Neck pain

Neck pain is a common symptom that can occur in a wide variety of conditions, ranging from benign musculoskeletal problems (e.g., neck sprain) to life-threatening neurological or vascular emergencies (e.g., compressive spinal emergencies, myocardial infarction). Initial management involves stabilizing the spine in case of C-spine injury and excluding immediately life-threatening causes of neck pain. Further clinical evaluation includes a focused medical history to evaluate for red flags (e.g., chronic inflammatory conditions, malignancy) and a focused spine examination and neurological examination. Diagnostic testing is guided by clinical evaluation findings and may include imaging and laboratory studies. Management depends on the underlying cause and symptom severity. Emergency surgical management is indicated in some immediately life-threatening causes of neck pain (e.g., vertebral fractures, compressive spinal emergencies, aortic dissection). Symptomatic treatment for non-life-threatening causes of neck pain involves analgesia and physical therapy. Referral for surgery can be considered in patients with chronic neck pain refractory to conservative treatment.

Causes of posterior neck pain

Mechanical

• Degenerative disc disease
• Spondylolisthesis
• Facet joint syndrome
• Myofascial pain syndrome
• Cervical dystonia ^[4]

Neurological

• Cervical radiculopathy
• Cervical myelopathy
• Occipital neuralgia ^[5]

Infectious/inflammatory

• Meningitis
• Osteomyelitis
• Spinal epidural abscess
• Arthritis, e.g., rheumatoid arthritis
• Ankylosing spondylitis
• Polymyalgia rheumatica (PMR)
• Fibromyalgia
• Shingles

Vascular

• Vertebral artery dissection
• Vertebral artery thrombosis
• Spinal epidural hematoma ^[6]
• Subarachnoid hemorrhage ^[7]

Traumatic

• C-spine fracture
• Cervical vertebral dislocation
• Atlantoaxial subluxation
• Neck sprain, whiplash injury

Neoplastic

• Primary bone tumors
• Spinal cord tumors
• Metastatic spinal tumors

Causes of anterior neck pain

Mechanical

• Muscle strain
• Thoracic outlet syndrome

Infectious/inflammatory

• Deep neck infections
• Ludwig angina
• Acute suppurative thyroiditis
• Pharyngitis
• Laryngitis
• Sialadenitis
• Cervical lymphadenopathy
• Shingles

Neoplastic

• Thyroid nodule or goiter
• Thyroid cancer
• Laryngeal carcinoma
• Esophageal carcinoma
• Salivary gland cancers

Others

• Esophageal disorders (e.g., reflux, esophagitis)
• Carotid artery dissection

Causes of referred neck pain

Many thoracic and abdominal conditions can cause pain that radiates to the neck, e.g.:

• Acute coronary syndrome (ACS)
• Aortic dissection ^[8]

Approach ^[1][2][3]

• ABCDE survey
• Traumatic injuries
  • Follow the approach to blunt neck trauma or the approach to penetrating neck trauma.
  • Suspected C-spine injury
    • Immediate spinal precautions, even before airway management
    • Urgent CT C-spine without IV contrast
    • Cervical spine clearance
    • See also “Initial management of C-spine injury.”
• Assess for red flags in neck pain and identify and manage immediately life-threatening causes of neck pain.
• Focused clinical evaluation for neck pain
• Specialist consults as needed (e.g., neurosurgery, neurology, otolaryngology)
• Obtain etiology-specific diagnostics and initiate treatment.

Maintain a high index of suspicion for traumatic C-spine injuries in older patients and those with certain comorbidities (e.g., rheumatoid arthritis, ankylosing spondylitis, trisomy 21). ^[1]

Red flags in neck pain ^[2][3][9]

Red flag features can suggest a serious underlying cause and should prompt consideration of further diagnostics.

History

• Trauma
• Recent C-spine surgery
• Age > 50 years
• Immunosuppression (e.g., due to long-term steroid use)
• IV drug use
• Chronic inflammatory conditions (e.g., rheumatoid arthritis, ankylosing spondylitis, PMR)
• Trisomy 21
• Known malignancy

Features and findings

• Musculoskeletal
  • Severe neck tenderness
  • Limited neck mobility
  • Torticollis
• Neurological
  • Signs of stroke
  • Signs of carotid and vertebral artery dissection
  • Signs of compressive myelopathy, e.g.:
    • Hyperreflexia, altered muscle tone
    • Sensory loss
    • Bladder or bowel dysfunction
    • Ataxia, gait disturbance
• Infectious/inflammatory: meningismus, fever
• Cardiovascular: chest pain, diaphoresis, dyspnea, syncope
• Constitutional: B symptoms

Immediately life-threatening causes of neck pain ^[1][2][3]

