Abstract
Diagnosing the source of axial pain, particularly in the cervical region, presents a considerable challenge due to the extensive range of potential underlying conditions. While numerous diagnostic frameworks exist, a truly comprehensive guide tailored for practical application in diverse clinical settings remains elusive. This article provides an expansive overview of medical conditions that can manifest as neck pain, ranging from common musculoskeletal issues to rare systemic diseases. We propose a diagnostic algorithm designed to categorize these conditions into clinically relevant subgroups. This classification system aims to streamline the diagnostic process, facilitating targeted investigations and specialist referrals, ultimately saving time and reducing unnecessary diagnostic procedures. This review and the proposed algorithm serve as a valuable resource for medical education and daily practice, particularly for automotive repair professionals who frequently encounter customers describing such symptoms, enabling them to better understand and communicate with healthcare providers about cervical pain.
Keywords: Cervical pain, Neck pain, Differential diagnosis, Diagnostic algorithm, Automotive repair, Musculoskeletal pain, Spinal pain, Diagnosis
Introduction
Neck pain is a pervasive complaint encountered across various healthcare settings, from orthopedic and emergency departments to general practice and even indirectly in automotive repair environments when customers describe discomfort related to driving posture or accidents [1]. The differential diagnosis for neck pain is remarkably broad, often challenging even seasoned clinicians to arrive at a definitive diagnosis without a systematic approach. While straightforward conditions like cervical radiculopathy due to disc herniation are readily identifiable through clinical examination and imaging, differentiating them from less common etiologies such as spinal tumors or infections requires a structured diagnostic process. Delayed diagnosis, particularly in cases of rare but serious conditions like spinal infections, can significantly impact patient outcomes [2]. Therefore, a comprehensive and efficient method for differential diagnosis is crucial to narrow down diagnostic possibilities, minimize unnecessary testing, and expedite accurate diagnosis, benefiting both patients and professionals who interact with them, including those in automotive repair who need to understand customer complaints related to discomfort while driving.
This article outlines a practical methodology for categorizing the diverse causes of neck pain based on simple clinical criteria. Our objective is to create a diagnostic roadmap that bridges the gap between exhaustive lists of potential diagnoses and the targeted diagnostic tests and imaging modalities required for confirmation or exclusion. We offer concise definitions for each condition to provide a broad overview, rather than exhaustive descriptions of individual pathologies, focusing on the differential diagnosis of cervical pain within the broader context of axial pain.
Existing literature often addresses diagnostic workups for low back pain, frequently emphasizing acute versus chronic pain classification and the identification of red flags suggestive of serious pathology, such as cancer or infection [3]. However, the reliability of red flags in diagnosing severe back pain etiologies has been questioned [3]. While cervical and thoracic pain are sometimes addressed separately, these discussions are often extrapolated from low back pain literature. This isolated approach can be limiting, potentially causing clinicians to overlook interconnected spinal regions. This review offers a holistic, systematic approach to diagnosing patients presenting with spinal complaints, with a particular focus on Cervical Differential Diagnosis.
Literature Review
Referred Pain in the Cervical Region
Referred pain, a critical consideration in cervical differential diagnosis, is characterized by pain perceived in the neck originating from a non-cervical source, typically lacking local signs or tenderness upon palpation and cervical motion [4, 5]. It is vital to recognize that neck pain can stem from pathologies outside the cervical spine [6]. For instance, acute myocardial infarction, especially involving the inferior wall, can manifest as neck and left shoulder pain, accompanied by chest discomfort, shortness of breath, and sweating. Aortic dissection can cause sudden, severe neck and upper back pain, potentially mimicking musculoskeletal pain but carrying life-threatening implications.
Pulmonary conditions such as Pancoast tumors (lung cancer at the apex) can cause shoulder and neck pain due to brachial plexus involvement. Esophageal spasm or rupture can also refer pain to the neck and upper back. Intra-abdominal pathologies, such as cholecystitis or pancreatitis, can occasionally refer pain to the upper back and neck. Even conditions like cervical lymphadenitis (inflammation of lymph nodes in the neck) due to infections like tonsillitis or infectious mononucleosis can present as neck pain, although typically associated with localized tenderness and other systemic symptoms. It’s crucial to consider these referred pain patterns in the cervical differential diagnosis to avoid misdiagnosing and mistreating non-spinal conditions as primary cervical disorders, especially in automotive repair contexts where customers may describe pain seemingly related to posture but originating elsewhere.
Trauma and Overuse in Cervical Pain
Trauma and overuse are common etiologies of neck pain. Traumatic fractures, dislocations, and ligamentous tears of the cervical spine are significant concerns. However, the history of trauma may not always be apparent, especially in altered mental status patients or nonverbal individuals. Conversely, a history of trauma might be a “red herring,” diverting attention from the actual underlying cause. Cervical strains and sprains, resulting from low-energy injuries, overuse, or sudden movements, are frequent causes of neck pain. Whiplash injuries, commonly occurring in motor vehicle accidents, are well-recognized sources of neck pain [7].
