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Evaluation of the adult patient with neck pain

Authors:
Zacharia Isaac, MD
Hillary R Kelly, MD
Section Editors:
Steven J Atlas, MD, MPH
Jeffrey G Jarvik, MD, MPH
Deputy Editors:
Lisa Kunins, MD
Susanna I Lee, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Oct 22, 2018.

INTRODUCTION — Neck pain has a prevalence of 10 to 20 percent in the adult population,

which 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 without recent major trauma is
addressed here. Acute traumatic neck injury, cervical radiculopathy, and cervical
spondylotic myelopathy are discussed separately:
●Cervical spine injury (see "Evaluation and acute management of cervical spinal column
injuries in adults" and "Spinal column injuries in adults: Definitions, mechanisms, and
radiographs")
●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 "Treatment of neck pain".)
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). (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. 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. 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 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.
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) is supportive; however, these findings are very common in asymptomatic
individuals [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 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 "Evaluation and acute management
of cervical spinal column injuries in adults", section on 'Clinical decision rules to determine
need for imaging'.)
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]. Other
factors that may affect reported symptom duration include cultural differences in
expectations of pain and the possibility of financial compensation [19,21-23] 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 [23].
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 [24]. 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 juxtapositioned to the
facet joints [25].
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. The diagnosis can be more definitively
established by demonstrating relief of symptoms with a local anesthetic injection to the
facet joint innervation [26,27].
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.
MPS is discussed in detail separately. (See "Overview of soft tissue rheumatic 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
1). 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 2).
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. Provocative maneuvers are often positive (see 'Provocative
maneuvers' below). The diagnosis of cervical radiculopathy is suspected on the basis of
clinical presentation. MRI scan showing evidence of cervical nerve root compression is
supportive but 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 focal neurologic signs in the arms and/orlegs. 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 2). Differential diagnosis includes multiple sclerosis, syringomyelia,
tumor, epidural abscess, amyotrophic lateral sclerosis, and other causes of spinal cord
dysfunction (table 3).
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 [28-31]. Its pathogenesis is not known,
but it is more common in Asians than non-Asians and in men than women. 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 [28,32]. 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. 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 "Angina
pectoris: Chest pain caused by myocardial ischemia")
●Infection – Osteomyelitis, discitis, deep neck abscess, meningitis (see "Vertebral
osteomyelitis and discitis in adults" and "Deep neck space infections" and "Clinical
features and diagnosis of acute bacterial meningitis in adults")
●Malignancy – Metastatic disease to 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: Pathophysiology, clinical features, and
diagnosis" and "Classification and 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 "Spontaneous
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 cholecystitis:
Pathogenesis, clinical features, and diagnosis" and "Superior pulmonary sulcus (Pancoast)
tumors")
EVALUATION
General approach — Initial assessment of the patient with neck pain begins with
identification of any "red flags," including recent major trauma (table 4), which will guide
the pace and nature of the diagnostic evaluation. (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, computed tomography [CT], or magnetic resonance
imaging [MRI]) is generally reserved for patients with red flags (table 4), 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 "Evaluation and acute management of
cervical spinal column injuries in adults".)
Red flags — The following clinical characteristics suggest the potential for serious disease
that requires urgent evaluation (table 4):
●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 3). (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 and 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 4). 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 "Classification and 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 degrees (picture 1).
•The cervical spine can bend an average of 45 degrees laterally (picture 2).
•The cervical spine can forward flex to 60 degrees.
•The cervical spine can extend backward 75 degrees.
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 [33].
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 (picture 4). The Spurling's maneuver (also called the
neck compression test) is performed by keeping the head in a forward flexed, ipsilaterally
rotated, and ipsilaterally tilted position. The modified Spurling's maneuver is performed by
keeping the head extended, ipsilaterally rotated, and ipsilaterally tilted. Additional axial
load by applying pressure on top of the head can be applied. 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 a
lower sensitivity [34]. 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 [34].
