Differential Diagnosis for Posterior Neck Pain
The differential diagnosis for posterior neck pain in an otherwise healthy adult is dominated by mechanical causes—particularly cervical radiculopathy from disc herniation or osteophyte compression, facet joint arthropathy, and cervical spondylosis—but systematic red-flag screening is mandatory to exclude serious pathology including infection, malignancy, and myelopathy. 1
Primary Mechanical Causes (Most Common)
Cervical Radiculopathy
- Nerve root compression from herniated discs or osteophytes represents the primary neuropathic cause, typically presenting with posterior neck pain radiating to the upper extremity with dermatomal sensory or motor deficits 1, 2
- Annual incidence is approximately 83 per 100,000 persons 2
- 75–90% of cases resolve with conservative nonoperative therapy (NSAIDs, physical therapy, activity modification) within 6–8 weeks 1, 2
- A positive Spurling's test is highly specific for nerve root compression 1
Facet Joint Arthropathy
- Causes localized mechanical pain that may be unilateral and radiate to the trapezius region 1, 2
- Cervical spondylosis affects 53.9% of individuals aged 18–97, with prevalence increasing with age 2
- Degenerative changes on imaging correlate poorly with symptoms—85% of asymptomatic adults over 30 show spondylotic changes 1
Cervical Disc Degeneration
- Extremely common but often asymptomatic 1
- Intervertebral disc degeneration is present in the majority of middle-aged adults without pain 1
Myofascial Pain Syndrome
- Biomechanical sources account for most neck pain presentations 3
- Responds to NSAIDs, muscle relaxants (short-term), and physical therapy 3
Serious Etiologies Requiring Urgent Evaluation
Infectious Causes
- Vertebral osteomyelitis or discitis: fever, night sweats, elevated inflammatory markers (ESR, CRP, leukocytosis), history of IV drug use or immunosuppression 1, 4
- Epidural abscess: progressive neurological deficits, intractable pain, vertebral body tenderness 1
Malignancy
- Metastatic disease to cervical vertebrae: intractable pain, constitutional symptoms (unexplained weight loss, night sweats), history of prior malignancy, vertebral body tenderness on palpation 1, 5
- Primary spinal tumors: progressive symptoms refractory to conservative treatment 1
- Lymphoma can present with spinal cord compression and neck pain radiating to extremities 5
Cervical Myelopathy
- Spinal cord compression from stenosis, disc herniation, or tumor 1
- Presents with progressive weakness, gait disturbance, hyperreflexia, bowel/bladder dysfunction 1
- Requires differentiation from radiculopathy through careful neurological examination 1
Inflammatory Arthritis
- Rheumatoid arthritis, ankylosing spondylitis cause persistent pain with elevated inflammatory markers 1
- May present with atlantoaxial subluxation 6
Vascular Causes
- Cervical arterial dissection: unilateral headache and neck pain, requires urgent vascular imaging 1
- Consider in patients over 50 with concomitant vascular disease 1
Critical Red Flags Requiring Immediate MRI
Any of the following mandates urgent MRI cervical spine without contrast within 12–24 hours: 1
- Constitutional symptoms: fever, unexplained weight loss, night sweats 1, 4
- Elevated inflammatory markers: ESR, CRP, leukocytosis 1, 4
- History of malignancy or risk factors for metastatic disease 1
- Immunosuppression: HIV, chronic steroids, chemotherapy, current or past IV drug use 1
- Progressive neurological deficits: new weakness, sensory changes, gait disturbance, bowel/bladder dysfunction 1
- Intractable pain despite 6–8 weeks of appropriate conservative therapy 1
- Vertebral body tenderness on palpation 1
- Recent trauma or coagulopathy 1
- Atypical positional pain that worsens with axial loading 1
Diagnostic Approach Algorithm
Acute Neck Pain (<6 Weeks) WITHOUT Red Flags
- Do not order imaging initially—most cases resolve spontaneously 1, 3
- Initiate conservative management: reassurance, activity modification, NSAIDs, physical therapy 1, 3
- Plain radiographs rarely change management and should not be routinely obtained 1
- Approximately 50% will have residual or recurrent symptoms at 1 year, but this does not alter initial management 1
Acute Neck Pain WITH Red Flags
- Obtain MRI cervical spine without contrast immediately—do not delay for specialist consultation 1
- MRI is superior to CT for soft tissue abnormalities, disc herniation, nerve root impingement, infection, tumor, and vascular pathology 1, 4
- Order blood cultures and inflammatory markers if infection suspected 1
Chronic Neck Pain (>6–8 Weeks) Despite Conservative Therapy
- Order MRI cervical spine without contrast to evaluate for nerve root compression and exclude serious pathology 1
- MRI has 88% accuracy in predicting nerve root lesions 1
- Consider EMG/nerve conduction studies only if diagnosis remains unclear after MRI or to differentiate cervical radiculopathy from peripheral nerve entrapment 1
First-Line Conservative Management
Pharmacologic Therapy
- NSAIDs (ibuprofen, naproxen) for anti-inflammatory effect and pain control 1, 3
- Acetaminophen when NSAIDs contraindicated 1, 3
- Short-term muscle relaxants for severe muscle spasm (caution regarding sedation) 1, 3
- Avoid opioids for acute mechanical neck pain—unfavorable risk-benefit profile 1
- Consider adjuvant antidepressants or anticonvulsants for chronic or neuropathic pain 3
Physical Therapy & Rehabilitation
- Structured programs focusing on cervical range of motion, postural correction, and strengthening are superior to no treatment 1, 6
- Avoid prolonged static neck positions and overhead activities 1
- Implement ergonomic workplace adjustments 1
Referral Criteria
Refer to spine specialist (neurosurgery or orthopedic spine) when: 1
- Symptoms persist beyond 6–8 weeks of appropriate conservative therapy
- Progressive neurological deficits develop
- MRI reveals significant pathology (moderate-to-severe foraminal stenosis, disc herniation with nerve root compression, spinal cord compression)
- Red-flag symptoms are present
Critical Pitfalls to Avoid
- Do not order imaging immediately in the absence of red flags—leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 1
- Do not interpret degenerative changes on imaging as causative without clinical correlation—spondylotic changes are present in 85% of asymptomatic individuals over 30 1
- Do not delay MRI when red flags are present—early imaging prevents missed serious pathology 1
- Avoid plain radiographs alone when red flags exist—they cannot rule out metastasis, infection, or epidural disease 1
- Do not use cervical provocative discography or anesthetic facet/nerve blocks for diagnosis—no evidence supports these 1