stiffness. Moving is healing." STarT MSK high-risk patients need this message delivered with psychological framework — consider co-prescribing NHS Talking Therapies (IAPT) with physiotherapy

Ergonomic and lifestyle advice is pragmatic self-management. It can help people stay active and confident, but should not be presented as proven disease-modifying treatment, and specific numerical claims about cervical loading, exercise effect sizes, mattress firmness, sleep position or screen-time limits are not well supported. Deep cervical flexor and general neck exercises are a reasonable part of an active rehabilitation programme.

Safety

Follow-up, monitoring & safety-netting

Done

Provide explicit, specific safety-netting at every neck pain consultation. The window to prevent myelopathy progression and vascular emergencies is narrow — patients must know when to re-present immediately. Follow-up should be determined by the clinical diagnosis and trajectory. Review sooner if neurological symptoms progress, weakness develops, gait or hand function deteriorates, bladder/bowel symptoms occur, or systemic red flags emerge. Timings below are a guide, not fixed rules.

1–2 weeks

Acute neck pain: analgesia adequacy review; confirm physiotherapy booked. Radiculopathy: neurological symptom trajectory — improving (continue), worsening (urgent spinal referral). Whiplash: yellow flag reassessment; confirm active mobilisation and physiotherapy engagement. NSAIDs started: check eGFR if elderly

4–6 weeks

Non-specific neck pain not improving: reassess yellow flags, consider physiotherapy intensification, review diagnosis. Radiculopathy: if power deteriorating → urgent spinal/neurosurgical referral regardless of duration. PMR / GCA on prednisolone: ESR/CRP recheck, bone protection reviewed, taper per specialist plan

3 months

Persistent neck pain: formal reassessment — NRS pain score, function (Neck Disability Index), psychological status. If not improving and yellow flags identified → pain management programme referral. Radiculopathy: if pain is uncontrolled or symptoms disabling despite conservative management → spinal/neurosurgical referral (NICE NG127). PMR: steroid dose review per specialist plan

6 months

Chronic neck pain (>6 months): pain management programme if not engaged. Review all analgesics — avoid long-term opioid use for non-specific neck pain. Consider acupuncture referral (NICE NG193 — a single course of no more than 5 hours of healthcare professional time for chronic primary pain). Rheumatology review for inflammatory arthritis

Annual

Cervical spondylosis with known myelopathy risk: annual neurological review (repeat Hoffmann's, reflexes, gait assessment). RA with cervical disease: symptom-led, specialist-directed imaging (no routine annual X-ray); urgent MRI + surgical opinion if myelopathic symptoms/signs. Long-term NSAID: eGFR, BP, GI symptoms every 6 months. PMR on prolonged steroids: DEXA, HbA1c, BP, ESR/CRP

Safety-net → 999

999 Sudden new severe neck pain + neurological symptoms (arm/leg weakness, face droop, speech difficulty, vertigo, diplopia) = stroke / arterial dissection until proven otherwise, including after any head/neck manipulation. Neck stiffness + fever + headache ± non-blanching rash = meningitis — 999; do not delay transfer; IV/IM ceftriaxone or benzylpenicillin if meningococcal disease strongly suspected and this does not delay transfer. New bladder / bowel dysfunction + bilateral limb weakness = cord emergency

Safety-net → same-day

Same-day Progressive arm weakness / new hand clumsiness / new gait disturbance — myelopathy progression. Sudden visual loss, blurring or double vision in patient with neck pain + age >50 — possible GCA: go to A&E or eye casualty immediately. New fever + severe neck pain + systemically unwell — epidural abscess / discitis

Safety-net → return if

Pain significantly worsens or changes character. New neurological symptoms develop (numbness, weakness, bladder/bowel). Bilateral arm symptoms develop. Symptoms not improving at 6 weeks. New systemic symptoms (fever, weight loss, night sweats). Lhermitte's sign develops (electric shock down spine on neck flexion)

Analgesic monitoring

Neuropathic agents (via local pathway only): review benefit early. Amitriptyline: consider cardiac risk factors per SPC/local guidance; anticholinergic effects (constipation, dry mouth, urinary retention). Gabapentin/pregabalin (if used): Schedule 3 CDs — renal dose adjustment, sedation, dependence/misuse, respiratory depression with opioids, driving advice (DVLA — patients must not drive if affected). Opioids: avoid for non-specific neck pain — review and deprescribe if inherited

Patient resources

NHS Choices neck pain information. Arthritis UK neck pain guide. Neck Disability Index (NDI) — 10-item PROM for tracking. STarT MSK tool — self-complete for risk stratification. NHS Talking Therapies (IAPT) self-referral for anxiety/depression contributing to pain

The safety-netting message for myelopathy must be specific and memorable. "If you notice your hands becoming clumsy, you start dropping things, or your walking becomes unsteady — come back same day" is more actionable than generic advice to "return if worried." Myelopathic deterioration can occur rapidly and unpredictably, particularly after minor trauma such as a fall — patients with known cervical stenosis are at specific risk. For GCA, the safety-netting message "go to A&E immediately if you have any change in your vision — even momentary" is a visual-loss prevention strategy; amaurosis fugax (transient monocular visual loss) is the warning event before permanent blindness and must be treated as a same-day emergency. For strongly suspected meningococcal disease, NICE NG240 (2024) recommends IV/IM ceftriaxone or benzylpenicillin as soon as possible, unless this delays transfer or there is severe allergy; for suspected bacterial meningitis, pre-hospital antibiotics are generally reserved for a clinically significant delay in transfer. Ceftriaxone is preferred where available; benzylpenicillin is a practical alternative — dose per NICE/SPC.