Atraumatic Neck PainAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

625 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Atraumatic Back Pain Sciatica And Radicular Back Pain Back Pain With Neurologic Deficit, Cauda Equina Concern Back Pain With Fever Or Immunosuppression, Spinal Infection Concern Atraumatic Neck Pain Neck Pain After Trauma Neck Pain With Meningismus Concern Acute Torticollis

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx73

HPI and context

›Neck pain syndrome characterization

›Time course

›Preceding activity

›Mechanical trigger

›Recent infection symptoms

›Recent procedure

›Recent chiropractic manipulation

›Recent travel

›Sick contacts

OPQRST

›OPQRST framework

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with movement

›Worse with swallowing

›Worse with coughing

›Relief with rest

›Relief with heat

›Quality

›Aching

›Sharp

›Burning

›Electric shock

›Region and radiation

›Midline posterior neck

›Paraspinal

›Radiation to shoulder

›Radiation to arm

›Radiation to jaw

›Severity

›Pain score 0 to 10

›Functional limitation severity

›Timing

›Constant

›Intermittent

›Nocturnal pain

›Morning stiffness duration

Associated symptoms

›Associated symptoms cluster

›Headache

›Fever

›Neck stiffness

›Photophobia

›Nausea

›Vomiting

›Dizziness

›Visual symptoms

›Dysarthria

›Dysphagia

›Facial droop

›Limb weakness

›Limb numbness

›Gait difficulty

›Bowel dysfunction

›Bladder dysfunction

›Chest pain

›Dyspnea

›Odynophagia

›Sore throat

Prior episodes and baseline

›Baseline and recurrence

›Prior similar episodes

›Prior imaging

›Prior injections

›Prior surgery

›Baseline neurologic status

›Baseline functional level

Special populations

›Population modifiers

›Pregnancy

›Postpartum

›Older adult

›Immunocompromised state

›Anticoagulant use

›Diabetes mellitus

02Alarm Features/alarm33

Immediate escalation triggers

›Immediate escalation criteria

›Airway compromise signs

›Hemodynamic instability

›Rapidly progressive neurologic deficit

›Altered mental status

›Sepsis physiology

High risk neurologic features

›Neurologic red flags

›Myelopathy signs

›Objective motor weakness

›New gait impairment

›New saddle anesthesia

›New bowel dysfunction

›New bladder dysfunction

Infection and malignancy features

›Infection and malignancy red flags

›Fever

›Immunosuppression

›IV drug use

›Recent bacteremia

›Unexplained weight loss

›History of malignancy

›Night pain

Vascular and headache features

›Vascular red flags

›Thunderclap headache

›Neck pain with focal neurologic symptoms

›Neck pain with partial Horner syndrome

›Neck pain after minor neck trauma

›Neck pain after cervical manipulation

Vital sign danger thresholds

›Concerning vital signs

›Temperature 38.0 C or higher

›Heart rate 120 or higher

›Systolic blood pressure under 90

›Respiratory rate 30 or higher

›Oxygen saturation under 92 percent on room air

03Medications/meds19

Current therapies and recent changes

›Medication exposure inventory

›Prescribed analgesics

›OTC analgesics

›Topical analgesics

›Muscle relaxants

›Neuropathic agents

›Recent steroid course

›Recent antibiotic course

High risk medication classes

›Medication risks relevant to neck pain workup

›Anticoagulants

›Antiplatelet agents

›Chronic corticosteroids

›Immunosuppressants

›Chemotherapy agents

Contraindications and interaction traps

›Common contraindications

›NSAID risk

›Acetaminophen cumulative dose risk

›Sedation risk with muscle relaxants

›Serotonergic agent interaction risk

04Diet/diet8

Exposures that can amplify symptoms

›Intake and exposure factors

›Dehydration risk

›Poor oral intake

›Caffeine excess

›Energy drink exposure

Metabolic contributors

›Metabolic contributors

›Reduced protein intake

›Reduced sleep associated intake changes

05Review of Systems/ros36

Neurologic

›Neurologic symptoms

›Headache

›Vision change

›Vertigo

›Syncope

›Weakness

›Numbness

›Paresthesia

›Ataxia

›Seizure

Infectious and inflammatory

›Inflammatory symptoms

›Fever

›Chills

›Night sweats

›Myalgias

›Rash

ENT and airway

›Upper aerodigestive symptoms

›Sore throat

›Odynophagia

›Dysphagia

›Voice change

›Drooling

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Diaphoresis

Musculoskeletal

›Musculoskeletal symptoms

›Shoulder pain

›Arm pain

›Joint swelling

›Morning stiffness

GI and GU

›Autonomic and sphincter symptoms

›Urinary retention

›Urinary incontinence

›Fecal incontinence

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral sources

›Family member history

›Caregiver history

›EMS report

›Prior chart review

Family history relevant to secondary causes

›Family history screen

›Premature coronary artery disease

›Aortic disease

›Stroke at young age

›Connective tissue disorder

Household and exposure context

›Exposure context

›Household viral illness

›Tuberculosis exposure

›Occupational exposure to infection

07Risk Factors/rf25

Infection risk

›Spinal infection risk factors

›IV drug use

›Indwelling vascular access

›Recent skin infection

›Recent dental infection

›Recent spinal procedure

›Diabetes mellitus

›Immunosuppression

Vascular risk

›Cervical artery dissection risk factors

›Minor neck trauma

›High velocity sports

›Recent cervical manipulation

›Migraine history

›Connective tissue disorder

Malignancy and fracture risk

›Structural risk factors

›Known malignancy

›Unexplained weight loss

›Chronic corticosteroid exposure

›Osteoporosis

›Anticoagulation

Degenerative and occupational risk

›Mechanical risk factors

›Repetitive overhead work

›Prolonged screen posture

›Heavy lifting job

›Prior cervical degenerative disease

08Differential Diagnosis/ddx75

Life threatening

›Life threatening etiologies

›Spinal epidural abscess (G06.1)

