Neck Pain:​Initial Evaluation

and Management
Marc A. Childress, MD, and Samantha Jayne Stuek, MD
Virginia Commonwealth University Fairfax Family Practice, Fairfax, Virginia

Neck pain is a common presenting symptom in the primary care setting and
causes significant disability. The broad differential diagnosis requires an efficient
but global assessment;​therefore, emphasis is typically placed on red flags that
can assist in the early recognition and treatment of more concerning diagnoses,
such as traumatic injuries, infection, malignancy, vascular emergencies, and
other inflammatory conditions. The critical element in appropriate diagnosis and
management of these conditions is an accurate patient history. Physical exam-
ination findings complement and refine diagnostic cues from the history but
often lack the specificity to be of value independently. Diagnostic tools such as

Illustration by John Karapelou

imaging and electrodiagnostic tests have variable utility, especially in chronic or
degenerative conditions. Treatment of mechanical or nonneuropathic neck pain
includes short-term use of medications and possibly injections. However, long-
term data for these interventions are limited. Acupuncture and other complementary and alternative therapies may be helpful
in some cases. Advanced imaging and surgical evaluation may be warranted for patients with worsening neurologic function
or persistent pain. (Am Fam Physician. 2020;​102(3):​150-156. Copyright © 2020 American Academy of Family Physicians.)

Neck pain is a common presenting symptom in pri- symptoms and the presence of neuropathic vs. nonneuro-
mary care, with an incidence of 10.4% to 21.3% per year.1 pathic symptoms can help determine the urgency of the
It is the fourth leading cause of disability worldwide.1 The evaluation.
prevalence of neck pain is higher in older adults because When evaluating a patient with neck pain, the physician
of degenerative changes in facet joints and the collapse of must be alert for red flags in the history and physical exam-
intervertebral disks.2 It is estimated that only one in five ination that may indicate the need for urgent testing and
people with neck pain seeks medical care.3 The differen- intervention. Similar to guidelines for the evaluation of
tial diagnosis is broad and includes common conditions lower back pain, a systematic approach that maintains vig-
such as muscular strains and arthritis, as well as more dire ilance for severe pathology in the neck is recommended.4
conditions such as fractures, spinal cord and nerve inju- Table 1 summarizes some of the more serious diagnoses and
ries, neoplastic disorders, infections, and inflammatory their associated clinical findings, as well as recommended
conditions. Family physicians must be able to recognize diagnostic tests. Figure 1 is a recommended approach to
when neck pain signals a potentially serious condition and patients with neck pain. This article does not focus on acute
should be able to generate an accurate diagnosis through traumatic injuries or vascular emergencies, but these ele-
findings from the patient’s history, physical examination, ments warrant consideration based on the presentation.
and appropriate testing. Rapidly progressive neuropathic symptoms warrant
more aggressive evaluation. Injury to the central spinal cord
Focused History or nerve roots may be the result of degenerative changes,
Obtaining an accurate clinical history is critical in the ini- trauma, mass effect, infection, or other inflammatory or
tial evaluation of neck pain. Acute vs. chronic timing of demyelinating conditions. Even without an acute presenta-
tion, physicians should be mindful of myelopathic signs and
CME This clinical content conforms to AAFP criteria for symptoms.4 Myelopathy refers to neurologic compromise
CME. See CME Quiz on page 143. resulting from a disturbance of spinal cord tracts within
Author disclosure:​ No relevant financial affiliations. the spinal canal. Initial symptoms include deep, aching
neck pain with possible radicular symptoms and muscle

150 American
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 NECK PAIN

weakness;​these can quickly progress

to gait changes, ataxia, and bowel BEST PRACTICES IN NEUROLOGY
and bladder dysfunction. Physical
5

examination findings associated with Recommendations from the Choosing Wisely Campaign
a myelopathic disease process include Recommendation Sponsoring organization
increased muscle tone, fasciculation,
clonus, hyperreflexia, the Babinski Do not do nerve conduction studies without also American Association of Neu-
doing a needle electromyogram for testing for romuscular & Electrodiagnostic
reflex, and the Lhermitte and Hoff- radiculopathy, a pinched nerve in the neck or back. Medicine
mann signs.
Concurrent systemic symptoms of Source:​For more information on the Choosing Wisely Campaign, see https://​w ww.choosing​
wisely.org. For supporting citations and to search Choosing Wisely recommendations relevant
fever, fatigue, or rash could indicate to primary care, see https://​w ww.aafp.org/afp/recommendations/search.htm.
an infectious etiology. These symp-
toms in a patient with neck stiffness,
photophobia, or other focal neuropathic findings should Certain comorbid disorders and patient factors increase
raise concern for meningitis, epidural abscess, or diskitis the risk of cervical spine conditions (Table 2). Cervical spine
(i.e., a bacterial infection of the intervertebral disk tissue). pathology is present in more than one-half of patients with
Similarly, neck pain in the setting of described or observed rheumatoid arthritis, and the long-term risk of severe pathol-
weight loss, significant lymphadenopathy, unexplained ogy in these patients is higher than in unaffected people.6
fever, or fatigue may signal malignancy or an underlying Individuals with trisomy 21 are at risk of atlanto-occipital
inflammatory condition. instability, which should prompt concern for complications

