Evaluation of the adult patient with neck pain

INTRODUCTION — Neck pain has a prevalence of 10 to 20 percent in the adult population, which is similar to that of low back pain. However, unlike low back pain, lost time from work related to neck pain is infrequent. Degenerative changes of the cervical spine represent the most common cause of acute and chronic neck pain in adults.

The evaluation of the adult patient with neck pain (including whiplash injury) without recent major trauma is addressed here. Acute traumatic neck injury, cervical radiculopathy, and cervical spondylotic myelopathy are discussed separately:

●Cervical spine injury (see "Cervical spinal column injuries in adults: Evaluation and initial management" and "Spinal column injuries in adults: Types, classification, and mechanisms")

●Cervical radiculopathy (see "Clinical features and diagnosis of cervical radiculopathy" and "Treatment and prognosis of cervical radiculopathy")

●Cervical spondylotic myelopathy (see "Cervical spondylotic myelopathy")

Treatment of neck pain is also discussed separately. (See "Management of nonradicular neck pain in adults".)

ANATOMY — Understanding the cervical spine and regional spinal cord anatomy is important for the evaluation of the patient with neck pain.

●Anatomy of the cervical spine – The cervical spine is comprised of seven vertebrae (figure 1). The articulation between the occiput and the first cervical vertebra (the atlantooccipital joint) allows for approximately one-third of flexion and extension and one-half of lateral bending of the neck [1]. The articulation between the first and second cervical vertebrae (the atlantoaxial joint) allows for 50 percent of rotational range of motion. The articulations between the second and seventh cervical vertebrae allow for approximately two-thirds of flexion and extension, 50 percent of rotation, and 50 percent of lateral bending.

The most common locations that exhibit degenerative changes are between C4 and C7 [1]. The nerve roots passing through the intervertebral foraminal in these areas are C5, C6, and C7. Uncovertebral articulations (also known as joints of Luschka) are present in the C3 to C7 spinal segments, which are located on the posterolateral border of the intervertebral disc and in the anteromedial portion of the intervertebral foramen. These articulations are not true synovial joints but can hypertrophy in association with disc degeneration. This results in narrowing of the intervertebral foramen, which is a common cause of cervical radiculopathy [2].

The cervical and trapezius muscles have two major functions: to support and provide movement and alignment for the head and neck and to protect the spinal cord and spinal nerves when the spinal column is under mechanical stress.

The normal cervical spine has a shallow lordosis, which is maintained by the neck muscles. The lordosis can be decreased in patients with degenerative changes. Severe degenerative changes in the cervical spine can result in reversal of the lordosis. The lordosis may also become accentuated in compensation in patients with prominent thoracic kyphosis. Alterations in spinal alignment, however, have not clearly been demonstrated to cause cervical pain.

●Neuroanatomy – There are eight cervical spinal nerves, each arising from the spinal cord and consisting of a ventral and a dorsal root (figure 2). The ventral root contains efferent fibers from alpha motor neurons in the ventral horn of the spinal cord. The dorsal root carries primary sensory afferent fibers from cells in the dorsal root ganglion. Cervical radiculopathy may be caused by degenerative changes in the spine that affect the nerve root. The findings vary with the level of nerve root involvement (table 1). This dermatomal/myotomal mapping is what is typically seen, though it may not always map precisely in this manner. (See 'Cervical radiculopathy' below.)

The dorsal and ventral spinal roots combine to form the spinal nerve. This spinal nerve then divides into two branches, a dorsal primary ramus and a ventral primary ramus. The dorsal ramus innervates the muscular, cutaneous, and articular components of the posterior neck. The ventral ramus innervates the prevertebral and paravertebral muscles and forms the brachial plexus, which supplies the upper limb.

Sensory cervical dermatomes are illustrated in the figure (figure 3).

A myotome is the group of muscles innervated by a spinal nerve. The diaphragm is innervated by C3 to C5 spinal nerves, and respiratory paralysis may result from spinal cord injuries above C5.

CAUSES — While the differential diagnosis of neck pain in adults is broad, most cases are caused by musculoskeletal conditions (eg, cervical strain, cervical spondylosis, cervical discogenic pain), with the remainder related to neurologic (eg, cervical radiculopathy) and non-spinal (eg, infection, malignancy, rheumatologic disease) disorders (table 2). It is not always possible to clearly identify the cause, in part because degenerative changes are common and nonspecific. Often, multiple cervical spine conditions occur together (eg, radiculopathy with disc degeneration) such that identifying a single etiology may be difficult.

Musculoskeletal conditions

Cervical strain — Cervical strain generally presents with pain and/or stiffness on neck movement. There is often a history of antecedent injury to the cervical paraspinal muscles, although it may result from the physical stresses of everyday life including poor posture and sleeping habits. In some cases, there may be no clear precipitating cause. Physical examination shows tenderness on palpation of the neck and trapezius muscles. Provocative maneuvers for cervical radiculopathy are negative. (See 'Provocative maneuvers' below.)

The diagnosis of cervical strain is made on the basis of clinical presentation. Imaging is unnecessary. Neck pain and stiffness may last for up to six weeks; alternative diagnoses should be considered in patients with longer-lasting or atypical symptoms.

Cervical spondylosis — "Spondylosis" is a nonspecific term used to describe effects generally ascribed to degenerative changes in the spine, usually with osteophyte production [3]. Degenerative changes are common findings on imaging in asymptomatic individuals [4]. However, depending on where the spondylotic changes occur, there may be associated radiculopathy. (See 'Radiculopathy/myelopathy' below.)

