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msk.mechanical-neck-pain.core.v1PRODUCTION
msk.mechanical-neck-pain.core.v1

Mechanical neck pain (axial / radicular / myelopathy / whiplash)

rheumatologyacutesubacutechronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Neck pain is a symptom and a triage problem, not a single diagnosis: the Bone & Joint Decade Task Force model (Guzman Spine 2008 PMID 18204387) frames it as an EPISODIC LIFETIME occurrence with variable recovery, graded I–IV (IV = major structural pathology — myelopathy, fracture, neoplasm, infection, systemic). The engine exists to NOT miss the cannot-miss Grade IV minority, apply the trauma rule correctly, and match non-pharm-first care to phenotype (only 46% of the historical literature is scientifically admissible — Carroll Spine 2008 PMID 18204397)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Scope framed: acuity band + axial-vs-radicular-vs-myelopathic established against the trauma gate and Grade IV screen

Patient inputs (19)

Age ≥65 is a Canadian C-Spine Rule high-risk factor mandating imaging; geriatric C-spine injury rate ≈2× and odontoid fracture 20% vs 5% (Touger NEXUS geriatric Ann Emerg Med 2002 PMID 12192352); cervical radiculopathy peak incidence 50–54 y (Radhakrishnan Brain 1994 PMID 8186959)

Acute (<6 wk) vs subacute (6–12 wk) vs chronic (>12 wk) drives acuity branch + treatment ladder (JOSPT 2017 Blanpied PMID 28666405)

Dermatomal arm pain gates the Wainner cervical-radiculopathy test-item cluster (Spurling A / distraction / rotation <60° / ULTT-A) (Wainner Spine 2003 PMID 12544957)

Blunt head/neck trauma in an alert, stable adult triggers the Canadian C-Spine Rule trauma gate before any non-trauma reasoning (Stiell JAMA 2001 PMID 11597285)

Dangerous mechanism or extremity paraesthesias are Canadian C-Spine Rule high-risk factors mandating radiography (Stiell JAMA 2001 PMID 11597285)

Inability to actively rotate the neck 45° left and right is the Canadian C-Spine Rule final discriminator (range-of-motion limb) (Stiell JAMA 2001 PMID 11597285)

Hoffmann sign, hyperreflexia, clonus, gait/balance loss, hand clumsiness, bowel-bladder change = degenerative cervical myelopathy (Grade IV) — escalate, NOT axial-pain management (Fehlings Global Spine J 2017 PMID 29164034)

Known malignancy raises the metastatic / pathological-fracture prior — a cannot-miss Grade IV cause (Guzman Spine 2008 PMID 18204387)

IVDU / immunosuppression / indwelling vascular catheter / recent infection raise discitis–osteomyelitis–epidural-abscess prior (Guzman Spine 2008 Grade IV PMID 18204387)

Fever + neck pain → spinal infection; constitutional symptoms → malignancy (Guzman Spine 2008 PMID 18204387)

Sudden severe posterior neck/occipital pain, Horner, cranial-nerve or posterior-circulation signs after neck strain/manipulation → vertebral/carotid artery dissection (cannot-miss vascular cause)

Progressive or severe motor weakness / multi-level deficit = urgent imaging + surgical referral (Fehlings Global Spine J 2017 PMID 29164034)

eGFR / Child-Pugh / CVD / PUD gate NSAID; informs the drug × comorbidity matrix (shared with msk.low-back-pain.core.v1; ACP/NICE mechanical-spine analgesia)

Existing opioid / gabapentinoid / NSAID exposure drives deprescribing + safety (opioid-restraint doctrine shared with msk.low-back-pain.core.v1)

Pregnancy/lactation contraindicates NSAID (esp. 3rd trimester) + duloxetine caution → special-population branch

Insidious onset, night pain, morning stiffness, exercise-improved → inflammatory neck pain → axSpA route (rheum.axial-spondyloarthritis.core.v1)

Whiplash WAD grade 0–IV + psychosocial yellow flags (depression/pain ratio >1 → OR 2.0 poor outcome) drive chronicity risk (Griggs J Back Musculoskelet Rehabil 2015 PMID 25322732)

Neck Disability Index baseline + serial functional tracking for subacute/chronic neck pain (JOSPT 2017 Blanpied PMID 28666405)

Anticoagulation alters fracture/dissection bleeding risk and NSAID GI safety; relevant to the dissection and special-population branches

