Red Flags - The Neck

Neck Pain - Red Flags

Neck pain is often poorly defined and often vague, however it is important to rule out serious pathology before beginning treatment.

Subjective Assessment - History

The pattern of pain should be determined immediately. Site, onset, nature and radiation are all things to take note of, as well as any previous surgery and/or trauma/injury.

Older patients often have a narrower cervical canal and are more likely to have osteoporosis. Younger patients could have congenital abnormalities of the spine.

Red flags include:

- Signifiant preceding neck surgery or trauma

- Systemic upset (weight loss, night sweats, fever)

- Severe pain

- Nocturnal pain

- <20 yrs old or >50 yrs old

- Signs of spinal cord compression

- Significant tenderness of vertebral body

- History of TB, HIV, Cancer or Inflammatory Arthritis

Neurological symptoms should prompt a neurological examination to exclude spinal cord compression or cervical myelopathy (such as clumsy hands, altered gait, disturbances of sexual, bladder or sphincter function). A background of inflammatory arthritis or Down's syndrome increases the chances of a more serious problem.


Expose and examine the neck and shoulders. Test for tenderness around the vertebrae which may suggest a vertebral fracture. Palpate laterally to assess cervical ribs for any issues.

Assess movements at the neck. Neck flexion may bring on "Lhermitte's Phenomenon" - which is where the patient may experience "electric shock" or a radiating burning sensation. This could suggest myelopathy (disease of the spinal cord) or demyelination (disease where the myelin sheath is damaged).

Neurological examinations would be conducted. Disc prolapse is common at C5/6 and C6/7. Inverted reflexes may suggest cervical myeloradiculopathy (disease of the spinal cord and spinal cord roots). Absent reflexes may be present at the level of the lesion and below. For example, a C5/6 lesion would give absent biceps reflex but the triceps, C7, may be exaggerated.

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