›Fever or sepsis physiology

›Focal neurologic deficit

›Elevated CRP or ESR

›Meningitis (G00.9)

›Fever

›Photophobia

›Altered mental status

›Cervical artery dissection (I77.71 carotid, I77.74 vertebral)

›Headache or neck pain with focal deficits

›Partial Horner syndrome

›Recent minor neck trauma

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Neck stiffness

›Vomiting

›Acute coronary syndrome atypical presentation (I21.9)

›Neck or jaw pain with exertion

›Diaphoresis

›Dyspnea

›Retropharyngeal abscess (J39.0)

›Fever

›Odynophagia

›Neck stiffness

›Cervical spinal cord compression

›Progressive weakness

›Hyperreflexia

›Gait dysfunction

Common

›Common etiologies

›Cervical strain and myofascial pain (M54.2)

›Paraspinal tenderness

›Worse with movement

›Cervical facet mediated pain

›Localized paraspinal pain

›Pain with extension rotation

›Cervical radiculopathy (M54.12)

›Dermatomal pain

›Paresthesia

›Positive Spurling

›Cervicogenic headache (G44.86)

›Unilateral neck triggered headache

›Reduced cervical range of motion

›Tension type headache (G44.209)

›Band like headache

›Stress or poor sleep trigger

Less common and zebras

›Less common etiologies

›Cervical myelopathy

›Hand clumsiness

›Wide based gait

›Polymyalgia rheumatica (M35.3)

›Age 50 or older

›Morning stiffness

›Rheumatoid arthritis cervical involvement (M06.9)

›Longstanding inflammatory arthritis

›Neurologic symptoms

›Ankylosing spondylitis axial spondyloarthritis (M45)

›Inflammatory back pain features

›Reduced spinal mobility

›Herpes zoster (B02.9)

›Dermatomal pain

›Rash evolution

›Thyroiditis (E06.9)

›Anterior neck pain

›Systemic symptoms

Mimics and pitfalls

›Mimics and pitfalls

›Shoulder pathology referred pain

›Pain with shoulder range of motion

›Normal cervical exam

›Temporomandibular disorder

›Jaw pain

›Clicking

›Esophageal pathology

›Odynophagia

›Chest discomfort

09Past Medical History/pmh17

Relevant chronic conditions

›Chronic disease modifiers

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Chronic kidney disease (N18.9)

›Coronary artery disease (I25.10)

›Stroke or TIA (I63.9 or G45.9)

›Cancer history (Z85.9)

›HIV (B20)

