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Causes of Neck Pain/Stiffness

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Context and age are important
Neck pain is a common complaint of patients presenting to a primary care
10% to 15% suffer from an episode of neck pain at any time
Acute neck pain generally resolves with conservative treatment,

Aetiology

Osteoarthritis
Usually 3 lowest cervical vertebrae
Root pain into arm

Red flags of significant disease

Fever, malaise, chills, new headache, photophobia, non-blanching rash
High velocity trauma in healthy population
Any Trauma in osteoporotic population
Pain worse when reclined at night
Syncope, Malignancy, Immune deficient
Sexual dysfunction
Sensory deficit on exam or motor deficits
Cranial nerve palsy, Faecal or Urinary continence issues
Upper neurone signs, meningeal signs
New onset ataxia

Differentials

Cause	Tests	Management
Muscle Strain	Clinical history and physical exam Imaging (X-ray, if trauma suspected)	Rest and activity modification NSAIDs (e.g., ibuprofen) for pain relief Physical therapy or stretching exercises
Whiplash Injury	Physical exam for tenderness and range of motion X-ray to rule out fractures MRI or CT scan if nerve damage suspected	Rest and ice packs for initial pain relief NSAIDs and muscle relaxants Physical therapy for range-of-motion exercises
Degenerative Disc Disease (Cervical Spondylosis)	X-ray to assess disc degeneration MRI to evaluate nerve root compression or spinal cord involvement	NSAIDs for pain management Physical therapy for strengthening and mobility Surgery (if severe nerve compression or spinal instability)
Herniated Disc	MRI to confirm disc herniation and nerve compression	Rest and physical therapy Oral steroids or epidural steroid injections for inflammation Surgical intervention if conservative treatment fails
Facet Joint Arthritis	X-ray or CT scan to assess joint degeneration MRI for nerve involvement	NSAIDs for pain and inflammation Physical therapy for mobility and strengthening Intra-articular steroid injections if severe
Meningitis	Physical exam (stiff neck, fever) Lumbar puncture (CSF analysis) for definitive diagnosis Blood cultures for bacterial infection	Immediate hospitalization IV antibiotics for bacterial meningitis Supportive care for viral meningitis
Cervical Radiculopathy	MRI to evaluate nerve root compression Nerve conduction studies (if needed)	NSAIDs and oral steroids Physical therapy for stretching and strengthening Epidural steroid injections or surgery for persistent cases
Spinal Stenosis	MRI to assess spinal canal narrowing	Physical therapy for strengthening NSAIDs for pain management Surgical decompression if severe stenosis with neurological deficits
Infections (e.g., Abscess, Osteomyelitis)	MRI or CT scan to identify infection Blood tests (e.g., WBC, ESR, CRP) Biopsy or culture to identify causative organism	IV antibiotics for bacterial infections Surgical drainage for abscess Hospitalization if sepsis or severe infection
Fibromyalgia	Clinical diagnosis based on widespread pain and tender points Blood tests to rule out other causes (e.g., thyroid, autoimmune diseases)	Exercise and physical therapy Medications (e.g., antidepressants, pregabalin) Cognitive behavioral therapy (CBT) for pain management
Torticollis (Wry Neck)	Clinical examination to assess muscle contracture Ultrasound or X-ray (if congenital or trauma-related)	Physical therapy and stretching exercises Botulinum toxin injections for spasticity Surgical intervention if conservative treatment fails
Stress and Anxiety	Clinical assessment of psychological factors	Relaxation techniques (e.g., yoga, meditation) Cognitive behavioral therapy (CBT) Medications (e.g., anxiolytics, antidepressants) if indicated
Neck Tumors	MRI or CT scan to identify mass Biopsy for histopathological diagnosis	Surgical excision if malignant Radiotherapy or chemotherapy if indicated Palliative care if advanced disease

Clinical

Clinical context - red flags such as fever, night sweats, night time pain
Mode of injury and events since
Presence of any cord or root signs and motor/sensory or sphincter issues
Signs of RA or Ankylosing spondylitis
Lifestyle IVDU and Osteomyelitis and sepsis
Chest pain and ECG for IHD

Investigations

Plain radiograph: Without a history of trauma, a 2-view examination (ie, anteroposterior, lateral) is sufficient. Flexion and extension views may be appropriate for symptomatic patients suspected of ligamental injury and spinal instability. Without neurology, this is usually sufficient.
MRI: those with neurology need MRI without contrast to assess for possible causes such as cervical disc herniation, cervical stenosis, and to rule out serious causes such as a spinal tumour and infection. MRI has a high sensitivity for visualizing disc herniation and spinal/neuroforaminal stenosis.
CT with myelogram is the alternative imaging choice for individuals with contraindications for MRI (ie, pacemaker, metal implants). It is more specific with greater sensitivity for detecting fractures compared to plain x-rays. Mode of choice for high-risk trauma patients who sustain a head injury, who are unable to follow directions, or who develop focal neurological deficits.
Nerve conduction studies to rule out peripheral neuropathy
Electromyography (EMG) is the most sensitive study to assess for nerve root involvement. My be better than MRI in asymptomatic adults.
Motor- and somatosensory-evoked potentials assess for spinal stenosis and may detect subclinical upper motor neuron signs

Management

ABC and resuscitation where needed. If neck injury then protects neck in collar until assessed and diagnostics are done. Management is dependent on likely cause.
Pain Management is usually needed using the usual pain pathways
Surgery were needed for an unstable neck or to remove a lesion or for decompression or fusion
Rehabilitation may well be needed to improve muscle tone and strength and flexibility

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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