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningprogressive_cervical_myelopathy
    Progressive degenerative cervical myelopathy — Hoffmann/hyperreflexia/clonus, gait-balance loss, hand clumsiness, bowel-bladder change (moderate/severe DCM) (Fehlings Global Spine J 2017 PMID 29164034)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcervical_artery_dissection
    Sudden severe posterior neck/occipital pain + neurological signs ± Horner, after neck strain/manipulation or spontaneously (vertebral/carotid artery dissection)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspinal_infection_neck
    Fever + severe neck pain with IVDU / immunosuppression / indwelling vascular catheter / recent bacteraemia (discitis–osteomyelitis–epidural abscess) (Guzman Spine 2008 Grade IV PMID 18204387)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretrauma_rule_positive_cervical_injury
    Canadian C-Spine Rule positive/indeterminate (age ≥65 / dangerous mechanism / paraesthesias / cannot rotate 45°) in blunt head/neck trauma (Stiell JAMA 2001 PMID 11597285; NEJM 2003 PMID 14695411)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetastatic_or_pathological_cervical_lesion
    Known malignancy or constitutional symptoms with progressive neck pain (metastatic / pathological cervical lesion — Grade IV) (Guzman Spine 2008 PMID 18204387)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogressive_severe_motor_deficit
    Progressive or severe motor weakness in a cervical-radicular or multi-level pattern without frank myelopathy (Radhakrishnan Brain 1994 PMID 8186959; Fehlings PMID 29164034)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatewhiplash_high_chronicity_risk
    Whiplash (WAD grade I–III) with high psychosocial yellow-flag burden — initial depression/pain ratio >1 (Griggs J Back Musculoskelet Rehabil 2015 PMID 25322732)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinflammatory_neck_pain_pattern
    Young adult with insidious, night, exercise-improved neck/spine pain + morning stiffness (inflammatory pattern → axial spondyloarthritis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_lactation_analgesia_special_pop
    SPECIAL POPULATION — pregnancy/lactation: neck pain requiring analgesia in a pregnant (esp. ≥20 wk / 3rd-trimester) or breastfeeding patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterenal_impairment_egfr_special_pop
    SPECIAL POPULATION — renal: eGFR <30 mL/min/1.73 m² (CKD-EPI 2021, race-neutral) with neck pain requiring analgesia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehepatic_impairment_child_pugh_special_pop
    SPECIAL POPULATION — hepatic: significant hepatic impairment (Child-Pugh B/C) with neck pain requiring analgesia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_stopp_start_special_pop
    SPECIAL POPULATION — geriatric (≥65 y): polypharmacy/frailty; CCR age ≥65 high-risk limb; STOPP/START-guided analgesia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_age_cutoff_exclusion
    SPECIAL POPULATION — paediatric (<18 y): this engine is adult-scoped; paediatric neck pain has distinct red flags and the CCR/NEXUS evidence base is largely adult
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateopioid_gabapentinoid_ddi_and_deprescribing
    SPECIAL POPULATION — drug-interaction / deprescribing: existing opioid, gabapentinoid, SSRI/SNRI, or strong CYP1A2 inhibitor exposure with mechanical neck pain
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Axial / whiplash neck pain — non-pharm-first symptom-control ladder (JOSPT 2017 Blanpied; Gross Cochrane 2016)
axis: neck_pain_axial_wad_symptom_controlstep 1 - Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)
Selected step "Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)" — Any rule-negative, red-flag-negative axial / whiplash neck pain
  • stay active + reassurance + education
    first line
    self_management
    triggers: red_flag_negative_neck_pain, whiplash_wad_0_to_2
    Favourable natural history; early activation and reassurance over rest/collar; whiplash symptoms plateau ~6 wk then improve (JOSPT 2017 Blanpied PMID 28666405; Griggs J Back Musculoskelet Rehabil 2015 PMID 25322732)
  • active cervico-scapulothoracic exercise programme
    first line
    physical_therapy
    triggers: subacute_or_chronic_neck_pain, cervicogenic_headache
    Specific strengthening + stretching: chronic NP long-term pain+function SMD −0.45 (95% CI −0.72 to −0.18); stabilisation SMD −14.90 (−22.40 to −7.39) (Gross Cochrane Man Ther 2016 PMID 27317503; JOSPT 2017 Blanpied PMID 28666405)
  • manual therapy adjunct ± thoracic mobilisation
    add on
    manual_therapy
    triggers: mobility_deficit_neck_pain, as_adjunct_to_exercise
    Manual therapy combined with exercise improves pain/function in mobility-deficit neck pain (JOSPT 2017 Blanpied PMID 28666405)

outpatient playbook — drug actions (4)

