Reasoning GP · Algorithm · 1-page summary
Neck pain in adults
For: adults with neck pain, with or without arm symptoms or a recent injury, in primary care. Not for: children; major trauma (local trauma pathway); headache-led presentations (headache algorithm).
Core rule: at every neck pain consultation ask about clumsy hands, unsteady gait and bladder change, and examine for upper motor neurone signs — missed cervical myelopathy causes irreversible cord damage.
0Stop — call 999 now
- Sudden severe neck pain + stroke signs (vertigo, diplopia, ataxia, dysarthria, Horner's, weakness), incl. after injury or manipulation → dissection → 999.
- Neck stiffness + headache + fever ± non-blanching rash, or thunderclap + meningism → 999. Strongly suspected meningococcal disease → IV/IM ceftriaxone or benzylpenicillin unless it delays transfer.
- Unstable fracture, cord injury, acute severe neurological deterioration, MSCC with rapid paralysis or sphincter loss → 999.
- Drooling, muffled voice, trismus, severe dysphagia (deep neck abscess) → 999; do not examine the throat alone.
1Triage — by pain pattern
| Pattern | Think |
|---|---|
| Axial ± shoulder ache | Mechanical — normal neurology |
| Dermatomal arm pain | Radiculopathy (C7, then C6) |
| Both arms ± legs, gait | Myelopathy — block 2 |
| Injury | Canadian C-spine rule — block 2 |
2Screen — serious causes
- Myelopathy (clumsy hands, gait change, brisk reflexes, upgoing plantars) → Same-day spinal discussion, Urgent MRI. Rapid progression, gait failure, bladder/bowel → Same-day emergency.
- Fever + severe neck pain (IV drug use, immunosuppression, spinal procedure) → abscess / discitis → Same-day hospital.
- Cancer + cord symptoms → Same-day MSCC coordinator now, MRI ≤24 h. Possible metastases, no neurology → MRI ≤1 week.
- Trauma: age ≥65, dangerous mechanism, limb paraesthesia, neurology or unassessable → spinal precautions, A&E now; CT first.
- Suspected GCA (≥50) → steroids now; visual symptoms → Same-day eye; else Urgent fast-track.
- Neck or thyroid lump, lymphadenopathy → assess against NG12. ≥60 + persistent bone pain → myeloma bloods.
3Assess
☐ Arm power, sensation, reflexes ☐ Hoffmann's, leg reflexes, plantars, gait ☐ Nodes incl. supraclavicular, thyroid ☐ Temporal arteries if >50 ☐ Yellow flags (STarT MSK)
No imaging for non-specific pain; no X-ray instead of MRI for myelopathy. After trauma: no movement testing until fracture excluded.
4Classify — only if blocks 0–2 are negative
- Mechanical — commonest; movement-related, normal neurology.
- Radiculopathy — dermatomal pain, paraesthesia ± weakness; no single test diagnostic.
- Whiplash — no fracture, instability or neurology → active management.
- Cervicogenic headache — unilateral, neck-triggered; after excluding other headaches.
- RA — atlanto-axial instability: no manipulation; myelopathic signs → Urgent MRI + surgeon. Also axial SpA, PMR.
- Uncertain or atypical → re-screen block 2; neurology (MND, neuropathy, MS).
5Treat today — doses: NICE/SPC, BNF, local formulary
- Mechanical / whiplash: reassure, stay active, gentle range-of-motion exercises. No collar, no prolonged rest.
- Analgesia: paracetamol; NSAID lowest dose, shortest time, gastroprotection where indicated, with cautions; topical NSAID. No benzodiazepines or escalating opioids.
- Radiculopathy: analgesia + activity/physio. No routine oral steroids or gabapentinoids; neuropathic agents via local pathway (local: amitriptyline first).
- Work and driving: "may be fit for work" fit note over long sick leave; drive once pain and medication allow.
6Refer routinely
- Physiotherapy (self-referral where available): mechanical pain, whiplash, radiculopathy, cervicogenic headache.
- Spinal/neurosurgical: radiculopathy with uncontrolled pain or disabling symptoms (NG127); weakness worsening → Urgent.
- Rheumatology: persistent synovitis — small joints, >1 joint or ≥3 months → ≤3 working days. PMR: prednisolone 15 mg after bloods; refer if atypical, GCA or relapse.
- Pain programme / NHS Talking Therapies: pain >3 months with high STarT MSK risk.
7Never reassure by
- "It's age" — for clumsy hands or an unsteady gait.
- Normal CRP or white cell count with fever and severe neck pain.
- Absent Kernig's or Brudzinski's sign.
- "Degenerative changes" on a scan — common without symptoms.
- A negative Spurling's test.
- A whiplash (Quebec) grade — it is descriptive, not a treatment rule.
8Safety-net — say it, then document it
999 “Call 999 for sudden severe neck pain with weakness, face droop, speech difficulty, the room spinning or double vision, including after neck manipulation; neck stiffness with fever, headache or a rash that does not fade; or new bladder or bowel problems with weakness in your arms or legs.”
Same day: “Contact us the same day for worsening arm weakness, clumsy hands or dropping things, unsteady walking, or fever with severe neck pain and feeling unwell. If you are over 50, any change in your vision: go to A&E or eye casualty immediately. Come back if pain worsens or changes, numbness, weight loss or night sweats start, or you are not improving at 6 weeks.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Upper-limb neurology, myelopathy signs and gait recorded
After injury: trauma pathway / Canadian C-spine rule applied
Diagnosis named, or uncertainty → specialist; yellow flags screened
Follow-up planned by trajectory; safety-net given and documented
Summary of the full Reasoning GP neck pain algorithm, which holds the history, examination, dermatomes, investigations, whiplash, lifestyle and evidence. Sources: NICE NG127 (neurological referral), NG41 (spinal injury), NG234 (spinal metastases and MSCC), NG240 (meningitis), NG12 (suspected cancer, updated April 2026), NG100 (rheumatoid arthritis), NG193 (chronic primary pain), BSR GCA guideline, JOSPT neck pain guideline 2017 and local formulary. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.