Prior procedures and devices

›Prior spine and invasive history

›Prior cervical surgery

›Prior epidural injection

›Implanted neurostimulator

›Indwelling vascular catheter

Baseline function

›Baseline function and supports

›Independent ambulation status

›Baseline continence status

›Home supports reliability

10Physical Exam/exam45

General and vitals

›Overall appearance and stability

›Toxic appearance

›Fever pattern

›Hemodynamic stability

›Respiratory distress signs

Neck and spine

›Cervical spine exam

›Midline tenderness

›Paraspinal tenderness

›Range of motion limitation

›Pain with rotation

›Pain with extension

›Step off deformity

Neurologic

›Neurologic exam

›Mental status

›Cranial nerves

›Motor strength upper extremity

›Motor strength lower extremity

›Sensation

›Reflexes

›Hoffmann sign

›Clonus

›Babinski sign

›Gait assessment

Meningeal and headache focused

›Meningeal irritation screen

›Nuchal rigidity

›Photophobia observed

›Rash

Vascular and cardiopulmonary

›Vascular and heart exam

›Carotid bruit

›Pulse symmetry

›Cardiac auscultation

›Lung exam

ENT and airway

›ENT and airway assessment

›Oropharynx appearance

›Trismus

›Voice quality

›Drooling

Musculoskeletal adjacent joints

›Shoulder and upper limb screen

›Shoulder range of motion

›Rotator cuff strength

›Scapular tenderness

Pitfalls

›Pitfalls and subtle findings

›Pain out of proportion

›Objective weakness masked by pain

›New hyperreflexia

11Lab Studies/labs30

Infection and inflammation

›Infection and inflammation labs

›CBC

›Leukocytosis

›Neutrophil predominance

›CRP

›Elevated value supports inflammatory process

›Normal value does not exclude early infection

›ESR

›Elevated value supports inflammatory process

›Normal value does not exclude early infection

›Blood cultures when febrile or sepsis physiology

›Two sets before antibiotics when possible

›Contamination risk interpretation

Metabolic and medication safety

›Metabolic safety labs

›Creatinine and electrolytes

›NSAID safety context

›Contrast safety context

›AST ALT when acetaminophen heavy use risk

›Hepatic dysfunction risk context

›Alcohol use risk context

Cardiac and vascular evaluation

›Cardiac evaluation when referred pain concern

›Troponin with ischemic concern

›Serial testing timing local protocol dependent

›Early negative does not exclude ACS

›D dimer not recommended as sole exclusion for dissection

›Variable performance

›False negatives reported

Pregnancy

›Pregnancy testing when relevant

›Urine pregnancy test

›Serum pregnancy test when high suspicion or critical decision

12Imaging/img65

Scoring Systems

›Decision tools for imaging selection

›NEXUS low risk criteria for cervical spine imaging in trauma

›Not validated for atraumatic presentations

›Consider only when trauma or fall history suspected

›Canadian C spine rule for cervical spine imaging in trauma

›Not validated for atraumatic presentations

›Consider only when trauma or fall history suspected

›Ottawa subarachnoid hemorrhage rule for acute headache

›Use when acute severe headache presentation fits criteria

›Not for chronic headache pattern

MRI

›MRI cervical spine

›Indications

›Suspected spinal epidural abscess

›Suspected vertebral osteomyelitis or discitis

›Myelopathy signs

›Progressive neurologic deficit

›Protocol pearls

›Gadolinium enhancement when infection concern

›Include whole region of suspected involvement

›Limitations

›Availability delays

›Motion artifact

›Contraindications and precautions

›Non compatible implanted device

›Severe claustrophobia

›CT based evaluation

›CT cervical spine without contrast

›Indications

›Suspected fracture with possible unwitnessed trauma

›Severe midline tenderness with high risk history

›Limitations

›Poor soft tissue infection detection compared with MRI

›Radiation exposure

›CTA head and neck

›Indications

›Suspected cervical artery dissection

›Focal neurologic symptoms with head or neck pain

›Contraindications and precautions

›Contrast allergy history

›Reduced kidney function

›Limitations

›False negatives for small intimal flaps

›Motion artifact

›CT head without contrast

›Indications

›Thunderclap headache with neck pain

›Altered mental status

›Limitations

›Sensitivity decreases with time from onset

›Does not exclude dissection

Ultrasound

›Ultrasound and POCUS roles

›Carotid duplex ultrasound

›Potential utility

›Hemodynamically significant stenosis detection

›Follow up imaging adjunct

›Limitations

›Limited for vertebral artery dissection

›Limited for high cervical segments

›Soft tissue ultrasound anterior neck

›Potential utility

›Superficial abscess detection

›Lymph node assessment

›Limitations

›Limited for deep space neck infection

›Does not replace CT neck when deep infection concern

13Special Tests/spec27

Bedside maneuvers for radicular patterns

›Cervical radiculopathy exam maneuvers

›Spurling test

›Reproduction of dermatomal arm pain

›Avoid excessive force

›Shoulder abduction relief sign

›Symptom relief suggests nerve root involvement

›Compare both sides

›Upper limb tension test

›Symptom reproduction with nerve tension

›False positives with myofascial pain

Myelopathy screening maneuvers

›Cervical myelopathy screening

›Hoffmann sign

›Suggests upper motor neuron involvement

›Not diagnostic alone

›Lhermitte phenomenon

›Electric shock sensation with neck flexion

›Suggests cervical cord pathology

Meningitis and deep infection evaluation

›CNS infection evaluation elements

›Lumbar puncture indications

›Suspected meningitis after neuroimaging decision

›Persistent concern with negative initial imaging

›Lumbar puncture cautions

›Concern for elevated intracranial pressure

›Coagulopathy or anticoagulation

Do not do items

›Avoid potentially harmful bedside tests

›Provocative vertebral artery tests

›High velocity cervical manipulation in acute pain

14ECG/ecg19

Indications in atraumatic neck pain

›ECG indications

›Neck or jaw pain with exertion

›Diaphoresis

›Dyspnea

›Syncope

›Older age with risk factors

High risk ECG findings

›High risk patterns

›ST elevation

›ST depression

›New T wave inversion

›New left bundle branch block

Rhythm and conduction

›Rhythm evaluation

›Atrial fibrillation

›Bradyarrhythmia

›Ventricular tachycardia

›High grade AV block

Serial ECG logic

›Serial ECG timing

›Repeat with ongoing ischemic symptoms

›Repeat with rising troponin local protocol dependent

15Assessment/ax26

Problem representation

›Clinical syndrome framing

›Uncomplicated mechanical neck pain

›Neck pain with radicular symptoms

›Neck pain with myelopathy features

›Neck pain with systemic infection features

›Neck pain with vascular or neurologic event concern

›Neck pain with deep neck space infection concern

Working diagnosis examples with codes

›Working diagnosis candidates

›Cervicalgia (M54.2)

›Localized paraspinal tenderness

›No objective neurologic deficit

›Cervical radiculopathy (M54.12)

›Dermatomal symptoms

›Provocative maneuver reproduction

›Cervicogenic headache (G44.86)