Abnormalities seen on cervical spine imaging include osteophyte formation along the vertebral bodies and changes in the facet joints and lamina at multiple vertebral levels (image 1 and image 2). However, correlation between the degree of disease on imaging and the presence or severity of pain is poor. Given that multilevel degenerative joint disease is normally seen in asymptomatic individuals, reliable attribution of neck symptoms to cervical spondylosis is difficult [5].

Cervical discogenic pain — Cervical discogenic pain results from disc degeneration. It typically presents with pain and/or stiffness on neck movement, which is sometimes associated with pain in the upper extremities. Symptoms are often exacerbated when the neck is held in one position for prolonged periods, such as occurs with driving, reading, or working at a computer. Physical examination shows decreased range of motion associated with pain, and cervical radicular signs are usually absent. Provocative maneuvers for cervical radiculopathy are negative. (See 'Provocative maneuvers' below.)

Pain in this setting is largely mechanical, resulting from derangement in the disc architecture and inability to effectively distribute pressures between the disc, vertebral endplates, and facet joints. It can occur with or without local inflammation.

The diagnosis of cervical discogenic pain may be suspected on the basis of clinical presentation. Findings of degenerative changes of the discs on magnetic resonance imaging (MRI) are supportive; however, these findings are very common in asymptomatic individuals and it can be difficult to reliably attribute neck pain to discogenic changes [6-8]. In a 12-year prospective study, changes on MRI indicating progressive disc degeneration were seen in 81 percent of asymptomatic subjects (mean age 39 years) at study onset [7]. Thus, the term "cervical discogenic pain" (or alternatively "cervical internal disc disruption syndrome") is used to describe patients who are symptomatic with disc-related neck pain, whereas the broader term "disc degeneration" refers to the common imaging findings that in many cases have little or no clinical significance [9,10].

Whiplash injury — Whiplash injury is defined as neck injury resulting from an acceleration-deceleration mechanism that causes sudden extension and flexion of the neck [11-13]. These injuries are also commonly referred to as cervical strains or sprains. (See 'Cervical strain' above.)

The extension-flexion mechanism can injure intervertebral joints, discs, and ligaments; cervical muscles; and/or nerve roots. Injury to the zygapophyseal joint, commonly referred to as the facet joint, is likely the most common cause of whiplash-related upper neck pain and headaches [14,15].

Whiplash injuries most commonly occur following rear-end or side impact motor vehicle collisions, but can occur from other mechanisms (eg, occupation requiring repeatedly positioning the neck in extension). Symptoms typically include neck pain and stiffness which may present immediately after the injury or may be delayed for several days. Other symptoms may include headache, shoulder or back pain, dizziness, paresthesias, fatigue, and sleep disturbances.

Whiplash injuries are classified according to the associated signs and symptoms [11]:

●Grade 1 – Complaint of neck pain or stiffness only; no physical signs

●Grade 2 – Complaint of neck pain or stiffness with associated musculoskeletal signs (eg, decreased range of motion, point tenderness)

●Grade 3 – Complaint of neck pain or stiffness with associated neurologic signs (eg, decreased or absent deep tendon reflexes, weakness, sensory deficits)

●Grade 4 – Complaint of neck pain or stiffness with associated fracture or dislocation

The term "whiplash injury" generally refers to grade 1 to 3 injuries; grade 4 injuries (associated with fracture or dislocation) are generally associated with more substantial trauma and are considered a distinct entity.

Whiplash injury is typically diagnosed clinically based on characteristic presentation and clinical findings. Most patients do not require imaging. In patients with recent trauma, clinical decision rules (eg, NEXUS low-risk criteria or Canadian C-spine rule) can be used to determine the need for cervical spine imaging. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Clinical decision rules'.)

Whiplash injury is often associated with persistent low intensity pain [16]. In a systematic review of 47 studies, approximately 50 percent of adults with whiplash injury reported neck pain at one year out from the injury [17]. Clinical predictors of pain at one year include pain severity at the time of injury and reduction in cervical range of motion [18-20]. Psychosocial factors may also play a role (eg, social supports, depression, somatization, catastrophizing) [21-23]. Other factors that may affect reported symptom duration include cultural differences in expectations of pain and the possibility of financial compensation [19,24-26]. A legislative change in Australia removing financial compensation for pain and suffering from whiplash injuries was associated with improvement in functional status and pain indices in patients with whiplash compared with historical controls [26].

The pathophysiology of this condition is unclear. Microvascular bleeding and local release of inflammatory mediators may explain the acute injury, but some patients remain symptomatic for months or even years. Soft tissue injury may be associated with the degree of impairment. A study using high-resolution MRI of the cervical spine in patients with a remote history of whiplash injury (mean six years) and symptoms that had persisted at least three months following injury demonstrated soft tissue damage, particularly of the alar ligaments, not seen in control subjects [27]. In a study comparing whiplash patients with asymptomatic controls using color Doppler ultrasound, a high blood flow pattern was detected at the enthesis of the spinous processes and bilaterally juxtaposed to the facet joints [28].

Cervical facet osteoarthritis — Cervical facet osteoarthritis generally presents with pain and/or stiffness on neck movement. Pain may arise spontaneously or may be brought on by a flexion-extension injury. In the latter setting, there is some overlap with whiplash injury. (See 'Whiplash injury' above.)

Symptoms can be somatically referred to the shoulders, periscapular region, occiput, or proximal limb. Physical examination shows decreased range of motion associated with neck spasm. Provocative maneuvers for cervical radiculopathy are negative. (See 'Provocative maneuvers' below.)

The diagnosis of cervical facet osteoarthritis is based on clinical findings and correlative imaging findings of osteoarthritic changes; however, facet joint changes are relatively common and don’t correlate well with presence or severity of pain. The diagnosis may be more definitively established by demonstrating relief of symptoms with a local anesthetic injection to the facet joint innervation [29,30].

