Neck Pain & Radiculopathy

Non-specific neck pain presents as cervical or periscapular pain that may refer diffusely to the occiput, shoulder, or upper arm but does not radiate below the elbow in a dermatomal pattern and lacks neurological symptoms.

Cervical radiculopathy is dermatomal arm pain typically worse than neck pain, sharp, shooting, burning, or electric in quality. Symptoms are aggravated by neck extension and ipsilateral rotation (foraminal narrowing) and may ease with the shoulder abduction relief sign (hand on the head reduces nerve root traction). Numbness, weakness, or paraesthesia signal radiculopathy.

Cervical myelopathy presents insidiously: difficulty with fine motor tasks (buttons, handwriting, dropping objects), bilateral hand clumsiness, gait disturbance and unsteadiness, with urinary urgency or hesitancy as a late sign. Significant neck pain may be absent.

Whiplash-associated disorders follow acceleration-deceleration injury, with neck pain and stiffness onset sometimes delayed hours to days. May include headache, dizziness, and paraesthesia.

Examination: cervical range of movement; Spurling test (extension, ipsilateral lateral flexion, axial compression - reproduction of dermatomal arm pain is positive, high specificity but lower sensitivity); shoulder abduction relief sign; Lhermitte sign (electric shock down the spine on neck flexion, suggestive of cord pathology).

Upper limb neurological screen by myotome, dermatome, reflex - C5 to T1 distribution:

• •C5: deltoid (shoulder abduction), biceps reflex (C5-6), lateral arm (regimental badge)
• •C6: brachioradialis reflex, wrist extension, thumb and index sensation, biceps contributes to elbow flexion (C5-6)
• •C7: triceps reflex, elbow extension, wrist flexion, middle finger
• •C8: finger flexion and grip, ring and little finger, medial forearm
• •T1: finger abduction (interossei), thumb abduction (APB), medial arm

UMN and myelopathy signs: hyperreflexia, ankle clonus, upgoing plantars, Hoffmann sign (flicking the middle-finger DIP into extension produces involuntary thumb or index flexion), spastic gait, and the inverted reflex pattern (absent reflex at the compressed level with brisk reflexes below - classically absent biceps with brisk triceps).

Differentials: shoulder pathology (commonest C5 radiculopathy mimic - always examine the shoulder), thoracic outlet syndrome, CTS and cubital tunnel (double crush is common), cardiac referred pain, polymyalgia rheumatica, and Pancoast tumour (C8/T1 with Horner syndrome in a smoker - must not miss).

Most neck pain does not require investigation. Imaging is reserved for red flags, suspected myelopathy, objective neurological signs, persistent radiculopathy, or when intervention is being considered.

• •Plain radiographs: not routine. Indicated for suspected fracture (Canadian C-spine Rule), instability, or inflammatory spondyloarthropathy. Spondylotic changes correlate poorly with symptoms
• •MRI: investigation of choice for suspected myelopathy (urgent), persistent radiculopathy with objective signs, or suspected malignancy or infection. For radiculopathy without neurological signs, imaging is generally deferred until 4-6 weeks
• •CT: useful for fracture characterisation and surgical planning. CT myelography if MRI contraindicated
• •NCS / EMG: helps differentiate cervical radiculopathy from peripheral nerve entrapment when double-crush is suspected
• •Bloods (FBC, ESR, CRP): only when infection, malignancy, inflammatory spondyloarthropathy, or polymyalgia rheumatica is suspected

There is no single NICE guideline corresponding to NG59 for neck pain. Management is guided by NICE CKS, NICE CG173 for neuropathic pain, and clinical pathway documents.