TABLE 1

Findings That Warrant Urgent Evaluation in Patients with Neck Pain

Condition Historical findings Physical examination findings Next steps

Infection (e.g., diskitis, epi- Fever, meningism, night sweats, Kernig sign, nuchal rigidity, Antibiotics, CRP, ESR, lumbar
dural abscess, herpes zoster, photophobia photophobia puncture, MRI with or with-
meningitis, osteomyelitis) out contrast, white blood
cell count

Inflammatory condition Generalized joint pain, morning Other joints affected CRP, ESR, radiography, rheu-
(e.g., ankylosing spondylitis, stiffness that improves with exercise matoid factor testing
polymyalgia rheumatica,
rheumatoid arthritis)

Malignancy (e.g., chor- Anorexia, fever, history of malig- Significant bony tender- MRI
doma, metastasis, multiple nancy, intractable night pain, pain ness, other signs similar to
myeloma, spinal cord tumor) not relieved at rest, weight loss myelopathy

Myelopathy (e.g., amyo- Ataxia, bowel and bladder dysfunc- Babinski reflex, clonus, Electromyelography, MRI,
trophic lateral sclerosis, tion, deep aching neck pain, gait fasciculations, Hoffmann urgent neurosurgical
cervical cord compression, changes, tremor, possible radicular sign, hyperreflexia, increased consultation
transverse myelitis) symptoms or weakness muscle tone, Lhermitte sign

Thoracic outlet syndrome Intermittent paresthesias, pain Positive Roos test, tender- MRI or ultrasonography
worsened by use, unilateral ness to palpation over distal (duplex or arterial)
symptoms;​may be confused with arm veins or at insertion of
cervical radiculopathy pectoralis minor

Vascular emergency (e.g., Ripping or tearing sensation in neck, Kernig sign, unilateral Urgent referral and imaging
arterial dissection, verte- diplopia, drop attacks, headache, decrease in sensation, unilat- (CT or CT angiography)
brobasilar insufficiency) syncope, transient ischemic attack eral weakness
symptoms, vertigo, vision changes

CRP = C-reactive protein;​CT = computed tomography;​ESR = erythrocyte sedimentation rate;​MRI = magnetic resonance imaging.

August 1, 2020 ◆ Volume 102, Number 3 www.aafp.org/afp American Family Physician 151
 NECK PAIN

of even mild trauma, as well

FIGURE 1 as for advanced or prema-
ture degenerative changes.7
Patient presents with neck pain Ankylosing spondylitis can
cause neck stiffness and pain.
History of trauma? (Low threshold in patients older than 50 years and in
Patients with this condition
those with rheumatoid arthritis, ankylosing spondylitis, or trisomy 21) also have an increased risk
of complications from mild
trauma.8 Numerous other
Yes No
processes and conditions can
Plain radiography; consider computed be considered in the differ-
tomography if instability is a concern; con- ential of neck pain, includ-
sult with specialist if findings are concerning ing herpes zoster, angina,
endocrine and compressive
Red flags for infection, malignancy, or systemic disease (e.g., tumors, fibromyalgia, and
fever, weight loss, injection drug use, immunocompromise)? psychogenic pain. Many of
these conditions can overlap
and be part of multifactorial
Yes No
presentations. One study
Plain radiography, MRI, blood Concern for myelopathy (e.g., estimated that 43% of neck
culture, complete blood count, ataxia, decreased dexterity, pain cases are nonneuro-
erythrocyte sedimentation rate, balance difficulty, urinary
and C-reactive protein level urgency, hyperreflexia, clonus)?
pathic, 7% are neuropathic,
and 50% are mixed.9
The remainder of the
Consultation with spinal surgeon Yes No patient history should focus
on specific descriptions of
MRI; consultation Neuropathic symptoms (e.g., radicular
with spinal surgeon pain, loss of distal sensation, extrem- any injury, including poten-
ity weakness, reflex asymmetry)? tial mechanism, inciting and
relieving factors, and pain
patterns throughout the day.
Yes No