›Headache triggered by neck movement

›Reduced neck range of motion

Severity and risk stratification

›High risk categorization

›Any alarm feature present

›Objective neurologic deficit present

›Immunocompromised with severe pain

›Persistent severe pain with night pain

Diagnostic uncertainty

›Alternate diagnosis tracking

›Infection cannot be excluded yet

›Vascular etiology cannot be excluded yet

›Referred cardiopulmonary pain cannot be excluded yet

16Plan/plan47

First 5 minutes workflow for critical patient

›Immediate stabilization and triage

›Continuous pulse oximetry when unstable

›Cardiac monitor when cardiopulmonary concern

›Two large bore IV when sepsis or neurologic emergency concern

›Point of care glucose when altered mental status

›Early stroke team activation when focal neurologic deficits

Analgesia and symptom control

›Multimodal analgesia options

›Acetaminophen 1000 mg PO once

›Maximum 4000 mg per day

›Lower maximum with liver disease

›Ibuprofen 400 mg PO once

›Repeat every 6 to 8 hours as needed

›Maximum 2400 mg per day

›Naproxen 500 mg PO once

›Repeat 250 to 500 mg every 12 hours as needed

›Avoid with high GI bleed risk

›Topical diclofenac gel local application

›Avoid on broken skin

›Additive NSAID exposure awareness

›Cyclobenzaprine 5 mg PO

›Up to three times daily as needed

›Avoid in older adults due to anticholinergic effects

›Gabapentin 100 mg PO at night for neuropathic symptoms

›Titrate by 100 to 300 mg per dose

›Renal adjustment needed

›Opioids not routine

›Consider short course only for severe refractory pain

›Avoid with concurrent sedatives

Targeted diagnostics and sequencing

›Diagnostic sequencing

›MRI cervical spine with contrast when spinal infection concern

›CTA head and neck when dissection concern

›CT head when thunderclap headache concern

›ECG and troponin when ischemic concern

Antibiotics and sepsis pathway when indicated

›Suspected spinal epidural abscess or vertebral osteomyelitis pathway

›Blood cultures before antibiotics when feasible

›Broad spectrum IV antibiotics after cultures when unstable

›Neurosurgery consultation early

Monitoring and reassessment loop

›Reassessment loop

›Pain score response after treatment

›Repeat neurologic exam after analgesia

›Vital sign trend every 30 to 60 minutes when concerning

›Escalate if new weakness or sensory level

Consultations

›Consultation triggers

›Neurology when suspected dissection or stroke symptoms

›Neurosurgery or spine when myelopathy or epidural abscess concern

›ENT when deep neck infection concern

›Cardiology when ACS concern

17Disposition/dispo27

ICU and high acuity criteria

›ICU level care criteria

›Airway compromise

›Sepsis with vasopressor requirement

›Rapidly progressive neurologic deficit

›Acute stroke requiring intervention

Inpatient admission criteria

›Admission criteria

›Suspected spinal epidural abscess

›Suspected vertebral osteomyelitis or discitis

›Myelopathy signs

›Persistent uncontrolled pain despite ED therapy

›Unable to ambulate safely

›Deep neck infection concern

Observation pathway criteria

›Observation appropriate when

›Pain requires repeated parenteral therapy

›Pending MRI or CTA with stable vitals

›Serial troponin and ECG required

Discharge criteria and follow up

›Discharge criteria

›No alarm features

›Normal neurologic exam

›Pain controlled with oral regimen

›Reliable follow up

›Clear return precautions provided

›Follow up timing

›Primary care within 3 to 7 days

›Physical therapy referral within 1 to 2 weeks when mechanical pattern

›Neurology within 1 week for persistent radicular symptoms

›Spine specialist within 1 week for progressive radicular symptoms

18Discharge Instructions/di21

Copy discharge instructions

›Neck pain today appears most consistent with a non dangerous mechanical cause based on your exam and testing

›Return now if weakness develops in an arm or leg

›Return now if numbness spreads or you have trouble walking

›Return now if you cannot control urine or stool

›Return now if fever occurs or you feel progressively more unwell

›Return now if you develop a sudden severe headache

›Return now if you develop trouble speaking, facial droop, or vision changes

›Return now if chest pain or shortness of breath occurs

›Pain control options at home

›Acetaminophen up to 1000 mg every 6 to 8 hours as needed

›Do not exceed 4000 mg total in 24 hours

›Ibuprofen 400 mg every 6 to 8 hours as needed if safe for you

›Avoid ibuprofen if you have kidney disease, stomach bleeding history, or take blood thinners unless advised

›If a muscle relaxant was prescribed, do not drive or mix with alcohol

›Activity

›Gentle movement is usually better than bed rest

›Avoid heavy lifting until improving

›Avoid high velocity neck manipulation until cleared

›Follow up

›Arrange follow up with your clinician in 3 to 7 days

›Seek earlier follow up if symptoms are not improving in 48 to 72 hours

19References/r18

Guidelines and key evidence

›Neck Pain Clinical Practice Guidelines Revision 2017 Journal of Orthopaedic and Sports Physical Therapy 2017

›American Physical Therapy Association Orthopaedic Section linked CPG

›Focus on non surgical management and classification

›NICE Clinical Knowledge Summaries Neck pain cervical radiculopathy updated regularly

›Primary care pathway framing

›Symptom and red flag guidance

›IDSA Clinical Practice Guidelines for Native Vertebral Osteomyelitis in Adults 2015

›MRI with gadolinium emphasized for detecting epidural extension

›Blood cultures and targeted antimicrobial strategy

›ACEP Clinical Policy Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache 2019

›Secondary headache evaluation framework

›Imaging and lumbar puncture decision considerations

›AHA Scientific Statement Treatment and Outcomes of Cervical Artery Dissection in Adults 2024

›Antithrombotic therapy duration often 3 to 6 months

›Therapy choice individualized

›NEXUS Low Risk Criteria validation study New England Journal of Medicine 2000

›Trauma oriented cervical spine imaging rule

›Not validated for atraumatic neck pain

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Atraumatic Neck PainAPPROACH

