Neck Pain Red Flags and When Not To Worry - Orthopedic & Sports Medicine

Article by Paul Ingraham | Featured on Pain Science

We fear spine pain more than we fear other kinds of pain. Backs and necks seem vulnerable. And yet most spinal pain does not have a serious cause. The bark of neck pain is usually worse than its bite. This article explains how to tell the difference.

Please do seek care immediately if you’ve been in an accident or you have very severe or weird pain or other symptoms — obviously. This article is for non-emergency situations. But if you have neck pain that’s been starting to worry you, this is a good place to get some reassurance and decide whether or not to talk to a doctor.

Although it’s rare, once in a while neck pain may be a warning sign of cancer, infection, autoimmune disease, or some kind of structural problem like spinal cord injury or a threat to an important blood vessel. Some of these ominous situations cause hard-to-miss signs and symptoms other than pain and are likely to be diagnosed correctly and promptly — so, if it feels serious, go get checked out. Otherwise, if you are aware of the “red flags,” you can get checked out when the time is right — and avoid excessive worry until then.

The rule of thumb is that you should start a more thorough medical investigation only when all three of these conditions are met, three general red flags for neck pain:

it’s been bothering you for more than about 6 weeks
it’s severe and/or not improving, or actually getting worse
there is at least one other “red flag” (see below)

And there is one (hopefully obvious) situation where there’s no need to wait several weeks before deciding the situation is serious: if you’ve had an accident with forces that may have been sufficient to fracture your spine or tear nerves. I didn’t really have to tell you that, did I? Well, I did for legal reasons!

Several more specific red flags for neck pain: a checklist

Check all that apply. Most people will not be able to check many of these! But the more you can check, the more worthwhile it is to ask your doctor if it’s possible that there’s something more serious going on than just neck pain. Most people who check off an item or two will turn out not to have an ominous health issue. But red flags are reasons to check… not reasons to worry.

Signs of arthritis are not red flags

One of the most common concerns about the neck that is not especially worrisome: signs of “wear and tear” on the cervical spine, arthritis, and degenerative disc disease, as revealed by x-ray, CT scans, and MRI. Many people who have clear signs of arthritic degeneration in their spines will never have any symptoms, or only minor, and/or not for a long time.10 For instance, about 50% of fortysomethings have clinically silent disk bulges, and even at age 20 there’s a surprising amount of spinal arthritis. The seriousness of these signs is routinely overestimated by patients and healthcare professionals alike.11

Signs of arthritis are almost never diagnostic on their own.12 Do yourself a favour: don’t assume that you have a serious problem based only on pain plus signs of arthritis. Pain is common; serious degeneration is not.

Percentages of people with various kinds of spinal degeneration *but no pain*. Source: Brinjikji et al
Imaging finding	Age
	20	30	40	50	60	70	80
Disc degeneration	37%	52%	68%	80%	88%	93%	96%
Disk height loss	24%	34%	45%	56%	67%	76%	84%
Disk bulge	30%	40%	50%	60%	69%	77%	84%
Disk protrusion	29%	31%	33%	36%	38%	40%	43%
Annular fissure	19%	20%	22%	23%	25%	27%	29%
Facet degeneration	4%	9%	18%	32%	50%	69%	83%

Sharp, stabbing, and shooting neck pains are usually false alarms

Sharp neck pain is not in itself a red flag. Believe it or not there is no common worrisome cause of neck pain that is indicated by a sharp quality. In fact, oddly, sharp pains are actually a bit reassuring, despite how they feel. In isolation — with no other obvious problem — they usually indicate that you just have a temporary, minor source of irritation in the cervical spine. Serious causes of neck pain like infections, tumours, and spinal cord problems tend grind you down with throbbing pains, not “stab” you.

Sharp, shooting pains are mostly neurological false alarms about relatively trivial musculoskeletal troubles: your brain reacting over-protectively to real-but-trivial irritations in and around the spine. The brain takes these much more seriously than it really needs to, but evolution has honed us to be oversensitive in this way. That’s not to say that the brain is always over-reacting, but it usually is. Most of the time, a sharp pain is a warning you can ignore.

The cervical spine is also surrounded by a thick, tangled web of nerves. In general, those nerves are amazingly difficult to irritate, much harder than people think, but it’s not impossible. Many sharp and shooting neck pains are probably caused by minor neuropathy (pain from nerve irritation) that will ease gradually over several days or a few weeks at the worst, like a bruise healing. It’s unpleasant, but not actually scary, like banging your funny bone (ulnar nerve): that thing can really take a licking and keep on ticking. So can the nerves in your neck.

Is a stiff neck serious?

