Red flags
- Fever, night sweats, or unexplained weight loss
- Excruciating pain, cervical lymphadenopathy, intractable night pain, pain that is increasing, exquisite tenderness over the vertebral body, or generalised neck stiffness
- Nausea or vomiting
- New or severe headache
- Photophobia or phonophobia
- Visual loss
- Skin erythema, wounds, or exudate
For other red flags symptoms please review: NICE CKS: What are the signs and symptoms of cervical radiculopathy?
Are Red flags present?
- YES:
- YES: Urgent phone to Orthopaedics on-call (Bleep 3000) plus SCI referral
- ?contact MSCC
- NO: Follow assessment pathway
Neck assessment pathway
| Non-specific neck pain |
Nerve root radicular pain +/- radiculopathy |
Whiplash |
Acute Torticollis |
|
Gradual or sudden onset
+/- diffuse shoulder/scapulae pain
+/- headaches
Positional asymetry, limited AROM often asymmetrical.
No objective loss of sensation or muscle strength
Non dermatomal spread
Possible tenderness in intervertebral joints/ hypertonic muscles/ tenderness.
|
Gradual or sudden onset
Neck pain with bilateral or unilateral shoulder pain that approximates to that of a dermatome.
Postural asymmetry
Cx AROM may be limited and pain may radiate into U/Ls with AROM.
Neuro signs- dermatomal/ myotomal / reflex changes
|
Neck pain, stiffness and headache post trauma.
Reduced Cx AROM
Muscle spasm +/- U/L pain / paraesthesia
May experience fatigue, dizziness, dysphagia or nausea.
May experience deafness or tinnitus
May experience memory loss
May experience TMJ pain
Psychological considerations
|
Sudden onset
No history of trauma
Unilateral neck / shoulder pain
Diffuse muscle spasm and tenderness
Abnormal Cx movements
Asymmetrical head position and neck
Recurrence is common
|
- Consider Self Supported Management
- Review Cx spine guidance as necessary
- Refer onto MSK PHYSIOTHERAPY if no improvement with self management.
- Consider yellow flags / other pathology / structures / Alternative findings / Medication history / pain control / Natural history / communication /education / patient empowerment
|
|
Most will resolve in days to 8 weeks.
1 to 2 may continue to have low-grade symptoms or recurrences for more than one year.
Can recur or become chronic
Non-specific neck pain info
|
Most will improve within 4 weeks.
After 4 to 6 weeks consider onward referral to ORTHOPAEDICS if persistent debilitating arm pain +/- loss of power or sensation remain unchanged/ worsening despite conservative treatment, including neurogenic analgesia
Radicular neck pain info
|
Recovery times may vary.
Approx 40% recover within 12 weeks.
Approx 50% recover within 1 year.
Whiplash info
|
Usually resolve 7 to 10 days.
Majority resolve <6 to 8 weeks
Torticollis info
|
No improvement
- Consult senior colleague
- Reflect / Review guidance & spinal guidance.
- Discuss with spinal team.
Refer to GP:
- If appropriate analgesics are required
- Systemic inflammatory disease is suspected
- A non MSK pathology is suspected as source of symptoms (ie.visceral)
- Patient exhibits high levels of distress with the possibility of clinical levels of anxiety and depression.
Refer to Neurosurgery:
- The patient presents with persistent debilitating arm pain with progressive neurological deficit (e.g. loss of power/sensation/altered reflexes) and they are not responding to treatment
- OR persistent myotomal weakness is detected at any one nerve root in the absence of pain
- OR myotomal weakness is detected at more than one spinal nerve root.
- Referral may also be made if the patient wants a further opinion/investigation, or is unable to accept the self-management philosophy.
Refer to Chronic Pain:
- Patients with persistent non-specific neck pain and significant yellow flags that hamper their ability to engage in an active rehabilitation process should also be discussed with a senior colleague. Where appropriate, these patients should then be referred to the pain management team for a multidisciplinary biopsychosocial assessment.
TAM (Treatments and Medicines) NHS Highland