BACK AND NECK · 19 SECTIONS

⚲

625 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx73

HPI and context

›Neck pain syndrome characterization

›Time course

›Preceding activity

›Mechanical trigger

›Recent infection symptoms

›Recent procedure

›Recent chiropractic manipulation

›Recent travel

›Sick contacts

OPQRST

›OPQRST framework

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with movement

›Worse with swallowing

›Worse with coughing

›Relief with rest

›Relief with heat

›Quality

›Aching

›Sharp

›Burning

›Electric shock

›Region and radiation

›Midline posterior neck

›Paraspinal

›Radiation to shoulder

›Radiation to arm

›Radiation to jaw

›Severity

›Pain score 0 to 10

›Functional limitation severity

›Timing

›Constant

›Intermittent

›Nocturnal pain

›Morning stiffness duration

Associated symptoms

›Associated symptoms cluster

›Headache

›Fever

›Neck stiffness

›Photophobia

›Nausea

›Vomiting

›Dizziness

›Visual symptoms

›Dysarthria

›Dysphagia

›Facial droop

›Limb weakness

›Limb numbness

›Gait difficulty

›Bowel dysfunction

›Bladder dysfunction

›Chest pain

›Dyspnea

›Odynophagia

›Sore throat

Prior episodes and baseline

›Baseline and recurrence

›Prior similar episodes

›Prior imaging

›Prior injections

›Prior surgery

›Baseline neurologic status

›Baseline functional level

Special populations

›Population modifiers

›Pregnancy

›Postpartum

›Older adult

›Immunocompromised state

›Anticoagulant use

›Diabetes mellitus

02Alarm Features/alarm33

Immediate escalation triggers

›Immediate escalation criteria

›Airway compromise signs

›Hemodynamic instability

›Rapidly progressive neurologic deficit

›Altered mental status

›Sepsis physiology

High risk neurologic features

›Neurologic red flags

›Myelopathy signs

›Objective motor weakness

›New gait impairment

›New saddle anesthesia

›New bowel dysfunction

›New bladder dysfunction

Infection and malignancy features

›Infection and malignancy red flags

›Fever

›Immunosuppression

›IV drug use

›Recent bacteremia

›Unexplained weight loss

›History of malignancy

›Night pain

Vascular and headache features

›Vascular red flags

›Thunderclap headache

›Neck pain with focal neurologic symptoms

›Neck pain with partial Horner syndrome

›Neck pain after minor neck trauma

›Neck pain after cervical manipulation

Vital sign danger thresholds

›Concerning vital signs

›Temperature 38.0 C or higher

›Heart rate 120 or higher

›Systolic blood pressure under 90

›Respiratory rate 30 or higher

›Oxygen saturation under 92 percent on room air

03Medications/meds19

Current therapies and recent changes

›Medication exposure inventory

›Prescribed analgesics

›OTC analgesics

›Topical analgesics

›Muscle relaxants

›Neuropathic agents

›Recent steroid course

›Recent antibiotic course

High risk medication classes

›Medication risks relevant to neck pain workup

›Anticoagulants

›Antiplatelet agents

›Chronic corticosteroids

›Immunosuppressants

›Chemotherapy agents

Contraindications and interaction traps

›Common contraindications

›NSAID risk

›Acetaminophen cumulative dose risk

›Sedation risk with muscle relaxants

›Serotonergic agent interaction risk

04Diet/diet8

Exposures that can amplify symptoms

›Intake and exposure factors

›Dehydration risk

›Poor oral intake

›Caffeine excess

›Energy drink exposure

Metabolic contributors

›Metabolic contributors

›Reduced protein intake

›Reduced sleep associated intake changes

05Review of Systems/ros36

Neurologic

›Neurologic symptoms

›Headache

›Vision change

›Vertigo

›Syncope

›Weakness

›Numbness

›Paresthesia

›Ataxia

›Seizure

Infectious and inflammatory

›Inflammatory symptoms

›Fever

›Chills

›Night sweats

›Myalgias

›Rash

ENT and airway

›Upper aerodigestive symptoms

›Sore throat

›Odynophagia

›Dysphagia

›Voice change

›Drooling

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Diaphoresis

Musculoskeletal

›Musculoskeletal symptoms

›Shoulder pain

›Arm pain

›Joint swelling

›Morning stiffness

GI and GU

›Autonomic and sphincter symptoms

›Urinary retention

›Urinary incontinence

›Fecal incontinence

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral sources

›Family member history

›Caregiver history

›EMS report

›Prior chart review

Family history relevant to secondary causes

›Family history screen

›Premature coronary artery disease

›Aortic disease

›Stroke at young age

›Connective tissue disorder

Household and exposure context

›Exposure context

›Household viral illness

›Tuberculosis exposure

›Occupational exposure to infection

07Risk Factors/rf25

Infection risk

›Spinal infection risk factors

›IV drug use

›Indwelling vascular access

›Recent skin infection

›Recent dental infection

›Recent spinal procedure

›Diabetes mellitus

›Immunosuppression

Vascular risk

›Cervical artery dissection risk factors

›Minor neck trauma

›High velocity sports

›Recent cervical manipulation

›Migraine history

›Connective tissue disorder

Malignancy and fracture risk

›Structural risk factors

›Known malignancy

›Unexplained weight loss

›Chronic corticosteroid exposure

›Osteoporosis

›Anticoagulation

Degenerative and occupational risk

›Mechanical risk factors

›Repetitive overhead work

›Prolonged screen posture

›Heavy lifting job

›Prior cervical degenerative disease

08Differential Diagnosis/ddx75

Life threatening

›Life threatening etiologies

›Spinal epidural abscess (G06.1)