  1. 1. stay active + reassurance + active exercise + education
    n/a • non-drug • ongoing
    trigger: Rule-negative, red-flag-negative neck pain
    First-line across acute/subacute/chronic; specific strengthening SMD −0.45 long-term (Gross Cochrane PMID 27317503; JOSPT 2017 Blanpied PMID 28666405)
  2. 2. naproxen (or ibuprofen)
    Naproxen 250–500 mg PO BID OR ibuprofen 400–600 mg PO TID with food • PO • BID–TID
    trigger: Pharmacologic treatment desired; no CKD/PUD/severe-CVD/3rd-trimester
    NSAID first-line analgesic (shared mechanical-spine doctrine)
  3. 3. cyclobenzaprine or methocarbamol (short course)
    Cyclobenzaprine 5 mg qHS–TID OR methocarbamol 1500 mg QID then 750 mg QID • PO • short course ≤2–3 wk
    trigger: Painful paraspinal spasm, NSAID insufficient
    Short SMR course; prefer methocarbamol in older adults (STOPP)
  4. 4. duloxetine
    30 mg PO daily × 1 wk → 60 mg PO daily • PO • once daily
    trigger: Chronic neuropathic-predominant radicular pain, no MAOI/uncontrolled-HTN/hepatic impairment
    SNRI 2nd-line for chronic neuropathic-predominant spine pain (shared mechanical-spine doctrine)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Alert, stable adult with blunt head/neck trauma → Canadian C-Spine Rule gate (Stiell JAMA 2001 PMID 11597285; NEJM 2003 PMID 14695411); Acute axial neck pain <6 weeks ± referred pain (JOSPT 2017 Blanpied PMID 28666405); Subacute neck pain 6–12 weeks (Bone & Joint Decade Task Force Guzman Spine 2008 PMID 18204387).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Mechanical neck pain (axial / radicular / myelopathy / whiplash)** (msk.mechanical-neck-pain.core.v1).
Phenotype framing: Terminal phenotype: (1) AXIAL mechanical neck pain (majority — no nerve-root signature, no myelopathic signs); (2) CERVICAL RADICULOPATHY (Wainner 4-test cluster 4/4 LR+ ≈ 30.3, 3/4 LR+ ≈ 3.5, ULTT-A best rule-OUT — Spine 2003 PMID 12544957; C7 most common then C6, favourable natural history 90% asymptomatic/mild at long-term, only 26% operated — Radhakrishnan Brain 1994 PMID 8186959; recent-onset radicular pain improves substantially even with wait-and-see — arm-pain VAS −19 mm over 6 wk, with collar/physiotherapy adding ≈−12 mm vs wait-and-see, Kuijper BMJ 2009 PMID 19812130 — supports conservative-first); (3) CERVICAL MYELOPATHY (cord-level signs — escalate, NOT axial management — Fehlings Global Spine J 2017 PMID 29164034; insidious onset + diagnostic delay common — Davies BMJ 2018 PMID 29472200); (4) WHIPLASH-ASSOCIATED DISORDER (Quebec WAD grade 0–IV; ≈50% still report neck pain at 1 y, greater initial pain/symptoms/disability + passive coping + depressed mood + fear-of-movement predict slower/less complete recovery — Carroll Spine 2008 PMID 18204405; baseline depression/pain ratio >1 → OR 2.0 — Griggs PMID 25322732); (5) REFERRED / co-existing MSK look-alike (cardiac, ENT/pharyngeal, TMJ, apical lung — non-spinal; also shoulder-girdle pain mimicking C5–C6 radicular pain → msk.shoulder-pain.core.v1; rotator-cuff / cervico-scapular tendinopathy → msk.tendinopathy.core.v1; cervical facet/uncovertebral spondylotic osteoarthritis sharing the chronic axial phenotype → msk.osteoarthritis.core.v1; widespread pain + ≥3-month duration + ACR-2016 criteria favouring central sensitisation → msk.fibromyalgia.core.v1); (6) INFLAMMATORY → route rheum.axial-spondyloarthritis.core.v1; (7) serious-secondary (escalate). MECE pivot: cord signs win over root signs win over axial; central-sensitisation widespread pattern is a co-existence flag, not a substitute for excluding Grade IV
Scope: Neck pain is a symptom and a triage problem, not a single diagnosis: the Bone & Joint Decade Task Force model (Guzman Spine 2008 PMID 18204387) frames it as an EPISODIC LIFETIME occurrence with variable recovery, graded I–IV (IV = major structural pathology — myelopathy, fracture, neoplasm, infection, systemic). The engine exists to NOT miss the cannot-miss Grade IV minority, apply the trauma rule correctly, and match non-pharm-first care to phenotype (only 46% of the historical literature is scientifically admissible — Carroll Spine 2008 PMID 18204397)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Axial / whiplash neck pain — non-pharm-first symptom-control ladder (JOSPT 2017 Blanpied; Gross Cochrane 2016)** — step "Step 1 — Non-pharmacologic core (FIRST-LINE for everyone)".
1. stay active + reassurance + education (self_management, first line) — Favourable natural history; early activation and reassurance over rest/collar; whiplash symptoms plateau ~6 wk then improve (JOSPT 2017 Blanpied PMID 28666405; Griggs J Back Musculoskelet Rehabil 2015 PMID 25322732)
2. active cervico-scapulothoracic exercise programme (physical_therapy, first line) — Specific strengthening + stretching: chronic NP long-term pain+function SMD −0.45 (95% CI −0.72 to −0.18); stabilisation SMD −14.90 (−22.40 to −7.39) (Gross Cochrane Man Ther 2016 PMID 27317503; JOSPT 2017 Blanpied PMID 28666405)
3. manual therapy adjunct ± thoracic mobilisation (manual_therapy, add on) — Manual therapy combined with exercise improves pain/function in mobility-deficit neck pain (JOSPT 2017 Blanpied PMID 28666405)