Rarely. Nearly all neck stiffness is minor, diffuse musculoskeletal pain: several mildly irritated structures adding up to uncomfortable, reluctant movement as opposed to physically limited movement. The most common scary neck stiffness is the “nuchal rigidity” of meningitis — which makes it very difficult and uncomfortable to tilt the head forward — but that will be accompanied by other serious warning signs, of course. Like feeling gross otherwise (flu-like malaise).

If you have severe neck stiffness for a long time, plus any other warning signs, there could be a worrisome cause — but still probably not, and probably not urgent. Investigate if you have enough red flags, and even then it’s likely to amount to nothing.

Miscellaneous medical causes of neck pain that might mean you can stop worrying about something worse

This section presents a comprehensive list of somewhat common medical problems that can cause neck pain (and might, conceivably, be confused with an “ordinary” case of neck pain). I’ll give you a quick idea of what they are and what distinguishes them. If you find anything on this list that seems awfully similar to your case, please bring the idea to your doctor like a dog with an interesting bone; and get a referral to a specialist if necessary.

Important! None of these are dangerous! Although some are quite unpleasant. Reading about medical problems on the Internet can easily freak us out,13 so the goal here is to identify possible causes of neck pain that are not so scary. If you can get a positive ID on one of these conditions, then you get to stop worrying about the threat of something worse.

Some skin problems on the neck can cause neck pain, but are usually obvious — most people will identify them as “skin problems on the neck” and not “a neck problem affecting the skin.” Herpes zoster (shingles) [CDC] causes a painful rash, cellulitis [Mayo] is extremely painful but superficial, and a carbuncle[Wikipedia] … well, it’s just a super zit, basically. If you can’t diagnose that one on your own, I can’t help you!

Bornholm disease [NHS] is a crazy viral disease with several other intimidating names.14 It feels like a vice-grip on the chest and lungs, is intensely painful, and sometimes also causes neck pain. If you feel like you can’t breathe, you should look into this. The infection is temporary. It’s an extremely unlikely diagnosis.

Trichinosis [Wikipedia] (or trichinellosis, or trichiniasis) is a parasitic disease caused by eating raw or undercooked pork and wild game. It can be mild or severe or fatal, and digestive disturbance is likely. It can also cause spasming and widespread muscle pain, including the neck. There’s a laundry list of other symptoms.

Temporal arteritis can cause neck pain as well as fierce headaches.

Temporal arteritis [healthline] is an inflammation of arteries in the temple, with a lot of symptoms: severe headache, fever, scalp tenderness, jaw pain, vision trouble, and ringing in the ears are all possible symptoms, along with neck pain. It’s almost unheard of in people younger than 50, and it usually occurs in people with other diseases or infections.

Lymphadenopathy. [Merck] The lymph nodes of the neck may bulge and swell in response to disease or infection. Once in a blue moon, someone might mistake these bulgings for muscle knots. More likely, it will be obvious that something else is going on: a variety of other symptoms.

Parsonage-Turner syndrome, [RareDiseases.org] inflammation of the brachial plexus. For no known reason, sometimes the web of nerves that exit the cervical spine, the brachial plexus, becomes rapidly inflamed. This condition may sometimes occur along with neck pain. Strong pain in the shoulder and arm develops quickly, weakens the limb, and even atrophies the muscles over several months. There is no cure, but most people make a complete recovery.

Thyroiditis, [Wikipedia] inflammation of the thyroid gland in the throat, can be difficult to diagnose, causing a bewildering array of vague symptoms. If your neck pain is accompanied by symptoms like fatigue, weight gain, feeling “fuzzy headed,” depression and constipation, consider checking with your doctor.

Eagle’s syndrome [Medscape] is a rare abnormal elongation of a bizarre little bit of bone at the back of the throat called the styloid process. Even a normal styloid process looks jarring when you first see one: it is so skinny and sharp that it makes one wonder how it can possibly not be stabbing something. Well, it turns out that in some cases it does “stab” you in the neck. This will cause a feeling of a lump in the throat and/or moderate intensity pains throughout the region, possibly including the side of the neck, although pain is more likely to dominate the jaw and throat.15

And one more important one …

Necks just hurt sometimes

The neck is one of a few areas of the body — along with the low back, jaw, and bowels — that is vulnerable to bouts of unexplained pain, sometimes quite stubborn. In most cases, the pain goes away. Pain is weird and unpredictable, and is often the result of the brain being overprotective and paranoid.

Worrying about the pain may be literally the worst thing you can do — not just a poor coping mechanism, but a genuine risk factor. Like noise pollution, the more you focus on it, the worse it gets. That’s why this article is focused on rational reassurance.

If you want more, carry on with my huge neck crick tutorial, for people with a frustrating sensation of mechanical stuckness. Or read about the weirdness of pain and learn more about how to tame your brain’s false alarm: Pain is Weird.

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