Non-specific neck pain - core management:

• •Reassurance and education: most neck pain is not serious and improves
• •Stay active: prolonged rest and cervical collars worsen outcomes and are NOT recommended
• •Exercise is the cornerstone: deep neck flexor and scapular stabiliser strengthening, postural retraining, general aerobic fitness
• •Manual therapy: consider as part of a multimodal package with exercise, not as a standalone. Counsel on the small but recognised risk of vertebral artery dissection with cervical manipulation

Pharmacological:

• •Paracetamol, oral NSAIDs (lowest effective dose, shortest period, with gastroprotection), or codeine per NICE CKS. NSAIDs have a stronger evidence base than paracetamol
• •Do not offer strong opioids for chronic neck pain
• •Neuropathic pain agents (NICE CG173): for prominent neuropathic radicular pain, consider amitriptyline, duloxetine, gabapentin, or pregabalin. Distinct from lumbar sciatica, where NG59 advises against gabapentinoids

Cervical radiculopathy:

• •Most disc-related radiculopathy improves over weeks to months without surgery
• •Conservative management as above for the first 4-6 weeks in the absence of neurological signs
• •MRI and specialist referral if objective neurological signs, progressive deficit, or persistence beyond 4-6 weeks
• •Cervical epidural or transforaminal injection may be considered by specialists for refractory severe radicular pain (evidence base more limited than for lumbar epidural)

Referral and surgery:

• •Urgent referral for myelopathy: progressive myelopathy does not improve without surgical decompression
• •Emergency referral for suspected vertebral artery dissection, malignant cord compression, or infection
• •Surgical options: ACDF (anterior cervical discectomy and fusion), cervical disc arthroplasty, posterior decompression with or without fusion, and posterior cervical foraminotomy

Whiplash-associated disorders:

• •Active management, early return to normal activities, no cervical collar
• •Address psychosocial risk factors early - the strongest predictors of chronicity in WAD

Acute non-specific neck pain and WAD: reassurance, early activity, gentle active ROM. No cervical collar.

Exercise therapy is the cornerstone. Useful components: craniocervical flexion (deep neck flexor) retraining, cervical extensor and scapular stabiliser strengthening, postural correction, and general aerobic fitness. No single exercise should be presented as universally most effective - active exercise and early mobilisation are the core messages.

Radiculopathy: progressive exercise as symptoms allow. Symptom-guided neural mobilisation (cervical lateral glide, upper limb sliders or tensioners). Scapular and thoracic mobility. Avoid excessive extension and ipsilateral rotation initially if they provoke symptoms.

Ergonomics: workstation review covering screen height, keyboard position, head posture, and breaks from sustained positions.

Post-operative: after ACDF, collar use varies by surgeon; progressive ROM then isometric and dynamic strengthening. Sedentary return at 2-6 weeks, manual work at 8-12 weeks.

Psychosocial factors - fear-avoidance, catastrophising, medicolegal involvement, low mood - are the strongest predictors of poor outcome.

• •NICE CKS Neck pain (non-specific and cervical radiculopathy): UK primary-care framework recommending reassurance, exercise-led active management, oral NSAIDs, and judicious imaging.
• •NICE CG173 Neuropathic pain (2013, updated 2020): amitriptyline, duloxetine, gabapentin, or pregabalin for neuropathic pain. Applies to cervical radicular pain.
• •Quebec Task Force WAD classification: grades 0-IV used internationally for whiplash severity and management triage.
• •Canadian C-spine Rule (Stiell et al., JAMA 2001): high-quality decision rule for cervical imaging after trauma; sensitivity approaches 100% for clinically important injury.
• •Spurling test diagnostic accuracy (Tong et al., 2002): high specificity for cervical radiculopathy with lower sensitivity, so a negative test does not exclude.
• •mJOA and Nurick scores: validated severity scales for cervical spondylotic myelopathy that guide surgical timing.

• •Cervical root numbering differs from the lumbar spine: a C5/C6 disc compresses the C6 root (root exits above the vertebra). C6 and C7 are the commonest cervical roots affected.
• •Cervical myelopathy is the must-not-miss diagnosis: gait disturbance, bilateral hand clumsiness, UMN signs, Hoffmann sign. Urgent referral.
• •The inverted reflex pattern (absent reflex at the compressed level with brisk reflexes below) is a classic myelopathy finding - absent biceps with brisk triceps is the textbook example.
• •Shoulder pathology is the commonest mimic of C5 radiculopathy. Always examine the shoulder.
• •Vertebral artery dissection: sudden neck pain or occipital headache with posterior circulation symptoms (5Ds, 3Ns). The vertebral artery enters the transverse foramen at C6.
• •NICE CG173 neuropathic pain agents may be used for cervical radiculopathy - distinct from lumbar sciatica, where NG59 advises against gabapentinoids.