Setting playbook (outpatient) — Triage out trauma + Grade IV serious-secondary causes, classify phenotype (axial / radicular / myelopathy / WAD / referred), deliver stay-active + exercise + education first-line, escalate pharm only on the evidence ladder, refer progressive myelopathy URGENTLY, avoid unnecessary imaging/opioids (JOSPT 2017 Blanpied PMID 28666405; Guzman Spine 2008 PMID 18204387; Fehlings Global Spine J 2017 PMID 29164034)
4. stay active + reassurance + active exercise + education n/a non-drug ongoing — Rule-negative, red-flag-negative neck pain (First-line across acute/subacute/chronic; specific strengthening SMD −0.45 long-term (Gross Cochrane PMID 27317503; JOSPT 2017 Blanpied PMID 28666405))
5. naproxen (or ibuprofen) Naproxen 250–500 mg PO BID OR ibuprofen 400–600 mg PO TID with food PO BID–TID — Pharmacologic treatment desired; no CKD/PUD/severe-CVD/3rd-trimester (NSAID first-line analgesic (shared mechanical-spine doctrine))
6. cyclobenzaprine or methocarbamol (short course) Cyclobenzaprine 5 mg qHS–TID OR methocarbamol 1500 mg QID then 750 mg QID PO short course ≤2–3 wk — Painful paraspinal spasm, NSAID insufficient (Short SMR course; prefer methocarbamol in older adults (STOPP))
7. duloxetine 30 mg PO daily × 1 wk → 60 mg PO daily PO once daily — Chronic neuropathic-predominant radicular pain, no MAOI/uncontrolled-HTN/hepatic impairment (SNRI 2nd-line for chronic neuropathic-predominant spine pain (shared mechanical-spine doctrine))

Non-pharmacologic actions:
- Cervico-scapulothoracic strengthening + stretching programme (Gross Cochrane PMID 27317503)
- Manual therapy adjunct ± thoracic mobilisation for mobility-deficit neck pain (JOSPT 2017 Blanpied PMID 28666405)
- Avoid prolonged cervical collar / immobilisation (JOSPT 2017 Blanpied PMID 28666405)
- Ergonomic + work-participation counselling (JOSPT 2017 Blanpied PMID 28666405)
- Referral to spine surgery if refractory radiculopathy after adequate conservative care (Radhakrishnan Brain 1994 PMID 8186959)

AVOID / contraindication checks:
- NSAID block if eGFR<30 or active PUD or severe HF or 3rd trimester pregnancy (shared ACP/NICE mechanical spine doctrine)
- Cyclobenzaprine avoid in elderly anticholinergic burden prefer methocarbamol (STOPP/START)
- Tizanidine hepatotoxicity and hypotension avoid with strong CYP1A2 inhibitors
- Opioid not routine lowest shortest not beyond acute episode monitor prescription indicator (shared opioid restraint doctrine)
- Prolonged cervical collar immobilisation not recommended (JOSPT 2017 Blanpied PMID 28666405)