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. The sensitivity and specificity of
Elvey's upper limb tension test were 0.97 and 0.22, respectively, in one study [35].
●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 [36].
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 [33]:
●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 "Treatment of neck pain" 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.
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, 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 [37,38]:
●Progressive neurologic findings suggesting spinal cord compression or myelopathy (eg,
muscle weakness or atrophy, sensory deficits, gait disturbance, bladder dysfunction)
●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)
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 4), 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 1). (See "Evaluation and acute management of cervical spinal column injuries in
adults", section on 'Radiographic evaluation of cervical spinal column injury'.)
●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", section on 'Imaging'.)
●Suspected malignancy – Cervical spine MRI with contrast the appropriate choice for
evaluation of suspected malignancy. If MRI is contraindicated or not available, cervical
spine 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 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 4). 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 without 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 "Evaluation and acute
management of cervical spinal column injuries in adults", section on 'Radiographic
evaluation of cervical spinal column injury'). 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 are 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 [39,40].
●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 [41-43]. 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 [44].
●Oblique views – In most cases, oblique views add little information, and their routine use
is not recommended [45].
The estimated radiation dose from cervical spine radiographs varies with the number of
views but is approximately 1.5 mSv (table 5).
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 [46-49]. 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.
Cervical spine MRI is usually performed without contrast. When underlying malignancy or
infection is suspected, gadolinium contrast is administered intravenously. Common
contraindications to intravenous gadolinium contrast include severe renal disease
(estimated glomerular filtration rate [eGFR] ≤30) and pregnancy.
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 "Evaluation and acute
management of cervical spinal column injuries in adults", section on 'CT for cervical spinal
column injury'.)
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 the
usually the first-line imaging examination is 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 neuroforamina 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 [50]. In addition, headache is common following lumbar puncture
performed for any reason, occurring in approximately 20 to 30 percent of cases [51].
(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 "Immediate hypersensitivity
reactions to radiocontrast media: Clinical manifestations, diagnosis, and treatment".)
The estimated radiation dose from cervical spine CT is approximately 2 mSv.
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 'Initial evaluation'.)
●Electrocardiogram and troponin are appropriate if myocardial ischemia is suspected.
(See "Angina pectoris: Chest pain caused by myocardial ischemia", section on 'Laboratory
tests'.)
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 5th to 6th 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 12th 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
●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. (See 'Introduction' above and 'Anatomy' above.)
●The differential diagnosis of neck pain is broad. The majority of neck pain complaints are
related to musculoskeletal causes, but numerous other conditions can present with neck
pain (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 4).
●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 4). (See 'Red flags' above.)
●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.)
●Only a minority of patients with nontraumatic neck pain require imaging. Imaging is
generally indicated in the following circumstances (see 'Indications' above):
•Progressive neurologic findings suggesting spinal cord compression or myelopathy
•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)
●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, magnetic resonance imaging (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, computed tomography (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 without contrast should be obtained.
●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.)
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designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst
Rev 2017; 4:CD010807.
Topic 7773 Version 37.0
GRAPHICS
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Lateral views of the cervical spine in two individuals with DISH. The
disc height is well preserved in both. The individual with more
extensive involvement (right panel) complained of mild dysphagia.
DISH: diffuse idiopathic skeletal hyperostosis.
Courtesy of John Esdaile, MD.
Graphic 75500 Version 3.0

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zone of reference (gray area)from Sheon,
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each trigger point. Tissue Rheumatic Pain: Recognition,
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dermatome. Patients with nerve root syndromes may have pain, paresthesias,
1996.
Goldberg, VM. Soft Tissue Rheumatic Pain: Recognition,
and diminished sensation in the dermatome of the nerve that is involved.
Graphic 79295 Version
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1996.
classification criteria
Graphic 66839 Version 1.0
for DISH
Criteria of Resnick and Niwayama
1. The presence of flowing calcification and ossification along the anterolateral aspect of at least
four contiguous vertebral bodies with or without associated localized pointed excrescences at the
intervening vertebral body-intervertebral disc junctions.
