Neck pain/stiffness

Musculoskeletal Causes

Cervical Strain/Sprain: Commonly due to poor posture, sudden movements, or overuse; presents with diffuse neck pain and muscle stiffness.
Cervical Spondylosis: Degenerative changes in the cervical spine, often in older adults; presents with chronic neck pain, stiffness, and possibly radicular symptoms if nerve roots are compressed.
Whiplash Injury: Occurs after sudden hyperextension and flexion of the neck, commonly in motor vehicle accidents; presents with neck pain, stiffness, and sometimes headache.
Cervical Disc Herniation: Neck pain with possible radiation to the shoulder or arm; may cause radiculopathy with sensory or motor deficits in the affected dermatome.
Torticollis: Involuntary contraction of neck muscles, leading to abnormal head posture and pain; can be congenital or acquired (e.g., due to infection or trauma).

Infectious Causes

Meningitis: Severe neck stiffness, headache, photophobia, and fever; Kernig’s and Brudzinski’s signs may be positive; requires urgent evaluation.
Osteomyelitis/Discitis: Infection of the cervical vertebrae or intervertebral discs; presents with severe, localised neck pain, fever, and often neurological deficits.
Retropharyngeal Abscess: Deep neck infection, more common in children; presents with neck pain, stiffness, fever, dysphagia, and potential airway compromise.
Lymphadenitis: Inflammation or infection of cervical lymph nodes; presents with localised neck pain, swelling, and often systemic signs of infection.

Rheumatologic Causes

Rheumatoid Arthritis: Can involve the cervical spine, particularly the atlantoaxial joint; presents with chronic neck pain, morning stiffness, and possible neurological symptoms if there is spinal cord compression.
Ankylosing Spondylitis: Chronic inflammatory condition affecting the spine; presents with progressive neck stiffness, pain, and reduced range of motion; often associated with back pain and sacroiliitis.
Polymyalgia Rheumatica: Inflammatory condition in older adults; presents with neck and shoulder stiffness, especially in the morning, and systemic symptoms such as fatigue and weight loss.
Fibromyalgia: Widespread musculoskeletal pain and stiffness, including the neck; often associated with fatigue, sleep disturbances, and cognitive difficulties.

Traumatic Causes

Fracture: Neck pain following trauma, such as a fall or motor vehicle accident; associated with severe pain, possible neurological deficits, and tenderness over the cervical spine.
Cervical Spine Instability: May result from trauma, rheumatoid arthritis, or congenital conditions; presents with neck pain, possible neurological symptoms, and a sensation of instability or ‘clunking.’

Neoplastic Causes

Primary Tumours: Rare in the cervical spine but may include osteosarcoma, chordoma, or meningioma; presents with persistent neck pain, often worsening at night, and possible neurological symptoms.
Metastatic Disease: More common than primary tumours; cancers of the breast, lung, prostate, and kidney often metastasise to the cervical spine, presenting with pain, neurological deficits, and possible pathological fractures.
Pancoast Tumour: Apical lung tumour that can invade the cervical spine or brachial plexus; presents with neck pain, shoulder pain, and neurological symptoms in the arm (e.g., Horner’s syndrome).

Symptomatology

Onset and Duration: Sudden onset may suggest trauma or acute disc herniation, whereas gradual onset is more typical of degenerative or rheumatologic causes.
Pain Characteristics: Determine if the pain is sharp, dull, or radiating; radiation to the arm suggests radiculopathy, while localised pain may indicate a musculoskeletal cause.
Associated Symptoms: Consider neurological symptoms (e.g., numbness, weakness), systemic symptoms (e.g., fever, weight loss), or morning stiffness, which can help narrow the differential diagnosis.
Exacerbating and Relieving Factors: Ask about activities or positions that worsen or alleviate the pain; for example, pain worsened by neck movement may suggest cervical spondylosis.
Functional Impact: Assess how the pain affects daily activities, work, and sleep; significant functional impairment may warrant more urgent investigation.

Background

Past Medical History: Important to note any history of neck trauma, cervical spine disorders, or rheumatologic diseases.
Drug History: Review current and past medications, particularly those that may affect bone density or immune function (e.g., corticosteroids).
Family History: Consider family history of rheumatologic diseases, spinal disorders, or malignancies that may predispose the patient to neck pain.
Social History: Assess lifestyle factors such as occupation, physical activity, and smoking, which can contribute to neck pain and stiffness.
Recent Infections: History of recent upper respiratory or systemic infections can point toward infective causes of neck pain, such as meningitis or lymphadenitis.

Laboratory Tests

Full Blood Count: To assess for infection or anaemia, particularly if systemic symptoms are present.
Inflammatory Markers: ESR and CRP may be elevated in infective, inflammatory, or neoplastic conditions.
Thyroid Function Tests: Consider if there is suspicion of thyroid disease contributing to musculoskeletal symptoms.
Rheumatoid Factor and Anti-CCP: Useful in diagnosing rheumatoid arthritis if joint symptoms are also present.
Blood Cultures: Indicated if there is suspicion of sepsis or osteomyelitis.
CSF Analysis: Mandatory if meningitis is suspected; should be done after imaging to rule out raised intracranial pressure.

Imaging and Specialist Tests

X-ray of the Cervical Spine: First-line imaging for assessing alignment, fractures, and degenerative changes.
MRI of the Cervical Spine: Gold standard for assessing soft tissue structures, including discs, spinal cord, and nerve roots; indicated if neurological symptoms are present or if a neoplastic, infectious, or inflammatory cause is suspected.
CT Scan: Useful in assessing bony structures, particularly in trauma cases or when MRI is contraindicated.
Nerve Conduction Studies and Electromyography: Indicated if radiculopathy or peripheral nerve compression is suspected.
Bone Scan: May be considered in cases of suspected osteomyelitis, malignancy, or occult fracture.

Infection