Myofascial pain syndrome — Myofascial pain syndrome (MPS) is a regional pain disorder associated trigger points, taut bands, and pressure sensitivity. MPS is a relatively common source of chronic pain in the general population. The pain of MPS is of a deep aching quality, occasionally accompanied by a sensation of burning or stinging. Myofascial trigger points are the characteristic finding on physical examination (figure 4A-B). The pain often occurs in one anatomic region, such as the right side of the neck and shoulder. This distinguishes MPS from fibromyalgia, which is typically associated with widespread pain, though there is considerable overlap between the two diagnoses.

MPS is discussed in detail separately. (See "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome'.)

Diffuse skeletal hyperostosis — Diffuse skeletal hyperostosis (DISH) is a syndrome of inappropriate bone deposition in the insertions of the ligaments and tendons. Large osteophytes connect adjacent vertebral bodies in a somewhat asymmetric fashion (image 3). Patients with DISH may have neck, thoracic spine, low back, and/or extremity pain. Spinal morning stiffness is common. Some affected patients may complain of dysphagia due to prominent anterior vertebral hyperostosis. The diagnosis is based on specific radiographic criteria (table 3).

The clinical features and diagnosis of DISH are discussed in detail separately. (See "Diffuse idiopathic skeletal hyperostosis (DISH)".)

Radiculopathy/myelopathy

Cervical radiculopathy — Cervical radiculopathy refers to dysfunction of the spinal nerve root. Degenerative changes of the spine (eg, cervical foraminal stenosis, cervical herniated disc) are responsible for 70 to 90 percent of cases. Other less common causes include herpes zoster, Lyme radiculopathy, and diabetic polyradiculopathy.

Cervical radiculopathy generally presents with pain, sensory abnormalities, and/or weakness in an upper extremity. Physical examination may show altered sensation in a dermatomal pattern (figure 3), decreased reflexes, and/or localized muscle weakness in a myotomal distribution. Provocative maneuvers are often positive (see 'Provocative maneuvers' below). The diagnosis of cervical radiculopathy is suspected on the basis of clinical presentation. MRI with evidence of cervical nerve root compression is supportive; however, imaging is usually not necessary unless there is progressive neurologic impairment. Symptoms may persist for up to six to eight weeks and may be recurrent.

The clinical features and diagnosis of cervical radiculopathy are discussed in detail separately. (See "Clinical features and diagnosis of cervical radiculopathy".)

Cervical spondylotic myelopathy — Cervical spondylotic myelopathy refers to spinal cord injury or dysfunction caused by degenerative changes narrowing the spinal canal. Patients may present with a variety of neurologic complaints including lower extremity weakness, gait or coordination difficulties, and bladder or bowel dysfunction. Physical examination may show upper motor neuron signs in the arms and/or legs. Lhermitte's sign (electric shock-like sensation in the neck, radiating down the spine or into the arms, produced by forward flexion of the neck) may be present. Provocative maneuvers (eg, Spurling's maneuver) should generally be avoided since this can worsen symptoms. The diagnosis of cervical spondylotic myelopathy is suspected clinically and confirmed by MRI scan showing cervical spinal canal narrowing, spinal cord compression and signal abnormality (image 4). Differential diagnosis includes multiple sclerosis, syringomyelia, tumor, epidural abscess, amyotrophic lateral sclerosis, and other causes of spinal cord dysfunction (table 4).

Distinguishing cervical spondylotic myelopathy from other causes of neck pain is critical because optimal neurologic recovery depends on early surgical decompression.

The diagnosis, clinical features, and management of cervical spondylotic myelopathy are discussed in detail separately. (See "Cervical spondylotic myelopathy".)

Ossification of the posterior longitudinal ligament — Ossification of the posterior longitudinal ligament (OPLL) is a condition of abnormal calcification of the posterior longitudinal ligament, usually in the cervical spine [31-34]. Its pathogenesis is not known, but it is more common in Asian populations than non-Asian populations and in males than females. OPLL can occur as an isolated condition or it may be associated with DISH, ankylosing spondylitis, and other spondyloarthropathies. Symptomatic patients typically present in the fifth to sixth decades of life with neck pain, stiffness, and progressive myelopathic symptoms. Cervical spine radiography or computed tomography (CT) is used to make the diagnosis. OPLL appears on imaging as flowing calcifications along posterior surface of the vertebra, which may be contiguous over several levels (image 5 and image 6) [31,35]. MRI can be helpful if the clinical evaluation suggests myelopathy or spinal cord compression.

Non-spinal conditions — Many non-spinal conditions can present with a constellation of symptoms that include neck pain (table 2). However, in most of these conditions, neck pain is not the most prominent feature and the diagnosis is often evident from other characteristic clinical manifestations (eg, fever, nuchal rigidity, exertional pain, diffuse joint pain):

●Cardiovascular disease – Angina pectoris and myocardial infarction (see "Approach to the patient with suspected angina pectoris")

●Infection – Osteomyelitis, discitis, deep neck abscess, meningitis (see "Vertebral osteomyelitis and discitis in adults" and "Deep neck space infections in adults" and "Clinical features and diagnosis of acute bacterial meningitis in adults")

●Malignancy – Metastatic disease to the cervical spine (see "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults")

●Neurologic conditions – Tension headache, cervical dystonia, Chiari malformations (see "Tension-type headache in adults: Etiology, clinical features, and diagnosis" and "Etiology, clinical features, and diagnostic evaluation of dystonia", section on 'Cervical dystonia' and "Chiari malformations")