›Fever or sepsis physiology

›Focal neurologic deficit

›Elevated CRP or ESR

›Meningitis (G00.9)

›Fever

›Photophobia

›Altered mental status

›Cervical artery dissection (I77.71 carotid, I77.74 vertebral)

›Headache or neck pain with focal deficits

›Partial Horner syndrome

›Recent minor neck trauma

›Subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Neck stiffness

›Vomiting

›Acute coronary syndrome atypical presentation (I21.9)

›Neck or jaw pain with exertion

›Diaphoresis

›Dyspnea

›Retropharyngeal abscess (J39.0)

›Fever

›Odynophagia

›Neck stiffness

›Cervical spinal cord compression

›Progressive weakness

›Hyperreflexia

›Gait dysfunction

Common

›Common etiologies

›Cervical strain and myofascial pain (M54.2)

›Paraspinal tenderness

›Worse with movement

›Cervical facet mediated pain

›Localized paraspinal pain

›Pain with extension rotation

›Cervical radiculopathy (M54.12)

›Dermatomal pain

›Paresthesia

›Positive Spurling

›Cervicogenic headache (G44.86)

›Unilateral neck triggered headache

›Reduced cervical range of motion

›Tension type headache (G44.209)

›Band like headache

›Stress or poor sleep trigger

Less common and zebras

›Less common etiologies

›Cervical myelopathy

›Hand clumsiness

›Wide based gait

›Polymyalgia rheumatica (M35.3)

›Age 50 or older

›Morning stiffness

›Rheumatoid arthritis cervical involvement (M06.9)

›Longstanding inflammatory arthritis

›Neurologic symptoms

›Ankylosing spondylitis axial spondyloarthritis (M45)

›Inflammatory back pain features

›Reduced spinal mobility

›Herpes zoster (B02.9)

›Dermatomal pain

›Rash evolution

›Thyroiditis (E06.9)

›Anterior neck pain

›Systemic symptoms

Mimics and pitfalls

›Mimics and pitfalls

›Shoulder pathology referred pain

›Pain with shoulder range of motion

›Normal cervical exam

›Temporomandibular disorder

›Jaw pain

›Clicking

›Esophageal pathology

›Odynophagia

›Chest discomfort

09Past Medical History/pmh17

Relevant chronic conditions

›Chronic disease modifiers

›Hypertension (I10)

›Diabetes mellitus type 2 (E11.9)

›Chronic kidney disease (N18.9)

›Coronary artery disease (I25.10)

›Stroke or TIA (I63.9 or G45.9)

›Cancer history (Z85.9)

›HIV (B20)