Cervical radiculopathy can result from repetitive stress or minor trauma exacerbating underlying degenerative changes. Central cord syndrome, often caused by hyperextension injuries in older individuals with cervical spondylosis, can present with neck pain along with disproportionate weakness in the upper extremities. Pathological fractures due to osteoporosis or metastatic disease can occur in the cervical spine, sometimes with minimal trauma. Stress fractures, although less common in the cervical spine compared to the lumbar region, can occur in athletes involved in repetitive neck extension activities. It is important to consider the spectrum of traumatic and overuse injuries in the cervical differential diagnosis, particularly when assessing individuals involved in accidents or those with physically demanding occupations, including drivers and mechanics who may experience neck strain from prolonged or awkward postures.
Infections of the Cervical Spine
Infections of the cervical spine, while less common than degenerative conditions, are critical to consider in the cervical differential diagnosis due to their potential for severe neurological complications. Osteomyelitis and discitis of the cervical spine can cause gradual or sudden onset of neck pain, often accompanied by fever, chills, and progressive pain that is constant and may worsen at night. In children, cervical spondylodiscitis can present with neck stiffness, torticollis, or even referred pain without obvious neck pain. Epidural abscess in the cervical region is a serious condition causing severe neck pain, fever, and rapidly progressive neurological deficits due to spinal cord compression.
Tuberculous spondylitis (Pott’s disease) of the cervical spine is a less acute infection, presenting with slowly progressive neck pain, stiffness, and potentially kyphotic deformity. Fungal infections and Brucellosis of the cervical spine are rarer but should be considered in immunocompromised individuals or those with relevant exposures. Meningitis, although primarily affecting the meninges surrounding the brain and spinal cord, can cause neck pain and stiffness as prominent symptoms. Even viral infections like influenza and COVID-19 can cause myalgias including neck pain. Prompt recognition of cervical spine infections is crucial in the cervical differential diagnosis to initiate timely treatment and prevent irreversible neurological damage.
Tumors in the Cervical Spine
Tumors, both benign and malignant, represent a critical category in the cervical differential diagnosis. Benign tumors such as osteoid osteoma and osteoblastoma in the cervical spine can cause persistent neck pain, often characterized by nocturnal exacerbation and relief with NSAIDs. Schwannomas and neurofibromas arising from cervical nerve roots can cause radicular neck pain and neurological symptoms. Meningiomas and calcifying pseudoneoplasms can also occur in the cervical spinal canal, causing neck pain and myelopathy.
Malignant tumors, including primary bone tumors like chondrosarcoma and metastatic lesions, are important considerations, especially in older individuals or those with a history of cancer. Metastases from breast, lung, prostate, kidney, and thyroid cancers are most common in the spine. Multiple myeloma and lymphoma can also involve the cervical vertebrae. Chordomas, while more common in the sacrococcygeal region, can occur in the cervical spine. Tumors should be considered in the cervical differential diagnosis, particularly in cases of persistent, progressive neck pain, night pain, unexplained weight loss, or neurological deficits.
Degenerative, Rheumatic, and Autoimmune Conditions Causing Cervical Pain
Degenerative conditions are the most prevalent cause of chronic neck pain. Cervical spondylosis, encompassing intervertebral disc degeneration, facet joint osteoarthritis, and ligamentous hypertrophy, is a common age-related process causing neck pain, stiffness, and potentially cervical radiculopathy or myelopathy. Cervical disc herniation can compress nerve roots or the spinal cord, leading to neck pain, radicular arm pain, and neurological deficits. Cervical spinal stenosis, narrowing of the spinal canal, can result in cervical myelopathy with neck pain, gait disturbance, and upper extremity weakness and numbness. Facet joint arthritis is another frequent source of mechanical neck pain, worsened by extension and rotation.
Rheumatic and autoimmune conditions also feature prominently in the cervical differential diagnosis. Rheumatoid arthritis frequently affects the cervical spine, particularly the atlantoaxial joint, potentially causing atlantoaxial subluxation, spinal cord compression, and neck pain. Ankylosing spondylitis and other spondyloarthropathies can involve the cervical spine, causing inflammatory neck pain, stiffness, and reduced mobility. Polymyalgia rheumatica can present with neck pain and stiffness, often in older adults, accompanied by proximal muscle pain and elevated inflammatory markers. Systemic lupus erythematosus (SLE) can also affect the cervical spine, causing inflammatory arthritis and rarely myelitis. Crowned dens syndrome, caused by calcium pyrophosphate deposition around the odontoid process, presents with acute, severe neck pain and stiffness. These degenerative, rheumatic, and autoimmune conditions represent a significant portion of the cervical differential diagnosis, necessitating careful consideration of clinical features, inflammatory markers, and imaging findings.