• Unstable vertebral injuries
• Compressive spinal emergencies
• Meningitis
• Spinal infections
• Myocardial infarction
• Aortic dissection
• Carotid and vertebral artery dissection
• Soft-tissue infections that can cause airway compromise

Focused history ^[1][2][9]

Pain characteristics

• Onset, quality, and duration
• Location, radiation (e.g., dermatomal distribution)
• Inciting and relieving factors
• Pain patterns throughout the day

Associated symptoms

• Paresthesia, numbness
• Decreased dexterity, difficulty balancing
• Clonus, tremor
• Weakness, muscle atrophy
• Bladder, bowel, or sexual dysfunction
• Vertigo
• Fever, B symptoms
• Clinical features of ACS

Past medical history

See “Red flags in neck pain” for relevant medical history.

Focused physical examination ^[1][2][9]

General physical examination

• Altered mental status
• Signs of respiratory distress
• Skin rash
• Lymphadenopathy

Examination of the spine

• Tenderness
• Range of motion
• Signs of fracture (e.g., palpable step or gap)

Do not examine range of motion before C-spine clearance in symptomatic or obtunded patients. ^[10]

Neurological examination

• Meningismus
• Examination of the motor system
• Gait examination
• Examination of the sensory system
• Cranial nerve examination
• Provocation maneuvers for cervical radiculopathy

Imaging ^[1][11]

Indications

• X-ray C-spine
  • Patients < 16 years of age with history of trauma and who meet criteria for imaging (e.g., NEXUS criteria) ^[12]
  • Consider for new, increasing, or chronic neck pain and no red flags in neck pain.
• CT
  • Adults with history of trauma and who meet criteria for imaging (e.g., NEXUS criteria, Canadian C-spine rule): CT C-spine without IV contrast ^[13]
  • Recent spinal surgery and new or increasing neck pain: CT C-spine without IV contrast
  • Concern for deep neck infection: CT neck with IV contrast ^[14]
  • Concern for stroke: CT head without IV contrast, additional neuroimaging for acute stroke as indicated ^[15]
  • Alternative if MRI is contraindicated
• MRI
  • Concern for spinal infection or known malignancy in patients with new or increasing neck pain: MRI C-spine without and with IV contrast
  • Signs of cervical myelopathy: MRI C-spine without and with IV contrast ^[16]
  • Chronic neck pain with radiculopathy and no red flags: MRI C-spine without IV contrast
  • Alternative if CT is contraindicated
• Angiography
  • Concern for carotid or vertebral artery dissection: CTA or MRA head and neck ^[15][17]
  • Concern for aortic dissection: CTA chest, abdomen, and pelvis ^[18]

Findings

See “Common immediately life-threatening causes of neck pain”, “Common spinal causes of neck pain”, and “Common nonspinal causes of neck pain.”

Abnormalities are common on C-spine imaging in both symptomatic and asymptomatic individuals; use clinical judgment when interpreting findings. ^[11]

Electromyography ^[2]

Consider electromyography in consultation with neurology to assess for neuropathy in patients with numbness, weakness, or pain in the extremities.

Laboratory studies ^[1][9]

Laboratory studies are not routinely required. Based on the suspected etiology, consider:

• Sepsis workup
• Lumbar puncture and CSF analysis
• Coagulation panel
• Troponin, D-dimer
• CMP

Spinal causes of neck pain

Nonspinal causes of neck pain

Symptomatic treatment of neck pain ^[1][2][9]

Studies on the treatment of neck pain are lacking; many recommendations are derived from studies on back pain. If pain persists despite symptomatic treatment, consider referral for surgical evaluation.

• Pharmacological treatment
  • Oral analgesics
    • Mild to moderate pain: NSAIDs
    • Moderate to severe pain: opioids, e.g., tramadol (second-line; for acute neck pain only)
  • Topical analgesics: NSAIDs, lidocaine patches
  • Injection of local anesthetics, corticosteroids, and botulinum toxin may be beneficial for certain causes.
  • Additional options with limited evidence include muscle relaxants and oral corticosteroids for radiculopathy.
• Nonpharmacological treatments
  • Physical therapy, strengthening exercises
  • Consider referral for psychotherapy, particularly for patients with risk factors for persistent neck pain. ^[2][46]
  • Additional options with limited evidence include spinal manipulation, massage therapy, and acupuncture.

• ABCDE approach
• Spinal precautions for C-spine injury
• Clinical evaluation for neck pain, focusing on red flags in neck pain
• Manage immediately life-threatening causes of neck pain.
• Diagnostics for neck pain guided by clinical suspicion
• Specialist consults as needed (e.g., neurosurgery, neurology)
• Treatment of underlying cause; symptomatic treatment of neck pain if no underlying cause found