Prior procedures and devices

›Prior spine and invasive history

›Prior cervical surgery

›Prior epidural injection

›Implanted neurostimulator

›Indwelling vascular catheter

Baseline function

›Baseline function and supports

›Independent ambulation status

›Baseline continence status

›Home supports reliability

10Physical Exam/exam45

General and vitals

›Overall appearance and stability

›Toxic appearance

›Fever pattern

›Hemodynamic stability

›Respiratory distress signs

Neck and spine

›Cervical spine exam

›Midline tenderness

›Paraspinal tenderness

›Range of motion limitation

›Pain with rotation

›Pain with extension

›Step off deformity

Neurologic

›Neurologic exam

›Mental status

›Cranial nerves

›Motor strength upper extremity

›Motor strength lower extremity

›Sensation

›Reflexes

›Hoffmann sign

›Clonus

›Babinski sign

›Gait assessment

Meningeal and headache focused

›Meningeal irritation screen

›Nuchal rigidity

›Photophobia observed

›Rash

Vascular and cardiopulmonary

›Vascular and heart exam

›Carotid bruit

›Pulse symmetry

›Cardiac auscultation

›Lung exam

ENT and airway

›ENT and airway assessment

›Oropharynx appearance

›Trismus

›Voice quality

›Drooling

Musculoskeletal adjacent joints

›Shoulder and upper limb screen

›Shoulder range of motion

›Rotator cuff strength

›Scapular tenderness

Pitfalls

›Pitfalls and subtle findings

›Pain out of proportion

›Objective weakness masked by pain

›New hyperreflexia

11Lab Studies/labs30

Infection and inflammation

›Infection and inflammation labs

›CBC

›Leukocytosis

›Neutrophil predominance

›CRP

›Elevated value supports inflammatory process

›Normal value does not exclude early infection

›ESR

›Elevated value supports inflammatory process

›Normal value does not exclude early infection

›Blood cultures when febrile or sepsis physiology

›Two sets before antibiotics when possible

›Contamination risk interpretation

Metabolic and medication safety

›Metabolic safety labs

›Creatinine and electrolytes

›NSAID safety context

›Contrast safety context

›AST ALT when acetaminophen heavy use risk

›Hepatic dysfunction risk context

›Alcohol use risk context

Cardiac and vascular evaluation

›Cardiac evaluation when referred pain concern

›Troponin with ischemic concern

›Serial testing timing local protocol dependent

›Early negative does not exclude ACS

›D dimer not recommended as sole exclusion for dissection

›Variable performance

›False negatives reported

Pregnancy

›Pregnancy testing when relevant

›Urine pregnancy test

›Serum pregnancy test when high suspicion or critical decision

12Imaging/img65

Scoring Systems

›Decision tools for imaging selection

›NEXUS low risk criteria for cervical spine imaging in trauma

›Not validated for atraumatic presentations

›Consider only when trauma or fall history suspected

›Canadian C spine rule for cervical spine imaging in trauma

›Not validated for atraumatic presentations

›Consider only when trauma or fall history suspected

›Ottawa subarachnoid hemorrhage rule for acute headache

›Use when acute severe headache presentation fits criteria

›Not for chronic headache pattern

MRI

›MRI cervical spine

›Indications

›Suspected spinal epidural abscess

›Suspected vertebral osteomyelitis or discitis

›Myelopathy signs

›Progressive neurologic deficit

›Protocol pearls

›Gadolinium enhancement when infection concern

›Include whole region of suspected involvement

›Limitations

›Availability delays

›Motion artifact

›Contraindications and precautions

›Non compatible implanted device

›Severe claustrophobia

›CT based evaluation

›CT cervical spine without contrast

›Indications

›Suspected fracture with possible unwitnessed trauma

›Severe midline tenderness with high risk history

›Limitations

›Poor soft tissue infection detection compared with MRI

›Radiation exposure

›CTA head and neck

›Indications

›Suspected cervical artery dissection

›Focal neurologic symptoms with head or neck pain

›Contraindications and precautions

›Contrast allergy history

›Reduced kidney function

›Limitations

›False negatives for small intimal flaps

›Motion artifact

›CT head without contrast

›Indications

›Thunderclap headache with neck pain

›Altered mental status

›Limitations

›Sensitivity decreases with time from onset

›Does not exclude dissection

Ultrasound

›Ultrasound and POCUS roles

›Carotid duplex ultrasound

›Potential utility

›Hemodynamically significant stenosis detection

›Follow up imaging adjunct

›Limitations

›Limited for vertebral artery dissection

›Limited for high cervical segments

›Soft tissue ultrasound anterior neck

›Potential utility

›Superficial abscess detection

›Lymph node assessment

›Limitations

›Limited for deep space neck infection

›Does not replace CT neck when deep infection concern

13Special Tests/spec27

Bedside maneuvers for radicular patterns

›Cervical radiculopathy exam maneuvers

›Spurling test

›Reproduction of dermatomal arm pain

›Avoid excessive force

›Shoulder abduction relief sign

›Symptom relief suggests nerve root involvement

›Compare both sides

›Upper limb tension test

›Symptom reproduction with nerve tension

›False positives with myofascial pain

Myelopathy screening maneuvers

›Cervical myelopathy screening

›Hoffmann sign

›Suggests upper motor neuron involvement

›Not diagnostic alone

›Lhermitte phenomenon

›Electric shock sensation with neck flexion

›Suggests cervical cord pathology

Meningitis and deep infection evaluation

›CNS infection evaluation elements

›Lumbar puncture indications

›Suspected meningitis after neuroimaging decision

›Persistent concern with negative initial imaging

›Lumbar puncture cautions

›Concern for elevated intracranial pressure

›Coagulopathy or anticoagulation

Do not do items

›Avoid potentially harmful bedside tests

›Provocative vertebral artery tests

›High velocity cervical manipulation in acute pain

14ECG/ecg19

Indications in atraumatic neck pain

›ECG indications

›Neck or jaw pain with exertion

›Diaphoresis

›Dyspnea

›Syncope

›Older age with risk factors

High risk ECG findings

›High risk patterns

›ST elevation

›ST depression

›New T wave inversion

›New left bundle branch block

Rhythm and conduction

›Rhythm evaluation

›Atrial fibrillation

›Bradyarrhythmia

›Ventricular tachycardia

›High grade AV block

Serial ECG logic

›Serial ECG timing

›Repeat with ongoing ischemic symptoms

›Repeat with rising troponin local protocol dependent

15Assessment/ax26

Problem representation

›Clinical syndrome framing

›Uncomplicated mechanical neck pain

›Neck pain with radicular symptoms

›Neck pain with myelopathy features

›Neck pain with systemic infection features

›Neck pain with vascular or neurologic event concern

›Neck pain with deep neck space infection concern

Working diagnosis examples with codes

›Working diagnosis candidates

›Cervicalgia (M54.2)

›Localized paraspinal tenderness

›No objective neurologic deficit

›Cervical radiculopathy (M54.12)

›Dermatomal symptoms

›Provocative maneuver reproduction

›Cervicogenic headache (G44.86)