●Referred shoulder pain – Impingement, adhesive capsulitis, rotator cuff tear (see "Evaluation of the adult with shoulder complaints")

●Rheumatologic conditions – Polymyalgia rheumatica, fibromyalgia (see "Clinical manifestations and diagnosis of polymyalgia rheumatica" and "Clinical manifestations and diagnosis of fibromyalgia in adults")

●Thoracic outlet syndrome (see "Overview of thoracic outlet syndromes")

●Vascular conditions – Vertebral artery or carotid artery dissection (see "Cerebral and cervical artery dissection: Clinical features and diagnosis")

●Visceral etiologies – Esophageal obstruction, biliary disease, apical lung tumor (see "Ingested foreign bodies and food impactions in adults" and "Acute calculous cholecystitis: Clinical features and diagnosis" and "Superior pulmonary sulcus (Pancoast) tumors")

EVALUATION

General approach — It is not always possible to reliably determine the specific cause of neck pain, nor is it necessary to do so in many cases. The initial evaluation focuses largely on excluding serious conditions that may require intervention. Once these have been excluded, differentiating between the various musculoskeletal conditions is less critical, particularly if symptoms resolve with symptomatic management.

Initial assessment of the patient with neck pain begins with identification of any "red flags," including recent major trauma (table 5), which will guide the pace and nature of the diagnostic evaluation (algorithm 1). (See 'Red flags' below.)

Patients with red flags generally require urgent evaluation. This typically includes imaging and/or testing based on the clinical concern (eg, laboratory tests and cultures if infection is suspected, electrocardiogram if angina pectoris is suspected).

For patients without red flags, the evaluation consists of the following:

●A detailed history and physical examination (see 'History and physical examination' below)

●Neurologic assessment (see 'Neurologic examination' below)

●Assessment of radicular symptoms or signs using provocative maneuvers (see 'Provocative maneuvers' below).

Most patients with atraumatic neck pain without red flags do not require imaging. Imaging (eg, cervical spine radiography, CT, or MRI) is generally reserved for patients with red flags (table 5), patients with progressive neurologic findings, and patients with moderate to severe neck pain (affecting sleep, daily activities, or occupation) who do not respond to conservative management over six weeks. (See 'Indications' below.)

Other studies (eg, electromyography/nerve conduction studies, laboratory tests) may be warranted in a limited number of clinical settings. (See 'Less commonly used studies' below.)

Major neck trauma — Patients with recent major neck trauma should have their vital signs stabilized and their neck immobilized using a backboard, rigid cervical collar and lateral head supports prior to referral for emergency care. A discussion of evaluation of the trauma patient is presented separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management".)

Red flags — The following clinical characteristics suggest the potential for serious disease that requires urgent evaluation (table 5):

●Neck pain associated with lower extremity weakness, gait or coordination difficulties, and/or bladder or bowel dysfunction suggests possible cervical cord compression or myelopathy. Potential causes include cervical spondylotic myelopathy, infection, malignancy, infarction, and other less common etiologies (table 4). (See 'Cervical spondylotic myelopathy' above and "Disorders affecting the spinal cord".)

●A shock-like paresthesia occurring with neck flexion (Lhermitte's sign) suggests compression of the cervical cord by a midline disc herniation or spondylosis but may also be a sign of intramedullary pathology such as multiple sclerosis. (See "Clinical features and diagnosis of cervical radiculopathy" and "Manifestations of multiple sclerosis in adults", section on 'Clinical symptoms and signs'.)

●Neck pain associated with fever raises concern for infection. Immunocompromised patients and those with a history of injection drug use are at increased risk of infection and thus there is a low threshold for performing an infectious workup in this setting. (See 'Non-spinal conditions' above.)

●Neck pain with unexplained weight loss or history of cancer raises concern for malignancy. (See 'Non-spinal conditions' above and "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults".)

●Neck pain associated with headache, shoulder or hip girdle pain, or visual symptoms in an older person may suggest rheumatologic disease (eg, polymyalgia rheumatica, giant cell arteritis). (See "Clinical manifestations and diagnosis of polymyalgia rheumatica" and "Clinical manifestations of giant cell arteritis".)

●Anterior neck pain is not typical for cervical spondylosis, and non-spinal causes of neck pain, including angina pectoris and visceral etiologies (esophageal obstruction, biliary disease, apical lung tumor) should be considered. (See 'Non-spinal conditions' above.)

History and physical examination — The history is aimed at characterizing the pain and excluding red flags (table 5). The clinician should ask about the onset, duration, and characteristics of the pain (eg, whether it radiates to the arm, whether there are associated paresthesias) and the extent to which pain limits activity.

Physical examination includes observation of neck movement, range of motion, palpation of the trapezius and paraspinal muscles, neurologic assessment for radicular and upper motor neuron signs, and provocative maneuvers in patients with radicular symptoms.

●Observation – The examination begins by noting the alignment and movement of the head, neck, and thoracic spine. Posture (upright, forward head with slumped thorax, or forward head with upright thorax) and general movements (rigid and guarded, general stiffness, or loose and free) should be observed.

●Range of motion – Neck rotation and lateral bending, when combined with palpation of the trapezius and paraspinal muscles for tenderness and spasm, are used to assess the degree of cervical spine involvement. The presence of torticollis can be consistent with acute muscle spasm or a herniated disk (see "Etiology, clinical features, and diagnostic evaluation of dystonia"). Assessment of the shoulder is important since overlapping symptoms can occur.