2. The presence of relative preservation of intervertebral disc height in the involved vertebral
segment and the absence of extensive radiographic changes of "degenerative" disc disease,
including vacuum phenomena and vertebral body marginal sclerosis.
3. The absence of apophyseal joint bony ankylosis and sacroiliac joint erosion, sclerosis, or
intraarticular osseous fusion.
Criteria of Utsinger
1. Continuous ossification along the anterolateral aspect of at least four contiguous vertebral
bodies, primarily in the thoracolumbar spine. Ossification begins as a fine, ribbon-like wave of
bone but commonly develops into a broad, bumpy, buttress-like band of bone.
2. Continuous ossification along the anterolateral aspect of at least two contiguous vertebral
bodies.
3. Symmetrical and peripheral enthesopathy involving the posterior heel, superior patella, or
olecranon, with the entheseal new bone having a well-defined cortical margin.
Exclusions:
i) Abnormal disc space height in the involved areas
ii) Apophyseal joint ankylosis
Categories of DISH according to the Utsinger criteria are:
Definite = criterion 1
Probable = criteria 2 and 3
DISH: diffuse idiopathic skeletal hyperostosis.
Data from: Resnick D, Niwayama G. Radiographic and pathologic features of spinal
involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976;119:559;
and Utsinger PD. Diffuse idiopathic skeletal hyperostosis. Clin Rheum Dis 1985; 11:325.
Graphic 60298 Version 6.0
MRI of cervical spondylitic myelopathy Important causes of
spinal cord
dysfunction*
Clini
Co Dia
Ag cal
urs gno
e featu
e sis
res
Mode
rate-
sever
e
Cer cases
vic Pro demo
al Us gres nstrat
spo ual sive e gait MRI
nd ly or and cerv
ylo >6 step leg ical
tic 0 wis spasti spin
my yea e city e
elo rs cou and
pat rse amyo
Cervical spondylitic myelopathy. Sagittal T2-weighted MRI of the hy troph
cervical spine shows spinal canal narrowing due to disc- y of
osteophyte complexes indenting the ventral aspect of the spinal hand
cord (arrows) and abnormal T2 hyperintense cord signal or
(arrowhead) confirming the diagnosis of myelopathy.
arms
MRI: magnetic resonance imaging.
Graphic 55057 Version 4.0 Chi
Tra
ldr
nsv Segm
en,
ers Sub ental MRI
yo
e acut cord and
un
my e syndr CSF
g
elit ome
adu
is
lts
 Pure motor syndrome or
Viral myelitis Any age Acute-subacute segmental cord MRI and CSF
syndrome
Epidural Subacute; may Segmental cord
Any age MRI
abscess worsen abruptly syndrome
Usually >60 MRI with diffusion-
Infarction Abrupt onset Anterior cord syndrome
years weighted sequences
>40 years
(dural fistula)
Vascular Acute and/or MRI, spinal
20s Radiculomyelopathy
malformation stepwise angiography
(intramedullary
AVM)

Subacute
Slowly
combined Any age Dorsal cord syndrome Vitamin B12 levels
progressive
degeneration
Slowly
progressive; Segmental cord
MRI, clinical
Radiation Any age beginning 6 to 12 syndrome or ventral
history
months after cord syndrome
radiation therapy
Children, Slowly
Syringomyelia Central cord syndrome MRI
young adults progressive
Epidural Usually >50 Subacute; may Segmental cord
MRI
metastasis years worsen abruptly syndrome
MRI with
Intramedullary Slowly
Young adults Central cord syndrome gadolinium
tumor progressive
enhancement
Usually >60
ALS Progressive Pure motor syndrome Electromyography
years
MRI: magnetic resonance imaging; CSF: cerebrospinal fluid; AVM: arteriovenous
malformation; ALS: amyotrophic lateral sclerosis.
