Differentiate between red flags, mechanical neck pain and nerve root pain

Also see section on Red Flags

History taking is most important in differentiating mechanical neck pain from nerve root pain or myelopathy and serious pathology.

If neck pain is mild:

• advice and information on self-management (see patient info below)
• activity modification, with reassurance that pain is not damaging, stay at work if possible (even if modification required).
• Referral should not be required on first contact

If neck pain is medium or high severity or chronic:

• advice as above PLUS refer to physiotherapy

If patient re-presents to GP with persisting symptoms reassess red flags (See management section).

Differential Diagnosis

Consider the following differential diagnoses:

• Myelopathy
• Fracture – history of trauma or osteoporosis risk
• Atypical nerve root pain
• Shingles and post-herpetic neuralgia
• Pathology in an adjacent structure
• Malignancy
• Infection
• Inflammatory back pain – see separate guidance

NB: Common findings such as osteoarthritis or cervical spondylosis are extremely common in asymptomatic people and may not be the source of pain.

The presence of 2 or more Red flags significantly raises the likelihood of serious spinal pathology.

Red flags:

Send to ED if suspicion of

• Cauda Equina Syndrome (CES)
  • Spinal infection (history immunosuppression, intravenous drug user (IVDU), fever, blood test sepsis, recent bacterial infection)

Refer URGENTLY to Spinal TEAM at RD&E via DRSS

• in presence of deteriorating neurology (consider upper and lower motor neurone signs)
• myelopathic signs (tingling, numbness or weakness)
• in cases of suspected cancer

Mark referrals clearly as URGENT and why.

Current NICE /UKSSB guidelines state MRI only for use in specialist clinic if it will change outcome. Patients should be told they may not need imaging if being referred to specialist clinic. There is a high level of incidental findings on scans e.g. disc degeneration therefore appropriate clinical interpretation is needed when feeding back MRI results.

X-ray is rarely required. Will it result in a change in management?

Bloods are appropriate for suspicion of infection or cancer.

Self-care and self-management underpins all activities within this guideline, please encourage patients to engage with this approach throughout.

Positive attitude to outcome – try to keep patient at work and maintain activity levels. Assess and address issues of distress or depression.

Encourage early activity – activity is not harmful and may help to reduce pain in many patients.

Education and rehabilitation – emphasise self-management and reinforce positive attitudes to outcome.

It is expected that patients will have completed a course of physiotherapy and had a prolonged period of conservative management before considering onward referral to any specialist service.

At each re-attendance:

• review diagnosis and reconsider differential diagnosis.
• retest neurology and range of movement/pain levels.
• check compliance with advice.
• check compliance/attendance with physiotherapy

Pharmacological interventions

• See formulary guidance on Acute Pain and Chronic Non-Malignant Pain
  • Consider oral non-steroidal anti-inflammatory drugs
    • When prescribing oral NSAIDs, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
  • Do not routinely offer opioids for managing acute neck pain
    • Only if an NSAID is contraindicated, not tolerated or has been ineffective, consider weak opioids (with or without paracetamol) for acute neck pain
    • In such circumstances, advise intermittent (not regular) use of opioid analgesia
  • Do not offer opioids for managing chronic neck pain

Guidance for healthcare professionals on drug driving

Referral Criteria

Refer To Physiotherapy:

• If pain is mild but symptoms are persisting after following advice and information on self-management (see supporting information below)
• If pain is medium or high in severity
• If neck pain is chronic in nature

Refer To Pain Clinic:

• If no improvement with physiotherapy and analgesia, and both the GP and the patient feel a pain clinic assessment would be beneficial.

Note: It is expected that patients will have completed a course of physiotherapy and had a prolonged period of conservative management before considering onward referral to any specialist service

Refer To RD&E Spinal Team:

• Patients with mechanical/non-specific neck pain AND nerve root pain who have failed primary care conservative management
• Patients with myelopathic signs
• Patients that have had previous surgical intervention in the cervical spine

Referral Instructions

Refer via e-Referral Service:

• Specialty: Orthopaedic
• Clinic Type: Neck Pain
• Service: DRSS-Eastern-Orthopaedics-Devon ICB- 15N

Referral Form

DRSS Referral Form

GP Information

MyHealth Devon

UKSSB (UK Spine Societies Board)

NICE – Neck pain-non-specific

Opioids and driving - Guidance for healthcare professionals

Sheffield aches and pains - guidance for primary care.

Patient Information

Recommended resources for patients and carers. NHS Devon does not take responsibility for the content of third party information resources.

MyHealth Devon

British Association Spinal Surgeons: patients area/ patient information

Chartered Society of Physiotherapy – neck pain exercises

Understanding pain and what to do in less than five minutes

Drugs and the driving law

NICE - patient information

The Pain toolkit – self-management website for people in chronic pain, wide ranging resource with details of the pain cycle, patient videos as well as guidance for health care professionals.

Sheffield Aches and Pains – Dealing with Neck Pain

Evidence

McCullough BJ, Johnson GR, Brook MI, Jarvik JG. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012; 262: 941-946.

Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378: 1560-1571

Pathway Group

This guideline has been signed off on behalf of the NHS Devon.

Publication date: February 2019