Normal range of motion for the cervical spine varies but is typically as follows:

•The cervical spine can rotate an average of 90° (picture 1)

•The cervical spine can bend an average of 45° laterally (picture 2)

•The cervical spine can forward flex to 60°

•The cervical spine can extend backward 75°

Abnormal neck range of motion is a nonspecific finding that may be seen in cervical strain, cervical spondylosis, cervical discogenic pain, cervical facet syndrome, diffuse skeletal hyperostosis, cervical radiculopathy, and cervical spondylotic myelopathy. Neck rotation may be more prominently affected by upper cervical spine abnormalities (C1 to C3), whereas lateral flexion impairment may be more prominent with lower cervical spine disease (C4 to C7).

●Muscle palpation – The paraspinal and upper trapezius muscles should be palpated to determine the degree of tenderness and spasm (picture 3). Paraspinal muscular tenderness can result from trauma to neck, head, or upper back, or it can be a nonspecific feature of a number of cervical spine syndromes.

Trapezius muscle tenderness is a nonspecific finding seen in many conditions including cervical muscle strain, fibromyalgia, whiplash, or cervical radiculopathy. Severe muscular rigidity and guarding are associated with severe neck strain, occult vertebral body fracture, and fracture/dislocation.

The superior division of the trapezius muscle is often quite hard on palpation in older adults. The dorsal kyphotic posture (prominent C7 spinous process, drooped shoulders, and head forward) places the trapezius under constant tension. The extremes of rotation may show endpoint stiffness and mild pain.

Neurologic examination — A neurologic examination is warranted for all patients with new-onset neck pain, trauma, moderate or persistent neck pain symptoms, and referred shoulder or arm pain. It should include muscle strength, sensory, reflex and gait testing, and evaluation for upper motor neuron signs. The detailed neurologic examination is described separately. (See "The detailed neurologic examination in adults".)

A negative neurologic examination indicates a low likelihood of nerve root compression; however, positive findings are not specific for root compression [36].

Although there is some overlap in presentation, assessment of muscle strength, reflexes, and sensation, in combination with symptoms, can often target a specific root lesion in patients with cervical radiculopathy (table 1). (See "Clinical features and diagnosis of cervical radiculopathy".)

Provocative maneuvers — The following maneuvers may be helpful in patients with symptoms or signs of cervical radiculopathy:

●Spurling's maneuver – The Spurling's maneuver and modified Spurling's maneuver can be used to reproduce radicular pain. The Spurling's maneuver (also called the neck compression test) is performed by keeping the head in a neutral position and tapping or pressing down on the top of the head. If this fails to reproduce the patient's pain, the procedure is repeated with the head extended and rotated and tilted to the affected side (the modified Spurling’s maneuver) (picture 4). Several other head positions, including flexion, may be tested to provoke nerve irritation. Reproduction of symptoms beyond the shoulder is considered positive, whereas reproduction of neck pain alone is nonspecific. The modified Spurling's maneuver is most likely to provoke symptoms in patients with foraminal stenosis, central stenosis, or disc herniation involving the foramen. These tend to be the most common causes of radicular pain. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Pathophysiology'.)

This maneuver is highly specific for the presence of cervical root compression, but it has variable sensitivity [37]. Thus, a positive test is helpful, but a negative test does not rule out radicular pain. In a systematic review, the specificity of the Spurling's maneuver was consistently high, ranging from 0.89 to 1.00; sensitivity varied from 0.38 to 0.97 [37].

The Spurling maneuver should be performed with caution in patients with suspected rheumatoid arthritis, cervical malformations, or metastatic disease since it may cause further injury to the spine.

●Elvey's upper limb tension test – The Elvey's upper limb tension sign is a root tension sign for the upper extremity, which is akin to the straight leg raise in the lower extremity. The head is turned contralaterally, and the arm is abducted with the elbow extended. Reproduction of arm symptoms is considered positive. In one study, the sensitivity and specificity of Elvey's upper limb tension test were 0.97 and 0.22, respectively [38].

●Manual neck distraction test – Vertical upward traction is applied simultaneously under the jaw and at the occiput, mimicking the effect of traction. This test is positive if the pain is decreased when the head is lifted, indicating pressure on the nerve roots has been relieved (picture 5).

The sensitivity of testing may be increased by using a combination of these tests rather than a single test [39].

Assessment of severity — Assessment of pain severity can help inform decision-making regarding need for imaging and/or treatment. Mild pain generally refers to pain that does not limit or interrupt daily activities (such as driving, desk work, or sleep), does not affect performance of occupation, and is easily ignored when distracted. Moderate to severe pain generally refers to pain that negatively affects sleep or the ability to perform daily activities and/or occupation.

A 2007 multidisciplinary task force proposed the following classification schema for patients seeking care for neck pain [36]:

●Grade I – No signs of major pathology and little interference with daily activities

●Grade II – No signs of major pathology but may impact daily activities

●Grade III – Neck pain with neurologic signs or symptoms (radiculopathy)

●Grade IV – Neck pain with major pathology (eg, fracture, myelopathy, neoplasm, spinal infection)

These classifications can help determine urgency of care and appropriateness of intervention. For example, patients with grade I to II findings generally have a benign and self-limited course and initial treatment usually includes simple posture modifications, exercises to maintain range of motion, and/or use of oral analgesics [13]. Patients with grade III symptoms also tend to have a benign course, though some may require specific intervention. By contrast, patients with grade IV findings generally require more urgent evaluation and treatment. (See "Management of nonradicular neck pain in adults" and "Treatment and prognosis of cervical radiculopathy" and "Cervical spondylotic myelopathy", section on 'Treatment'.)