Progressive neurologic Physical therapy, home exercises, short-term

Physical Examination
deficit over 3 to 4 weeks? pain medications; consider plain radiography The physical examination
should target concerns
Yes No Persistent symptoms? revealed in the history
and distinguish between
MRI; surgical Physical therapy, home mechanical and neuro-
referral exercises, short-term pain Yes No pathic symptoms. Localized
medications; observe for
change in function and pain Consider alternate Continue current
bony tenderness or prom-
diagnoses, with specific management inence is an indication for
evaluation and care as with focus on imaging, whereas soft tissue
warranted; can consider improved function
complementary and
tenderness may represent
Improvement No improvement alternative therapies (e.g., myofascial pain, infection, or
beyond 4 to 6 weeks massage, acupuncture) lympha­deno­pathy. Although
range of motion measure-
Continue current
management with focus Consider MRI and ments are widely referenced,
on improved function surgical evaluation their diagnostic relevance is
MRI = magnetic resonance imaging. limited and nonspecific.10,11
Range of motion can be
Algorithm for evaluation and treatment of patients with neck pain. more useful in identifying
asymmetry or provocation

152 American Family Physician www.aafp.org/afp Volume 102, Number 3 ◆ August 1, 2020
 NECK PAIN

of local or radiating symptoms (e.g., shooting pain down the

TABLE 2 spine with neck flexion or extension).
Provocative tests can be helpful in the evaluation of sus-
Comorbid Conditions and Patient Factors pected neuropathic conditions (Table 3).12-15 The specificity
Associated with Neck Pain of the Spurling test (Figure 2 12) and the high sensitivity of
Condition/patient factor Potential pathology the upper limb tension test (Figure 312) make these evalu-
ations particularly valuable if radiculopathy is suspected.16
Age > 50 years Degenerative changes that
narrow the spinal canal, poten-
Further examination should include upper and lower
tially leading to myelopathy extremity strength and deep tendon reflexes if neuropathic
conditions are suspected. Radiculopathy is manifested
Chronic inflammation, Mar- Frailty fracture by dermatomal-based upper extremity pain (Figure 412),
fan syndrome, rheumatoid
arthritis changes in sensation, and weakness. In contrast, myelopa-
thy at similar levels in the neck can provoke less overt lower
Diabetes mellitus, immuno- Infection extremity findings, such as balance difficulties, spastic-
suppression, injection drug
ity, and weakness. Examination may reveal atrophy of the
use, kidney failure, liver fail-
ure, long-term steroid use hands, hyperreflexia, and the Lhermitte sign.5

Previous or current Spinal metastasis vs. primary Imaging and Other Diagnostic Tests
malignancy malignancy
The American College of Radiology recommends plain
Previous trauma Bony or ligamentous disrup- radiography as the initial imaging modality in patients
tion, whiplash-associated with new or increasing nontraumatic neck pain who do not
disorder have red flag symptoms.17 Validated clinical tools such as
Trisomy 21 Subluxation from atlantoaxial the National Emergency X-Radiography Utilization Study
ligament laxity criteria and the Canadian C-Spine Rule can help deter-
mine when radiography may be helpful.17,18 Immediate

TABLE 3

Provocative Tests for the Evaluation of Neck Pain

Test Description Clinical relevance

Babinski Dorsiflexion of the big toe when the plantar aspect of the foot is Limited stand-alone value, but can be more spe-
reflex stimulated with the blunt end of a reflex hammer (typically lateral cific when evaluating compressive upper motor
to medial from heel to metatarsal) neuron conditions (e.g., myelopathy)

Hoffmann Thumb adduction and flexion at the distal phalanx with possible Upper motor neuron test;​has low positive pre-
sign finger flexion after flicking the distal tip of the third or fourth finger dictive value for localizing spinal vs. brain lesions

Lhermitte Electric shock sensation down the spine or into the limbs with Suggests nonspecific central cord compression
sign neck flexion or extension or provocation;​can be positive in patients with
cervical myelopathy, multiple sclerosis, intraspi-
nal masses, or certain acute infections

Spurling test Passively move the patient’s neck into lateral flexion and extension, Well-established specificity and sensitivity for
(Figure 2) then apply gentle downward axial compression;​a positive result is cervical radiculopathy
pain radiating to the upper limb ipsilateral to the rotation position

Upper limb With patient supine and the shoulder in a neutral position with Highest sensitivity for cervical radiculopathy;​
tension test the elbow flexed, depress the shoulder, abduct it to 90 degrees, recommended for combined use with the
(Figure 3) extend the elbow and fingers, then extend and supinate the wrist Spurling test in patients with suspected cervical
while the patient flexes the neck to the contralateral and then ipsi- radiculopathy
lateral sides;​a positive result is reproduction of pain at any step

Information from references 12-15.