Monitoring

Regimen monitoring:
- symptom + function reassessment with NDI; whiplash plateau expected ~6 weeks (Griggs PMID 25322732)
- NSAID renal/GI/CV surveillance if comorbid risk (shared mechanical-spine doctrine)
- SMR sedation review; stop within 2–3 weeks
- re-screen Grade IV red flags + new myelopathic features at each visit (Guzman Spine 2008 PMID 18204387; Fehlings Global Spine J 2017 PMID 29164034)

Setting (outpatient) monitoring:
- NDI serial tracking; whiplash plateau expected ~6 weeks (Griggs PMID 25322732)
- re-screen Grade IV red flags + new myelopathic features at each visit (Guzman Spine 2008 PMID 18204387; Fehlings PMID 29164034)
- NSAID renal/GI/CV surveillance if comorbid risk; SMR sedation review
- opioid prescription count as a flagged quality indicator (shared opioid-restraint doctrine)

Follow-up plan: Self-management, activity maintenance, neck/scapulothoracic exercise-programme adherence (Gross Cochrane PMID 27317503), ergonomic and work-participation counselling (JOSPT 2017 Blanpied PMID 28666405). Episodic recurrence is expected (Bone & Joint Decade model — Guzman Spine 2008 PMID 18204387). Persistent or worsening neck pain → re-evaluate phenotype, re-stratify, consider specialist referral; reinforce against opioid escalation, unnecessary imaging, and non-evidence-based interventional procedures (de Rooij Cochrane 2025 PMID 41293993)
- Close-out criterion: Long-term self-management + exercise + work-participation plan in place with return precautions (any myelopathic feature / progressive deficit) taught

Monitoring phase: Re-screen red flags at each visit (new/progressive myelopathic signs, deficit, systemic features, dissection symptoms). Reassess function with the Neck Disability Index and re-evaluate WAD trajectory (whiplash plateau expected ~6 weeks then gradual improvement — Griggs PMID 25322732). Expect favourable course for axial pain and radiculopathy (Radhakrishnan Brain 1994 PMID 8186959); non-improvement or any new myelopathic feature → re-triage and urgent MRI/surgical referral. Monitor NSAID/SMR/opioid safety; opioid-restraint as a quality indicator (shared with msk.low-back-pain.core.v1)

Disposition

Current setting: outpatient — Triage out trauma + Grade IV serious-secondary causes, classify phenotype (axial / radicular / myelopathy / WAD / referred), deliver stay-active + exercise + education first-line, escalate pharm only on the evidence ladder, refer progressive myelopathy URGENTLY, avoid unnecessary imaging/opioids (JOSPT 2017 Blanpied PMID 28666405; Guzman Spine 2008 PMID 18204387; Fehlings Global Spine J 2017 PMID 29164034)

Disposition criteria:
- Continue outpatient matched care if rule-negative, red-flag-negative, non-myelopathic
- Refer/escalate if progressive myelopathy, progressive deficit, infection, unstable/odontoid fracture, or artery dissection

Escalation triggers (move to higher acuity):
- New/progressive myelopathic signs (Hoffmann, hyperreflexia, gait/bladder) → URGENT cervical MRI + spine surgery referral (Fehlings Global Spine J 2017 PMID 29164034)
- Progressive/severe motor deficit → urgent imaging + surgical referral
- Sudden severe posterior neck/occipital pain + neuro signs ± Horner → ED for suspected artery dissection
- Fever + neck pain + IVDU/immunosuppression → ED for suspected spinal infection (Guzman Spine 2008 PMID 18204387)

Patient Action Plan

**Neck pain self-management + red-flag plan**
Personalised values: phenotype_axial_radicular_or_wad, exercise_programme, analgesia_plan, comorbid_CKD_CVD_PUD.

**Improving / stable mechanical or whiplash neck pain** (green):
Triggers:
- Pain improving or stable, no arm weakness, no walking/balance change
- Doing the prescribed neck/shoulder exercises
- No fever, no new numbness, no hand clumsiness
Actions:
- Stay active and keep doing your exercise programme — avoid prolonged collar use (JOSPT 2017 Blanpied PMID 28666405)
- Use NSAID short-term as advised if you need it; avoid routine opioids
- Expect gradual improvement; whiplash often plateaus around 6 weeks then improves (Griggs PMID 25322732)
- Keep good posture and set up your workstation ergonomically