Imaging — Imaging is warranted in a small minority of patients with atraumatic neck pain (algorithm 1). In most patients in whom imaging is indicated, cervical spine radiography should be performed first. If this study identifies an abnormality other than age-appropriate degenerative changes, an MRI should then be obtained. However, if there is any concern for a potentially serious diagnosis (eg, infection, malignancy, serious neurologic deficits, or signs of spinal cord compression), an urgent MRI of the cervical spine should be performed instead of radiography.

Indications — While most atraumatic neck pain does not require imaging, it is generally indicated in patients with one or more of the following characteristics [40-42]:

●Progressive neurologic findings suggesting spinal cord compression, myelopathy (eg, muscle weakness or atrophy, sensory deficits, gait disturbance, bladder dysfunction), or severe radiculopathy

●Constitutional symptoms (fevers, chills, unexplained weight loss)

●Infectious risk (eg, injection drug use, immunosuppression) in conjunction with signs of infection such as fever, chills, generalized aches, or leukocytosis (though some patients with immunocompromise may not demonstrate leukocytosis in the setting of infection)

●History of malignancy

●Persistent moderate to severe neck pain (eg, lasting >6 weeks and affecting sleep or ability to perform daily activities and/or occupation)

As noted above, MRI imaging should be performed urgently in patients suspected of having an infection, malignancy, or spinal cord compression.

In the absence of red flags (table 5), imaging is not necessary in patients with mild acute or chronic neck pain that does not limit or interrupt daily activities, does not affect performance of occupation, and is easily ignored when distracted. Patients who have undergone low-velocity neck trauma (eg, whiplash) also generally do not require imaging.

The appropriateness of imaging, choice of examination modality, and use of contrast depends upon the clinical circumstances:

●Major neck trauma – The approach to cervical spine imaging in patients with major trauma is summarized in the algorithm and discussed in greater detail separately (algorithm 2). (See "Cervical spinal column injuries in adults: Evaluation and initial management".)

●Suspected spine or deep tissue infection – MRI of the cervical spine with contrast is the appropriate choice for evaluation of suspected osteomyelitis. If MRI is contraindicated or not available, cervical spine CT with contrast is an acceptable alternative. The diagnostic approach in patients with suspected osteomyelitis or deep tissue infection is discussed elsewhere. (See "Vertebral osteomyelitis and discitis in adults", section on 'Suggested clinical approach' and "Deep neck space infections in adults", section on 'Clinical suspicion and urgent imaging'.)

●Suspected malignancy – MRI of the cervical spine without and with contrast is the appropriate choice for evaluation of suspected malignancy. If MRI is contraindicated or not available, CT with contrast is an acceptable alternative. Technetium-99m skeletal scintigraphy (bone scan) or ¹⁸FDG-PET/CT may also be useful in patients with known or suspected malignancy to detect other sites of metastatic disease. The diagnostic approach to suspected malignancy is discussed elsewhere. (See "Epidemiology, clinical presentation, and diagnosis of bone metastasis in adults", section on 'Detection and diagnosis' and "Spinal cord tumors", section on 'Imaging'.)

●Myelopathy – In patients presenting with symptoms and signs of myelopathy (eg, lower extremity weakness, gait or coordination difficulties, bladder or bowel dysfunction), an urgent cervical spine MRI without contrast should be performed. If MRI is contraindicated or unavailable, CT myelography of the cervical spine is an acceptable alternative. (See "Cervical spondylotic myelopathy", section on 'Imaging'.)

●Progressive radiculopathy – Patients with serious neurologic deficits (eg, motor weakness) and/or progressive symptoms and signs of radiculopathy should undergo imaging with cervical spine MRI without contrast. If MRI is contraindicated or unavailable, CT myelography of the cervical spine is an acceptable alternative. If imaging reveals a corresponding anatomic abnormality (eg, disc protrusion, synovial cyst, foraminal or spinal canal stenosis), these findings can be used to guide treatment with surgical or percutaneous image-guided intervention. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Imaging studies' and "Treatment and prognosis of cervical radiculopathy".)

●Persistent moderate to severe neck pain without red flags – Imaging is indicated for patients with persistent moderate to severe neck pain (eg, lasting >6 weeks and affecting sleep or ability to perform daily activities and/or occupation) even if they lack "red flags" (table 5). For most of these individuals (eg, without concern for infection or malignancy, no localizing neurologic symptoms or signs, no major trauma), the preferred initial examination is cervical spine radiography. If there are concerning abnormalities noted on cervical spine radiography (eg, endplate erosion and soft tissue swelling raising concern about discitis/osteomyelitis, bony destruction raising concern about metastases, or bony remodeling suggesting underlying mass), cervical spine MRI with contrast should be performed. MRI is generally not indicated if radiographs are normal or show only degenerative changes.

For patients with indwelling hardware from prior surgery, radiography is the first-line imaging examination; it evaluates for hardware failure and adjacent transition level degeneration.

Modalities — Imaging examinations most commonly used to evaluate neck pain are radiography and MRI of the cervical spine. CT or CT myelography of the cervical spine serves as an alternative if MRI is contraindicated or unavailable. CT is the preferred examination in patients with history of major trauma (see "Suspected cervical spine injury in adults: Choice of imaging"). Plain-film myelography and Tc-99m bone scan of the neck are rarely used for evaluating for neck pain. Whether to use contrast with MRI or CT depends on the suspected diagnosis. (See 'Indications' above.)

Radiography — Cervical spine radiography or x-ray series typically consists of anterior-posterior (AP) and lateral views. The lateral view demonstrates vertebral alignment; the normal cervical lordotic curve can be replaced by a straightened or even a reversed curve in moderate to severe cases of cervical strain. The lateral view is also used to screen for the degree of osteoarthritis at facet and paravertebral joints, disk space narrowing from osteoarthritis, or other bony pathology (eg, compression fracture).