›Headache triggered by neck movement

›Reduced neck range of motion

Severity and risk stratification

›High risk categorization

›Any alarm feature present

›Objective neurologic deficit present

›Immunocompromised with severe pain

›Persistent severe pain with night pain

Diagnostic uncertainty

›Alternate diagnosis tracking

›Infection cannot be excluded yet

›Vascular etiology cannot be excluded yet

›Referred cardiopulmonary pain cannot be excluded yet

16Plan/plan47

First 5 minutes workflow for critical patient

›Immediate stabilization and triage

›Continuous pulse oximetry when unstable

›Cardiac monitor when cardiopulmonary concern

›Two large bore IV when sepsis or neurologic emergency concern

›Point of care glucose when altered mental status

›Early stroke team activation when focal neurologic deficits

Analgesia and symptom control

›Multimodal analgesia options

›Acetaminophen 1000 mg PO once

›Maximum 4000 mg per day

›Lower maximum with liver disease

›Ibuprofen 400 mg PO once

›Repeat every 6 to 8 hours as needed

›Maximum 2400 mg per day

›Naproxen 500 mg PO once

›Repeat 250 to 500 mg every 12 hours as needed

›Avoid with high GI bleed risk

›Topical diclofenac gel local application

›Avoid on broken skin

›Additive NSAID exposure awareness

›Cyclobenzaprine 5 mg PO

›Up to three times daily as needed

›Avoid in older adults due to anticholinergic effects

›Gabapentin 100 mg PO at night for neuropathic symptoms

›Titrate by 100 to 300 mg per dose

›Renal adjustment needed

›Opioids not routine

›Consider short course only for severe refractory pain

›Avoid with concurrent sedatives

Targeted diagnostics and sequencing

›Diagnostic sequencing

›MRI cervical spine with contrast when spinal infection concern

›CTA head and neck when dissection concern

›CT head when thunderclap headache concern

›ECG and troponin when ischemic concern

Antibiotics and sepsis pathway when indicated

›Suspected spinal epidural abscess or vertebral osteomyelitis pathway

›Blood cultures before antibiotics when feasible

›Broad spectrum IV antibiotics after cultures when unstable

›Neurosurgery consultation early

Monitoring and reassessment loop

›Reassessment loop

›Pain score response after treatment

›Repeat neurologic exam after analgesia

›Vital sign trend every 30 to 60 minutes when concerning

›Escalate if new weakness or sensory level

Consultations

›Consultation triggers

›Neurology when suspected dissection or stroke symptoms

›Neurosurgery or spine when myelopathy or epidural abscess concern

›ENT when deep neck infection concern

›Cardiology when ACS concern

17Disposition/dispo27

ICU and high acuity criteria

›ICU level care criteria

›Airway compromise

›Sepsis with vasopressor requirement

›Rapidly progressive neurologic deficit

›Acute stroke requiring intervention

Inpatient admission criteria

›Admission criteria

›Suspected spinal epidural abscess

›Suspected vertebral osteomyelitis or discitis

›Myelopathy signs

›Persistent uncontrolled pain despite ED therapy

›Unable to ambulate safely

›Deep neck infection concern

Observation pathway criteria

›Observation appropriate when

›Pain requires repeated parenteral therapy

›Pending MRI or CTA with stable vitals

›Serial troponin and ECG required

Discharge criteria and follow up

›Discharge criteria

›No alarm features

›Normal neurologic exam

›Pain controlled with oral regimen

›Reliable follow up

›Clear return precautions provided

›Follow up timing

›Primary care within 3 to 7 days

›Physical therapy referral within 1 to 2 weeks when mechanical pattern

›Neurology within 1 week for persistent radicular symptoms

›Spine specialist within 1 week for progressive radicular symptoms

18Discharge Instructions/di21

Copy discharge instructions

›Neck pain today appears most consistent with a non dangerous mechanical cause based on your exam and testing

›Return now if weakness develops in an arm or leg

›Return now if numbness spreads or you have trouble walking

›Return now if you cannot control urine or stool

›Return now if fever occurs or you feel progressively more unwell

›Return now if you develop a sudden severe headache

›Return now if you develop trouble speaking, facial droop, or vision changes

›Return now if chest pain or shortness of breath occurs

›Pain control options at home

›Acetaminophen up to 1000 mg every 6 to 8 hours as needed

›Do not exceed 4000 mg total in 24 hours

›Ibuprofen 400 mg every 6 to 8 hours as needed if safe for you

›Avoid ibuprofen if you have kidney disease, stomach bleeding history, or take blood thinners unless advised

›If a muscle relaxant was prescribed, do not drive or mix with alcohol

›Activity

›Gentle movement is usually better than bed rest

›Avoid heavy lifting until improving

›Avoid high velocity neck manipulation until cleared

›Follow up

›Arrange follow up with your clinician in 3 to 7 days

›Seek earlier follow up if symptoms are not improving in 48 to 72 hours

19References/r18

Guidelines and key evidence

›Neck Pain Clinical Practice Guidelines Revision 2017 Journal of Orthopaedic and Sports Physical Therapy 2017

›American Physical Therapy Association Orthopaedic Section linked CPG

›Focus on non surgical management and classification

›NICE Clinical Knowledge Summaries Neck pain cervical radiculopathy updated regularly

›Primary care pathway framing

›Symptom and red flag guidance

›IDSA Clinical Practice Guidelines for Native Vertebral Osteomyelitis in Adults 2015

›MRI with gadolinium emphasized for detecting epidural extension

›Blood cultures and targeted antimicrobial strategy

›ACEP Clinical Policy Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache 2019

›Secondary headache evaluation framework

›Imaging and lumbar puncture decision considerations

›AHA Scientific Statement Treatment and Outcomes of Cervical Artery Dissection in Adults 2024

›Antithrombotic therapy duration often 3 to 6 months

›Therapy choice individualized

›NEXUS Low Risk Criteria validation study New England Journal of Medicine 2000

›Trauma oriented cervical spine imaging rule

›Not validated for atraumatic neck pain

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.