**Not improving / new arm symptoms** (yellow):
Triggers:
- Pain not improving after several weeks of activity + exercise
- New or worsening arm pain, numbness or tingling
- Needing escalating pain medication
Actions:
- Contact your provider for reassessment and phenotype review
- Continue activity and exercise; do not start bed rest or a collar
- Review your medications with your provider before escalating
Contact provider when:
- Arm pain or numbness persisting or worsening
- Pain not improving despite several weeks of the plan

**Cannot-miss neck-pain emergency** (red):
Triggers:
- New hand clumsiness, dropping things, trouble with buttons (myelopathy)
- New problems walking or with balance, or new bladder/bowel control change
- New arm/leg weakness, or weakness that is getting worse
- Sudden severe back-of-head/neck pain, especially after neck strain or manipulation, with dizziness/double vision/slurred speech
- Fever with severe neck pain, especially if immunosuppressed or inject drugs
Actions:
- Go to the emergency department now
- Bring your medication list
- Tell the ED these are new neurological or systemic symptoms — emphasise possible spinal cord, infection, or artery problem
Contact provider when:
- Always seek emergency care for any spinal-cord, severe-deficit, dissection, or infection feature (Guzman Spine 2008 PMID 18204387; Fehlings Global Spine J 2017 PMID 29164034)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Progressive degenerative cervical myelopathy — Hoffmann/hyperreflexia/clonus, gait-balance loss, hand clumsiness, bowel-bladder change (moderate/severe DCM) (Fehlings Global Spine J 2017 PMID 29164034)
- [LIFE_THREATENING] Sudden severe posterior neck/occipital pain + neurological signs ± Horner, after neck strain/manipulation or spontaneously (vertebral/carotid artery dissection)
- [LIFE_THREATENING] Fever + severe neck pain with IVDU / immunosuppression / indwelling vascular catheter / recent bacteraemia (discitis–osteomyelitis–epidural abscess) (Guzman Spine 2008 Grade IV PMID 18204387)

Citations

- Bone & Joint Decade 2000–2010 Neck Pain Task Force (Guzman/Haldeman Spine 2008; WAD course/prognosis Carroll Spine 2008) + JOSPT Neck Pain Clinical Practice Guideline Revision 2017 (Blanpied) + Canadian C-Spine Rule (Stiell JAMA 2001 / NEJM 2003) + AO Spine Degenerative Cervical Myelopathy CPG 2017 (Fehlings) + DCM clinical review (Davies BMJ 2018) + cervical-radiculopathy provocative-test systematic reviews (Rubinstein 2006 / Thoomes 2017 / Lin 2025) + spontaneous carotid/vertebral artery dissection review (Schievink NEJM 2001); shared ACP/NICE mechanical-spine analgesia doctrine; 2026-floor surveillance anchor Cochrane nucleoplasty 2025 [PMID:18204387](https://pubmed.ncbi.nlm.nih.gov/18204387/)
- Cited evidence (PMID 18204397) [PMID:18204397](https://pubmed.ncbi.nlm.nih.gov/18204397/)
- Cited evidence (PMID 28666405) [PMID:28666405](https://pubmed.ncbi.nlm.nih.gov/28666405/)
- Cited evidence (PMID 11597285) [PMID:11597285](https://pubmed.ncbi.nlm.nih.gov/11597285/)
- Cited evidence (PMID 14695411) [PMID:14695411](https://pubmed.ncbi.nlm.nih.gov/14695411/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Bone & Joint Decade 2000–2010 Neck Pain Task Force (Guzman/Haldeman Spine 2008; WAD course/prognosis Carroll Spine 2008) + JOSPT Neck Pain Clinical Practice Guideline Revision 2017 (Blanpied) + Canadian C-Spine Rule (Stiell JAMA 2001 / NEJM 2003) + AO Spine Degenerative Cervical Myelopathy CPG 2017 (Fehlings) + DCM clinical review (Davies BMJ 2018) + cervical-radiculopathy provocative-test systematic reviews (Rubinstein 2006 / Thoomes 2017 / Lin 2025) + spontaneous carotid/vertebral artery dissection review (Schievink NEJM 2001); shared ACP/NICE mechanical-spine analgesia doctrine; 2026-floor surveillance anchor Cochrane nucleoplasty 2025 — PMID:18204387
  • Cited evidence (PMID 18204397) — PMID:18204397
  • Cited evidence (PMID 28666405) — PMID:28666405
  • Cited evidence (PMID 11597285) — PMID:11597285
  • Cited evidence (PMID 14695411) — PMID:14695411