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Neck pain - non-specific - Management
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How do I assess someone with neck pain?

  • Exclude non-musculoskeletal causes, such as cardiovascular, respiratory, and oesophageal diseases, and acute upper respiratory tract infection and sore throat.
  • Look for 'red flags' (that suggest a serious spinal abnormality). If present, refer urgently for investigations and further assessment.
  • If the neck pain and other symptoms follow recent sudden or excessive hyperextension, flexion, or rotation of the neck, see the CKS topic on Neck pain - whiplash injury.
  • If the neck pain is due to acute spasm with no obvious underlying cause, see the CKS topic on Neck pain - acute torticollis.
  • If the neck pain varies with different physical activities and with time, or is related to an awkward movement, poor posture, or overuse, suspect non-specific neck pain.
  • If there is unilateral neck, shoulder, or arm pain that approximates to a dermatome, suspect cervical radiculopathy, see the CKS topic on Neck pain - cervical radiculopathy. There may be altered sensation or numbness, or weakness in related muscles. However, the presence of pain or paraesthesia radiating into the arm is not specific for nerve root pain and may be present in people with non-specific neck pain.
  • Identify risk factors for developing neck pain:
    • Workplace associated risks: awkward neck postures, neck flexion, arm force, arm posture, duration of sitting, twisting or bending of the trunk, hand-arm vibration, and some workplace designs.
    • Excessive use of pillows.
  • Identify psychosocial factors that may indicate increased risk for chronicity and disability. Identify any excessive concerns about the neck pain, unrealistic expectations of treatment, disabling sickness behaviour, and problems with compensation, work, family, mood, and emotions.
  • Cervical X-rays, and other imaging studies and investigations are not routinely required to diagnose or assess neck pain with radiculopathy and non-specific neck pain.

Basis for recommendation

  • These recommendations are based on expert advice in a primary care textbook [Williams and Hoving, 2004].
  • Some evidence from prospective cohort and cross-sectional studies suggests that psychosocial factors and a high physical workload are important risk factors for neck pain. A Swedish survey found that 30% of respondents with chronic neck pain reported previous injury to the neck [Guez et al, 2003].
  • In the absence of 'red flags', plain X-rays of the cervical spine are unlikely to help and may lead to false-positive findings [Williams and Hoving, 2004].
    • Radiographs of the cervical spine may suggest muscle spasm (loss of normal cervical lordosis).
    • Features of degenerative disease are also common in asymptomatic people older than 30 years of age and correlate poorly with clinical symptoms. The boundary between normal ageing and disease is very difficult to define [Binder, 2007b].

What are the features of non-specific neck pain?

  • Typical features of non-specific neck pain:
    • Aggravated by particular movements, posture, and activities; and relieved by others. Commonly, exercise makes the pain worse and rest relieves it, but the opposite may also be true.
    • Radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae.
    • May be associated with paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength.
    • May be associated with odd sensations, such as temperature change or subjective weakness, but no objective loss of muscle power.
    • May have accompanying cervical stiffness — reversible or irreversible. Muscle stiffness and spasm are common.
    • May be associated with headache or dizziness, or pain in the spine.
    • Rarely, it may be associated with:
      • Dysphagia (due to large anterior osteophytes).
      • Syncope, triggering of migraine, or pseudo-angina.
  • Typical signs of non-specific neck pain:
    • Positional asymmetry: varies from a change in the most comfortable resting position of the neck to torticollis (the neck pulled to one side).
    • Unequal restriction or limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides), although this is common with ageing.
    • Tenderness in hypertonic muscles or intervertebral joints, which is usually poorly localized.
    • Soft-tissue signs: localized areas of increased muscle tone that can be palpated as nodules or tender bands.

Basis for recommendation

  • These recommendations are based on expert advice in a textbook [Williams and Hoving, 2004], and in review articles [Binder, 2007a; Binder, 2007b].
  • Involvement of the vertebral arteries and sympathetic nerves in the degenerative process may explain the wide variety of symptoms. For example, if dizziness or poor balance is exacerbated by neck movement, then vertebral artery involvement or irritation of the sympathetic nerves is usually the cause [Binder, 2007b].

What are the 'red flags' for non-specific neck pain?

  • 'Red flags' are clinical features that indicate an increased risk of specific conditions that can present with neck pain and require urgent attention.
  • A serious underlying cause is more likely in people presenting with:
    • New symptoms before the age of 20 years or after the age of 55 years.
    • Weakness involving more than one myotome or loss of sensation involving more than one dermatome.
    • Intractable or increasing pain.
  • 'Red flags' that suggest compression of the spinal cord (myelopathy):
    • Insidious progression.
    • Neurological symptoms: gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function.
    • Neurological signs:
      • Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs.
      • Upper motor neuron signs in the lower limbs (Babinski's sign — up-going plantar reflex, hyperreflexia, clonus, spasticity).
      • Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia).
    • Sensory changes are variable, with loss of vibration and joint position sense more evident in the hands than in the feet.
  • 'Red flags' that suggest cancer, infection, or inflammation:
    • Malaise, fever, unexplained weight loss.
    • Pain that is increasing, is unremitting, or disturbs sleep.
    • History of inflammatory arthritis, cancer, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection.
    • Lymphadenopathy.
    • Exquisite localized tenderness over a vertebral body.
  • 'Red flags' that suggest severe trauma or skeletal injury:
    • A history of violent trauma (e.g. a road traffic accident) or a fall from a height. However, minor trauma may fracture the spine in people with osteoporosis.
    • A history of neck surgery.
    • Risk factors for osteoporosis: premature menopause, use of systemic steroids.
  • 'Red flags' that suggest vascular insufficiency:
    • Dizziness and blackouts (restriction of vertebral artery) on movement, especially extension of the neck when gazing upwards.
    • Drop attacks.

Basis for recommendation

  • These recommendations are based on expert opinion in a primary care textbook [Williams and Hoving, 2004] and in review articles [Binder, 2007a; Binder, 2007b].
  • The negative predictive value of these 'red flag' clinical findings is high; if no 'red flags' are present, then it is unlikely that a serious spinal abnormality has been missed. Individual positive findings must be interpreted with care, as their positive predictive value for diagnosing serious disease is poor [Williams and Hoving, 2004].

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