* This is a partial list of causes. Refer to UpToDate topics on disorders affecting the spinal
cord for a more complete differential diagnosis.
Graphic 50336 Version 3.0
Red flags in patients with neck pain
Symptom or Clinical
finding significance
Raises
concern for
Recent major neck
cervical
trauma
spine
fracture
Neurologic Raises
symptoms or signs concern for
that suggest spinal cervical cor
cord issue (eg, d
 weakness, gait
difficulty, bowel or
compression
bladder
dysfunction)
Suggestive
Shock-like
of cervical
paresthesia
cord
(Lhermitte's
compression
phenomenon) with
or multiple
neck flexion
sclerosis
Suggestive
Fever or chills
of infection
Raises
concern for
History of injection
cervical
drug use
spine or disc
infection
Raises
Immunosuppressio
concern for
n
infection
Raises
concern for
infection or
Chronic
cervical
glucocorticoid use
spine
compression
fracture
Suggestive
Unexplained weight
of
loss
malignancy
Raises
concern for
metastatic
History of cancer
disease to
cervical
spine
Suggestive
of rheumatic
Headache, shoulder
disease (eg,
or hip girdle pain,
polymyalgia
or visual symptoms
rheumatica,
in older patient
giant cell
arteritis)
Suggestive
of a non-
Anterior neck pain spinal cause
(eg, angina
pectoris)
Graphic 114880 Version 3.0
Passive
Lateral
Upper
Spurling
Manual
Cervical
trapezius
bending
neck
neck
spine
maneuver
distraction
rotation
imaging
of
muscle
the
to detect
neck
of
palpation
test
adults
for
cervical
cervical
following
radiculopathy
radiculopathy
trauma Radiation dose
estimates for
spine imaging
Procedure Approximate effective dose Comparable duration of
(mSv) natural background
radiation (years)
Spine radiograph (x-ray) 1.5 0.5
CT spine 6 2
Fluoroscopic interventional 5 1.7
angiogram of the head and neck
CT angiogram of the head and 14 4.7
neck
CT: computed
tomography.
Data from:
1. RadiologyInfo
.org.
Available
at: https://w
ww.radiologyi
The upper portion of the trapezius muscle originates from the nfo.org/en/inf
seven cervical spinous processes and the distal aspect of the o.cfm?
The Spurling maneuver is used to detect cervical radiculopathy.
The paravertebral
acromial process. Palpate
and facet thejoints
superiorof thetrapezius
vertebral muscle
bodieshalfway
and the pg=safety-
Several
supporting
between positions
the muscles
acromionof allow
theand
head
the may be
spinous
neck to testedan
processes.
bend toaverage
provoke
Local ofnerve
muscular45 xray (Accesse
irritation.
Loss of First, the
rotation is maneuver
the universal is sign
performed
of neck with the head
pathology. Theheld in a
degrees laterally.
tenderness can result
The frompatient
trauma,
is asked buttothe
relax.
majority
The examiner
of cases are d on
neutral
patient
places
due position.
is
to one asked
reactive The
to
handcervical
on examiner
relax.
the muscular
shoulder taps
The examiner
and orone
strain. presses
places
handone down hand
on the on the
on of
side top
thetheof December 6,
the
CT: head.
computed
shoulder If this fails to on
tomography; reproduce
OR: the
operatingpatient'sis pain,
room; the procedure
C-spine: cervical
head.
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Bruce is hand
passively
C Anderson, the chin.
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MD. The
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spine; NEXUS: towith the
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side.head
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in the isneutral
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position. With
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radiographic
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Graphic 56871 Version 3.0 expeditiously. Refer to text for details. with common
Courtesy of Maria E Moreira, MD. computed
Graphic 93206 Version 2.0 tomography
examinations and the associated lifetime attributable risk of cancer. Arch Intern
Med 2009; 169:2078.
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[Atrial fibrillation]. Employment: Healthwise Inc [Patient education
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