August 1, 2020 ◆ Volume 102, Number 3 www.aafp.org/afp American Family Physician 153
 FIGURE 2 FIGURE 3

Demonstration of the Spurling test. Lateral flexion

and extension of the neck with axial compression.
Illustration by Marcia Hartsock
Adapted with permission from Childress MA, Becker BA. Nonoper-
ative management of cervical radiculopathy [published correction
appears in Am Fam Physician. 2017;​96(9):​566]. Am Fam Physician.
2016;​93(9):​749.

radiography does not improve patient-oriented outcomes B

in those who do not have recent trauma or red flag symp-
toms.18 In addition, imaging can detect abnormalities even Upper limb tension test. (A) Scapular depression with
in asymptomatic patients;​for example, magnetic resonance shoulder abduction. (B) Contralateral flexion of the
imaging (MRI) detects degenerative cervical disks in 15% of neck with extension of the elbow, wrist, and fingers,
asymptomatic patients in their 20s, increasing to more than and supination of the wrist.
85% of asymptomatic patients older than 65.19 Reprinted with permission from Childress MA, Becker BA. Non-
operative management of cervical radiculopathy [published cor-
The time to diagnosis and intervention can be critical
rection appears in Am Fam Physician. 2017;​96(9):​566]. Am Fam
when serious conditions are suspected. MRI is recom- Physician. 2016;​93(9):​749.
mended for patients with suspected infection, overt neu-
rologic compromise, or progressive neurologic symptoms;​
it may be appropriate for patients with moderate to severe Treatment Principles
neck pain that lasts longer than six weeks and does not In the absence of red flag findings that require urgent
resolve with standard treatment.20 Computed tomography care, treatment can generally focus on the patient’s level of
may be useful in trauma cases, when bony disruption is sus- pain and function. Many patients will improve over time,
pected, or when MRI is contraindicated. regardless of treatment or whether the cause is neuropathic
Electromyography and nerve conduction studies are not or nonneuropathic. For example, most patients with cervi-
recommended for patients with neck pain unless they also cal radiculopathy will improve with nonsurgical care:​80%
have numbness, weakness, or pain in the arms or legs. There to 90% have significantly improved pain and resolution of
is insufficient evidence for electrodiagnostic testing, even in weakness or reflex deficits within four weeks.21,22
cases of suspected radiculopathy.20 Electromyography may Conservative care for patients with neck pain often
be useful when peripheral neuropathy of the upper extrem- includes medications for pain relief. Although practice pat-
ity is a suspected alternative diagnosis.20 terns may prompt the use of specific agents, there is little

154 American Family Physician www.aafp.org/afp Volume 102, Number 3 ◆ August 1, 2020
 NECK PAIN
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Myelopathic signs and symptoms such as C Expert consensus evidence to support the long-term use
lower extremity weakness, balance prob- of these medications in most patients
lems, and bowel and bladder irregularities
with neck pain. Nonsteroidal anti-
should be evaluated and treated urgently. 5
inflammatory drugs and oral muscle
Patients with neck pain should be assessed C Consensus, usual prac- relaxants are commonly recommended
for comorbidities because underlying tice, expert opinion, for patients with nonneuropathic pain.
inflammatory or rheumatologic conditions disease-oriented evidence,
increase the risk of cervical spine injury. 6,8
and case series Data on the effectiveness of these med-
ications for neck pain are limited;​how-
Electrodiagnostic studies should not be C Consensus guideline, ever, these agents are not effective for
used routinely in the evaluation of isolated expert opinion, and
neck pain without peripheral neuropathic disease-oriented evidence
similar musculoskeletal conditions,
symptoms. 20 such as low back pain.23 Although there
is some evidence that oral corticoste-
Narcotic pain medications have no benefit B Systematic review
for cervical pain and should be used with
roids provide short-term pain relief in
caution. 26 patients with acute radiculopathy,24
there is little evidence that any medi-
A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality
patient-oriented evidence;​ C = consensus, disease-oriented evidence, usual practice, expert
cation affects recovery. Tramadol may
opinion, or case series. For information about the SORT evidence rating system, go to https://​ have some benefit, but only in the short
www.aafp.org/afpsort. term.25 Narcotics can provide modest
short-term pain relief, but there is no
evidence of sustained benefit, and the
risks of cognitive impairment and abuse limit their use.26
FIGURE 4 Inflammatory conditions may briefly respond to steroids
or nonsteroidal anti-inflammatory drugs, but there is min-
imal evidence that these medications provide lasting benefit
in degenerative conditions, despite their widespread use.4
C7 Similarly, injections of anesthetics, corticosteroids, or bot-
C6 ulinum toxin have shown little or no long-term benefit in
C5 acute or chronic neck pain.27,28 There is limited evidence for
the short-term use (one to two months) of radiofrequency
C8 ablation in patients with persistent cervical pain.29
T1
Given the broad range of potential neck pain etiologies
and the variety of complementary and alternative treatment
options, it is challenging to determine the value of these
treatments for neck pain. They generally provide modest
benefit compared with medication alone or no therapy.30
C5 Acupuncture has modest benefit in patients with mechan-
C6 ical neck pain.31 Isolated manipulation and mobilization
C7
C8 may provide temporary pain relief but not consistent long-
term benefit.32 Treatments such as dry needling, low-level
laser therapy, transcutaneous electrical nerve stimulation,
and compression therapy have some potential for short-
term pain relief, but no reliable long-term data exist to offer
specific guidance for these options.33,34
Surgical referral is warranted in cases of progressive neuro-
Dermatomal distribution of common cervical radicu-
lar symptoms.
logic deficit. For persistent but nonprogressive cases, appro-
priate thresholds and timing for referral are unclear. There is
Illustration by John Karapelou
some evidence to support surgical referral after four to eight
Adapted with permission from Childress MA, Becker BA. Nonoper- weeks of ongoing pain, but long-term data are limited.35
ative management of cervical radiculopathy [published correction
appears in Am Fam Physician. 2017;​96(9):​566]. Am Fam Physician. Data Sources:​ A PubMed search was completed in Clinical Que-
2016;​93(9):​748. ries using the key term neck pain in combination with the follow-
ing varied strings:​diagnosis, evaluation, and differential diagnosis.