Views other than the AP and lateral are generally not necessary in patients with suspected degenerative disease of the spine. Additional views may be useful in certain circumstances:

●Swimmer's view – A swimmer's view may be necessary for improved visualization of the cervicothoracic junction when obscured by overlying structures.

●Odontoid view – A supplemental open mouth (odontoid) view is often included in the setting of suspected atlantoaxial disease such as with inflammatory arthropathy and in suspected torticollis [43,44].

●Flexion and extension views – Flexion and extension views are added if underlying cervical spine instability is suspected (eg, degenerative, rheumatoid arthritis, Down syndrome). They are also used in patients with a history of cervical spine surgery (eg, discectomy and fusion, prosthetic disc) to assess mobility [45-47]. These views are not routinely performed in most patients as the clinical yield is low. In a series of 258 patients undergoing radiography for evaluation of neck-related disorders (axial cervical, upper extremity radicular, or myelopathic symptoms), findings on flexion and extension views did not reveal any findings that changed clinical management [48].

●Oblique views – In most cases, oblique views add little information, and their routine use is not recommended [49].

The estimated radiation dose from cervical spine radiographs varies with the number of views but is approximately 1.5 mSv (table 6).

If cervical spine radiography is normal or shows only for age-appropriate degenerative changes and the clinical evaluation does not reveal an appropriate indication for MRI, no further imaging is necessary.

Magnetic resonance imaging — Cervical spine MRI is more sensitive than radiography for detecting most etiologies of neck pain. MRI enables visualization of the spinal cord and nerve roots, bone marrow, discs and other soft tissues.

MRI is used to assess appropriateness and guide localization of surgical or percutaneous needle therapy [50-53]. However, a clear delineation of the suspected location of the spinal cord level or nerve root based on the symptoms and signs is essential if the MRI results are to be useful. Abnormalities such as disk herniation, bulge, or foraminal stenosis are seen in up to 19 percent of asymptomatic individuals [6]. Consequently, MRI should be obtained and findings interpreted in the context of a clinically suspected diagnosis.

Common contraindications to MRI are implanted cardiovascular devices not labeled "MRI safe," severe claustrophobia, or inability to lie still for the 20- to 30-minute duration of the examination. (See "Patient evaluation for metallic or electrical implants, devices, or foreign bodies before magnetic resonance imaging".)

Cervical spine MRI is usually performed without contrast. When underlying malignancy or infection is suspected, a gadolinium-based contrast agent (GBCA) is administered intravenously. Common contraindications to intravenous GBCA include pregnancy or a history of allergic reaction to gadolinium. Severe kidney disease (estimated glomerular filtration rate [eGFR] ≤30) is also a contraindication for administration of certain classes of earlier-generation GBCAs [54]. (See "Patient evaluation before gadolinium contrast administration for magnetic resonance imaging".)

Computed tomography — For most imaging indications of atraumatic neck pain, cervical spine CT or CT myelography is performed only when MRI is not available or contraindicated. Because CT images cortical bone better than MRI, CT is preferred in patients with history of major trauma for fracture detection. (See "Suspected cervical spine injury in adults: Choice of imaging".)

CT is also preferred over MRI for evaluating hardware failure or lack of fusion in patients with indwelling orthopedic hardware from prior surgery. However, radiography is usually the first-line imaging examination in such patients. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Issues related to prior surgery'.)

For most patients presenting with neck pain who undergo cervical spine CT as an alternative to MRI (because MRI is not available or contraindicated), CT is usually performed without contrast. However, this depends on the specific clinical concern:

●If infection or malignancy is suspected, intravenous iodinated contrast is administered.

●If cord compression is suspected, CT myelography can be performed. In this examination, CT is performed after intrathecal administration of contrast material. Compared with noncontrast CT, CT myelography better visualizes narrowing of the spinal canal but does not improve evaluation of the neural foramina as the root sleeves do not usually extend into the foramina.

CT myelography involves an intrathecal injection with attendant <1 percent risk for minor adverse events (eg, self-limited hematoma, transient nerve root irritation); serious complications are rare [55]. In addition, headache is common following lumbar puncture performed for any reason, occurring in approximately 20 to 30 percent of cases [56]. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment", section on 'Adverse events'.)

Acute reaction from iodinated contrast has also been reported and is thought to occur at lower rates than with intravenous administration. (See "Diagnosis and treatment of an acute reaction to a radiologic contrast agent", section on 'Iodinated contrast'.)

The estimated radiation dose from cervical spine CT is approximately 8.8 mSv [57].

Less commonly used studies

Electrodiagnostic testing — Electrodiagnostic tests (eg, electromyography, nerve conduction studies) are not necessary for the routine evaluation of neck pain. These tests are sometimes used to distinguish cervical radicular pain from other causes of extremity dysesthesia (eg, peripheral nerve entrapment, peripheral neuropathy). The role of electrodiagnostic testing in evaluation of patients with cervical radiculopathy and cervical spondylotic myelopathy is discussed separately. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Electrodiagnostic studies' and "Cervical spondylotic myelopathy", section on 'Electrophysiology'.)

A detailed description of these tests are provided in separate topic reviews. (See "Overview of electromyography" and "Overview of nerve conduction studies".)

