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Red flags in neck pain

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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  • When considering neck pain it is important to exclude 'red flags'(that suggest a serious spinal abnormality)

    • if present, refer urgently for investigations and further assessment (1,2,3,4)
      • Red flags for neck pain:
        • trauma, preceding neck surgery, osteoporosis risk, myelopathy, history of cancer, unexplained weight loss, fever, history of infections (e.g. TB, HIV), history of inflammatory arthritis, and any of the following signs and symptoms:

          • new symptoms below age 20 or above age 55 years

          • constant, progressive, non-mechanical pain

          • insidious progression of pain (3)

          • signs of spinal cord compression
            • neurological symptoms should prompt a neurological examination to exclude spinal cord compression or cervical myelopathy (such as clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function)
            • cord compression can present with upper motor neurone signs in the lower limbs (upper going plantar reflexes, hyper-reflexia, spasticity and clonus) and lower motor neurone signs in the upper limbs (atrophy and hyporeflexia)

          • Lhermitte's sign (flexion of the neck producing an electric shock sensation down the spine and into the limbs)
            • can suggest an underlying serious cause such as myelopathy or demyelination

          • dizziness, drop attacks, blackouts
            • may indicate vascular insufficiency, which is more common in older patients

          • vertebral body tenderness
            • localized "exquisite" tenderness when palpating a vertebral body (3)

          • lymphadenopathy/cervical rib
            • examination - in supraclavicular region for cervical rib, and anteriorly for cervical lymph nodes, which may indicate infection or cancer

          • pulsatile mass
            • indicates a carotid artery aneurysm, especially after neck manipulation or trauma
            • requires urgent referral

    • Management
      • the urgency of the referral depends on the mode of onset, severity of the neurological deficit and the rate of progression
      • a history of substantial preceding trauma and cervical spine tenderness should prompt consideration for immediate immobilisation, A&E referral and imaging to exclude fracture or instability
      • immediate referral is indicated if spinal cord compression is suspected - features suggestive of spinal cord compression require an immediate surgical review
      • consider urgent referral, imaging or specialist opinion if any of these red flags are present (4)
      • the need for surgical intervention would be assessed on the basis of further investigations


  1. ARC (January 2002). Rheumatic Disease in Practice.
  2. ARC (Issue 8 (Hands On Series 6) Spring 2011), Neck pain: management in primary care
  3. CKS. Neck pain - cervical radiculopathy (Accessed June 17th 2018).
  4. GP Online. Neck pain - red flag symptoms (Accessed June 17th 2018).

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