Key Facts

Neck pain is the second most common musculoskeletal presentation after low back pain. Most cases are non-specific and self-limiting. Careful clinical assessment is essential to identify the minority with serious pathology requiring urgent intervention.

Epidemiology

• Annual prevalence: 30-50% of adults
• Point prevalence: 10-15%
• Chronic neck pain: 15%
• More common in women and office workers
• Peak age: 40-60 years

Aetiology

• Non-specific (mechanical): poor posture, muscle strain, cervical spondylosis
• Cervical radiculopathy: disc prolapse or osteophyte compressing nerve root
• Cervical myelopathy: spinal cord compression (spondylosis, disc prolapse, OPLL)
• Whiplash-associated disorder: acceleration-deceleration injury (usually RTA)
• Serious pathology: fracture, malignancy (metastases), infection (discitis, epidural abscess), inflammatory arthritis (RA — atlantoaxial subluxation)

Pathophysiology

• Cervical spine is highly mobile with complex anatomy; vulnerable to degenerative changes and injury
• Cervical spondylosis (degenerative disc disease and osteophyte formation) is universal with ageing
• Disc prolapse: typically posterolateral, compressing exiting nerve root
• Myelopathy: narrowed spinal canal (spondylosis, disc, ligament hypertrophy) compresses spinal cord
• Non-specific pain: likely involves muscles, facet joints, discs, ligaments

Non-Specific Neck Pain

• Axial pain in the posterior neck
• May radiate to shoulder/trapezius
• Mechanical: worse with sustained postures, better with position change
• Limited range of motion
• No neurological deficit

Cervical Radiculopathy

• Arm pain worse than neck pain, dermatomal distribution
• Paraesthesiae and numbness in nerve root distribution
• Weakness (muscle group specific to root)
• Spurling test positive (neck extension + lateral flexion + axial load reproduces arm symptoms)

Cervical Myelopathy

• Subtle, progressive gait disturbance (spastic ataxia)
• Hand clumsiness (loss of fine motor control)
• Upper motor neurone signs: hyperreflexia, spasticity, upgoing plantars, clonus
• Lhermitte sign: electric shock sensation down spine on neck flexion
• Bladder dysfunction (late)

Red Flags

• Progressive neurological deficit (myelopathy)
• Lhermitte sign
• Bilateral arm symptoms
• Bladder/bowel dysfunction
• Fever, IV drug use, immunosuppression (infection)
• History of malignancy, unexplained weight loss
• Severe trauma (fracture)
• Rheumatoid arthritis (atlantoaxial subluxation)

Bedside

• Full neurological examination of upper and lower limbs
• Spurling test (cervical radiculopathy)
• Hoffman sign, Babinski reflex (UMN signs — myelopathy)
• Grip and release test (impaired in myelopathy)
• Assessment of gait (spastic ataxia in myelopathy)

Bloods

• Not routinely required for non-specific neck pain
• ESR, CRP: if inflammatory/infectious cause suspected
• RF, anti-CCP: if RA suspected

Imaging

• Not routinely indicated for non-specific neck pain
• MRI cervical spine: investigation of choice if red flags, myelopathy, or persistent radiculopathy
• CT cervical spine: after trauma (Canadian C-spine rules or NEXUS criteria)
• X-ray: limited role; flexion/extension views for RA instability assessment

Special Tests

• Nerve conduction studies: if diagnostic uncertainty between radiculopathy and peripheral neuropathy
• CT myelogram: if MRI contraindicated

Non-pharmacological

• Reassurance: most neck pain is not serious and improves within 4-6 weeks
• Stay active: avoid prolonged rest, maintain normal activities
• Exercise programme: stretching, strengthening, range of motion; supervised or home-based
• Manual therapy: mobilisation or manipulation (physiotherapy/chiropractic) — part of multimodal treatment
• Ergonomic advice: workstation assessment, posture correction, regular breaks
• Whiplash: early return to activity; NO cervical collar (delays recovery); exercises

Pharmacological

• NSAIDs: ibuprofen 400mg TDS or naproxen 250-500mg BD (short course)
• Paracetamol: as adjunct
• Muscle relaxant: diazepam 2-5mg TDS for acute spasm (maximum 1 week)
• Neuropathic agents: amitriptyline 10-75mg ON or gabapentin for radicular neuropathic pain
• Avoid opioids for chronic neck pain

Surgical

• Cervical myelopathy (progressive): urgent neurosurgical decompression (anterior cervical discectomy and fusion — ACDF, or posterior decompression)
• Cervical radiculopathy: surgery if failure of 6-12 weeks conservative management with persistent significant symptoms
• Cervical fracture: stabilisation as indicated

Referral Criteria

• Emergency neurosurgery: progressive myelopathy, acute spinal cord injury
• Urgent: suspected myelopathy, progressive neurological deficit, suspected malignancy/infection
• Routine: persistent radiculopathy >6 weeks, failed conservative management
• Physiotherapy: all patients with neck pain for exercise and manual therapy

• Non-specific neck pain: >60% improve within 4-6 weeks; 30% develop chronic symptoms
• Whiplash: >80% recover within 3 months; 10-20% develop chronic pain (Quebec Task Force classification)
• Cervical radiculopathy: >80% resolve with conservative management
• Cervical myelopathy: progressive without treatment; surgery stabilises or improves in >70% but recovery depends on duration and severity pre-operatively
• Psychosocial factors (yellow flags) are the strongest predictors of chronicity
• Cervical spondylosis is radiographically present in >85% of those >60 years and poorly correlates with symptoms

Canadian C-Spine Rules (Post-Trauma)

Cervical Nerve Root Syndromes

Cervical Myelopathy — Clinical Features