Laboratory tests — Laboratory studies are not necessary for the routine evaluation of neck pain, particularly if a musculoskeletal etiology is suspected. Laboratory testing may be helpful when non-spinal causes of neck pain are suspected (eg, rheumatologic, infectious, oncologic). Examples include (see 'Non-spinal conditions' above):

●Markers of inflammation (eg, erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) may be elevated in patients with chronic inflammatory conditions (eg, polymyalgia rheumatica, giant cell arteritis, rheumatoid arthritis). (See "Clinical manifestations and diagnosis of polymyalgia rheumatica" and "Diagnosis and differential diagnosis of rheumatoid arthritis" and "Clinical manifestations of giant cell arteritis".)

●Complete blood cell count (CBC) with differential, ESR, CRP, and appropriate cultures should be obtained in patients with suspected infection. (See "Vertebral osteomyelitis and discitis in adults", section on 'Suggested clinical approach'.)

●CBC, urinalysis, and basic serum chemistries may be appropriate in initial tests in patients with suspected malignancy. (See "Overview of the classification and management of cancers of unknown primary site", section on 'Subsequent evaluation of CUP'.)

●Electrocardiogram and troponin are appropriate if myocardial ischemia is suspected. (See "Approach to the patient with suspected angina pectoris", section on 'Diagnostic tests in all patients'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Upper spine and neck disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Neck pain (The Basics)" and "Patient education: Whiplash (The Basics)")

●Beyond the Basics topic (see "Patient education: Neck pain (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy – Neck pain is common in adults, with a prevalence of 10 to 20 percent. The most common cause of acute and chronic neck pain in adults is degenerative changes of the cervical spine, which can present with or without neurologic dysfunction. The most common locations that exhibit degenerative changes are between C4 and C7, affecting the C5, 6, and 7 nerve roots. However, degenerative changes do not correlate well with presence or severity of pain. (See 'Introduction' above and 'Anatomy' above.)

●Causes – The differential diagnosis of neck pain is broad. The majority of neck pain complaints are likely related to musculoskeletal causes, but numerous other conditions can present with neck pain (table 2) (see 'Causes' above):

•Axial neck pain – Axial neck pain may be caused by muscle strain, disc degeneration, whiplash, cervical facet osteoarthritis, myofascial pain, or diffuse skeletal hyperostosis. (See 'Musculoskeletal conditions' above.)

•Neck pain with extremity pain or deficit – Neck pain associated with extremity pain and/or neurologic deficit may be caused by cervical radiculopathy, cervical spondylotic myelopathy, or, less commonly, ossification of the posterior longitudinal ligament (OPLL). These conditions are discussed separately. (See "Cervical spondylotic myelopathy" and "Clinical features and diagnosis of cervical radiculopathy".)

•Non-spinal causes – Non-spinal conditions that may present with neck pain include coronary artery disease, diabetic neuropathy, local and systemic infections, malignancy, neurologic conditions (eg, tension headache), referred shoulder pain, rheumatologic conditions (polymyalgia rheumatica, fibromyalgia), thoracic outlet syndrome, vascular disease, and visceral conditions (eg, esophageal obstruction, biliary disease). Many of these conditions are evident based on the clinical setting, accompanying symptoms (eg, fever, neck stiffness, diffuse joint pain) or other "red flag" findings (table 5).

●Red flags – Although cervical spine degenerative changes are the most common cause of neck pain in adult patients, it is important to be aware of signs and symptoms that may indicate more serious pathology (table 5). (See 'Red flags' above.)

●Evaluation – The physical examination includes observation of neck movement, range of motion, palpation of the trapezius and paraspinal muscles, neurologic examination for radicular and upper motor neuron signs, and provocative maneuvers. (See 'History and physical examination' above.)

●Imaging for some patients – Only a minority of patients with nontraumatic neck pain require imaging (algorithm 1). Imaging is generally indicated in the following circumstances (see 'Indications' above):

•Serious, persistent, or progressive neurologic findings suggesting spinal cord compression, myelopathy, or severe radiculopathy

•Constitutional symptoms (fevers, chills, unexplained weight loss)

•Infectious risk (eg, injection drug use, immunosuppression)

•History of malignancy

•Persistent moderate to severe neck pain (eg, lasting >6 weeks and affecting sleep or ability to perform daily activities and/or occupation)

●Imaging modalities – For patients with an indication for imaging, the choice of initial imaging modality and use of contrast depends on the clinical circumstances (see 'Indications' above and 'Modalities' above):

•For evaluation of suspected infection or malignancy, MRI of the cervical spine with contrast is the appropriate choice. (See "Vertebral osteomyelitis and discitis in adults", section on 'Suggested clinical approach' and "Spinal cord tumors", section on 'Imaging'.)

•In patients presenting with symptoms and signs of myelopathy or progressive radiculopathy, MRI without contrast is the appropriate choice. If MRI is contraindicated or unavailable, CT myelography is an acceptable alternative. (See "Cervical spondylotic myelopathy", section on 'Imaging' and "Clinical features and diagnosis of cervical radiculopathy", section on 'Imaging studies'.)

•For most other patients in whom imaging is indicated, cervical spine radiography is usually the initial study. If radiography suggests an underlying abnormality other than age-appropriate degenerative changes, an MRI with contrast should be obtained.

●Other tests

•Electrodiagnostic tests (eg, electromyography, nerve conduction studies) are not necessary for the routine evaluation of neck pain. These tests are sometimes used to distinguish cervical radicular pain from other causes of extremity dysesthesia (eg, peripheral nerve entrapment, peripheral neuropathy). (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Electrodiagnostic studies' and "Cervical spondylotic myelopathy", section on 'Electrophysiology'.)

•Laboratory testing for patients with neck symptoms is not routinely indicated, particularly if a musculoskeletal etiology is suspected. Laboratory testing may be helpful when non-spinal causes of neck pain are suspected (eg, rheumatologic, infectious, oncologic). (See 'Laboratory tests' above.)