Osteoarthritis - usually affects the lowest 3 cervical vertebrae.
Cervical root pain may radiate into the arm.
Other causes include degenerative disc disease, trauma, infection, or inflammatory arthritis.

🚨 Red Flags for Serious Disease

Fever, malaise, chills, new headache, photophobia, non-blanching rash (infection or meningitis).
High-velocity trauma in healthy patients OR any trauma in osteoporotic patients.
Pain worse when reclined at night 🛏️.
Syncope, history of malignancy, or immunosuppression.
Neurological deficits ➝ sensory or motor loss, cranial nerve palsies, upper motor neurone signs.
Faecal/urinary incontinence, new-onset ataxia, sexual dysfunction.
Meningeal signs ➝ think meningitis or subarachnoid haemorrhage.

📝 Differentials

Cause	Notes (Tests + Management)
💪 Muscle Strain	Tests: History + exam; X-ray if trauma suspected. Management: Rest, NSAIDs, physiotherapy/stretching.
🚗 Whiplash	Tests: Exam, X-ray for fracture, MRI/CT if nerve damage suspected. Management: Rest, NSAIDs, muscle relaxants, physiotherapy.
🦴 Cervical Spondylosis (DDD)	Tests: X-ray for degeneration, MRI for nerve/root compression. Management: NSAIDs, physiotherapy, surgery if severe.
💥 Herniated Disc	Tests: MRI confirmation. Management: Rest, physiotherapy, steroids/epidural injections, surgery if refractory.
⚙️ Facet Joint Arthritis	Tests: X-ray/CT, MRI for nerve involvement. Management: NSAIDs, physiotherapy, steroid injections.
🧠 Meningitis	Tests: Exam, LP (CSF), blood cultures. Management: Hospitalisation + IV antibiotics (urgent).
⚡ Cervical Radiculopathy	Tests: MRI spine, nerve conduction studies. Management: NSAIDs, steroids, physiotherapy, surgery if persistent.
📉 Spinal Stenosis	Tests: MRI spinal canal narrowing. Management: Physiotherapy, NSAIDs, decompression surgery if severe.
🦠 Infections (abscess, osteomyelitis)	Tests: MRI/CT, bloods (WCC, ESR, CRP), biopsy. Management: IV antibiotics, drainage if abscess.
🌐 Fibromyalgia	Tests: Clinical diagnosis; bloods to exclude mimics. Management: Exercise, CBT, pregabalin/antidepressants.
↔️ Torticollis	Tests: Clinical exam, imaging if trauma/congenital. Management: Physio, Botox, surgery if severe.
😰 Stress/Anxiety	Tests: Clinical assessment. Management: CBT, relaxation, anxiolytics/antidepressants.
🎗️ Neck Tumours	Tests: MRI/CT, biopsy. Management: Surgery, chemo/radiotherapy, palliation if advanced.

🩺 Clinical Assessment

Look for red flags: fever, night sweats, night pain.
History: mechanism of injury, progression, systemic symptoms.
Examine: cord/root signs, cranial nerves, motor/sensory deficits, sphincter function.
Check for signs of RA, ankylosing spondylitis.
Risk factors: IV drug use ➝ abscess/osteomyelitis, malignancy, sepsis.
Always consider cardiac causes (chest pain ➝ ECG for IHD).

🔬 Investigations

Plain X-ray: AP + lateral views sufficient if no trauma/neurology. Flexion/extension if instability suspected.
MRI: if neurological signs ➝ disc herniation, stenosis, tumour, infection.
CT (± myelogram): alternative if MRI contraindicated. Gold standard for fractures in trauma 🚑.
Nerve conduction studies: differentiate radiculopathy vs peripheral neuropathy.
EMG: very sensitive for nerve root involvement.
Evoked potentials: assess stenosis/upper motor neuron pathology.

🛠️ Management

Protect airway, breathing, circulation. Immobilise neck if trauma until cleared.
Pain relief ➝ stepwise analgesia with NSAIDs/paracetamol ± opioids.
Surgical options: decompression, fusion, tumour removal where indicated.
Rehabilitation: physio for strength, flexibility, posture correction.

📚 References

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Causes of Neck Pain/Stiffness

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🧬 Aetiology