August 1, 2020 ◆ Volume 102, Number 3 www.aafp.org/afp American Family Physician 155
 NECK PAIN

The search included meta-analyses, randomized controlled trials, 13. Davies BM, Mowforth OD, Smith EK, et al. Degenerative cervical
clinical trials, and reviews. Also searched were the Agency for myelopathy. BMJ. 2018;​360:​k 186.
Healthcare Research and Quality Effective Healthcare Reports, 14. Grijalva RA, Hsu FP, Wycliffe ND. Hoffmann sign:​clinical correlation
the Cochrane database, DynaMed, and Essential Evidence Plus. of neurological imaging findings in the cervical spine and brain. Spine
Search dates:​May 1 and July 18, 2019, and May 16, 2020. (Phila Pa 1976). 2015;​40(7):​475-479.
15. Cook C, Roman M, Stewart KM, et al. Reliability and diagnostic accuracy
of clinical special tests for myelopathy in patients seen for cervical dys-
The Authors function. J Orthop Sports Phys Ther. 2009;​39(3):​172-178.
16. Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of
MARC A. CHILDRESS, MD, is chair of the Department of the diagnostic accuracy of provocative tests of the neck for diagnosing
Family Medicine at Inova Fairfax (Va.) Hospital and associate cervical radiculopathy. Eur Spine J. 2007;​16(3):​307-319.
director of the Primary Care Sports Medicine Fellowship at 17. American College of Radiology. ACR Appropriateness Criteria:​cervical
Virginia Commonwealth University Fairfax Family Practice. neck pain or cervical radiculopathy. Updated 2018. Accessed June 30,
2019. https://​acsearch.acr.org/docs/69426/Narrative/
SAMANTHA JAYNE STUEK, MD, is a second-year resident at 18. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain:​
Virginia Commonwealth University Fairfax Family Practice. systematic review and meta-analysis. Lancet. 2009;​373(9662):​463-472.
19. Matsumoto M, Fujimura Y, Suzuki N, et al. MRI of cervical intervertebral
Address correspondence to Marc A. Childress, MD, Virginia discs in asymptomatic subjects. J Bone Joint Surg Br. 1998;​80(1):​19-24.
Commonwealth University Fairfax Family Practice, 3650 Joseph 20. Bono CM, Ghiselli G, Gilbert TJ, et al.;​North American Spine Society.
Siewick Dr., Ste. 400, Fairfax, VA 22033 (email:​mchildress@​ An evidence-based clinical guideline for the diagnosis and treatment of
ffpcs.com). Reprints are not available from the authors. cervical radiculopathy from degenerative disorders. Spine J. 2011;​1 1(1):​
64-72.
21. Honet JC, Puri K. Cervical radiculitis:​treatment and results in 82
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156 American Family Physician www.aafp.org/afp Volume 102, Number 3 ◆ August 1, 2020