Vascular Causes of Cervical Pain
Vascular etiologies of neck pain are less common but can be serious. Vertebrobasilar insufficiency (VBI), caused by reduced blood flow in the vertebral and basilar arteries, can manifest as neck pain, dizziness, vertigo, visual disturbances, and even stroke symptoms. Neck movements, particularly rotation or extension, can sometimes provoke VBI symptoms. Carotid artery dissection, a tear in the carotid artery wall, can cause neck pain, headache, and Horner’s syndrome, and is a risk factor for stroke. Spinal cord infarction in the cervical region, although rare, can cause sudden onset of neck pain and neurological deficits. Epidural or subdural hematoma of the cervical spine can occur after trauma or in patients with bleeding disorders, causing acute neck pain and spinal cord compression. While less frequent, vascular causes should be considered in the cervical differential diagnosis, especially in patients with risk factors for vascular disease or those presenting with atypical neck pain accompanied by neurological or systemic symptoms.
Congenital and Developmental Cervical Conditions
Congenital and developmental anomalies of the cervical spine can lead to neck pain. Klippel-Feil syndrome, characterized by congenital fusion of cervical vertebrae, can cause neck pain, limited range of motion, and scoliosis. Chiari malformations, involving herniation of cerebellar tissue into the spinal canal, can cause neck pain, headaches, and neurological symptoms. Syrinx (syringomyelia), a fluid-filled cavity within the spinal cord, can develop in the cervical region due to Chiari malformations or other causes, leading to neck pain, sensory disturbances, and weakness. Torticollis, or wry neck, can be congenital due to sternocleidomastoid muscle contracture or secondary to various underlying conditions, causing neck pain and deformity. These congenital and developmental conditions should be considered in the cervical differential diagnosis, particularly in children and adolescents presenting with neck pain or structural abnormalities.
Psychogenic Cervical Pain
Psychogenic neck pain, also termed somatoform neck pain, is diagnosed after excluding organic causes. Conditions like somatoform disorders, conversion disorders, and malingering can manifest as neck pain. Diagnosis is typically by exclusion and requires careful assessment of psychological factors and symptom consistency. While psychogenic pain is a valid diagnosis, it is crucial to thoroughly investigate and rule out organic etiologies before attributing neck pain to psychological factors, ensuring comprehensive cervical differential diagnosis.
Metabolic and Endocrine Disorders Causing Cervical Pain
Metabolic and endocrine disorders can indirectly contribute to neck pain. Osteoporosis, a common metabolic bone disease, increases the risk of vertebral compression fractures in the cervical spine, leading to neck pain. Paget’s disease of bone can affect the cervical vertebrae, causing bone pain and potential nerve compression. Hyperparathyroidism and renal osteodystrophy can also lead to bone pain and pathological fractures in the spine, including the cervical region. Osteomalacia, characterized by soft bones due to vitamin D deficiency, can cause generalized bone pain, including neck pain. While less direct, these metabolic and endocrine conditions should be considered as contributing factors in the cervical differential diagnosis, especially in older individuals or those with known metabolic disorders.
Iatrogenic Cervical Pain
Iatrogenic causes, resulting from medical treatments, can contribute to neck pain. Failed neck surgery syndrome, analogous to failed back surgery syndrome, refers to persistent neck pain after cervical spine surgery. This can be due to various factors, including incomplete decompression, adjacent segment disease, epidural fibrosis, or infection. Certain medications, such as statins, bisphosphonates, and aromatase inhibitors, have been associated with musculoskeletal pain, potentially including neck pain. Cervical epidural injections, while intended to relieve pain, can sometimes cause post-procedure neck pain or complications like epidural hematoma or arachnoiditis. Iatrogenic factors should be considered in the cervical differential diagnosis, particularly in patients with a history of cervical spine interventions or medication use.
Idiopathic Cervical Pain
Idiopathic neck pain refers to neck pain without a clearly identifiable underlying cause despite thorough investigation. Conditions like fibromyalgia and myofascial pain syndrome can manifest as chronic neck pain with trigger points and muscle tenderness, but without specific structural pathology. Torticollis, in many cases, is idiopathic, involving involuntary neck muscle contractions causing pain and abnormal head posture. Cervical dystonia is another idiopathic neurological disorder causing involuntary neck muscle spasms and pain. While idiopathic diagnoses are made after excluding other etiologies, it’s important to recognize these conditions as distinct entities in the cervical differential diagnosis, focusing on symptomatic management and functional improvement.
Method: A Clinical Grouping Approach to Cervical Differential Diagnosis
Upon initial evaluation of a patient presenting with neck pain, clinicians have access to essential diagnostic tools: history taking, physical examination, and basic laboratory and imaging studies. Our experience suggests that utilizing these tools systematically can often lead to a clear diagnosis or, at minimum, guide the diagnostic process by categorizing the patient’s condition into a clinically relevant subgroup. This categorization facilitates targeted investigations and specialist referrals, streamlining the diagnostic journey. We aim to share this structured approach, beneficial for both less experienced practitioners and seasoned specialists, to enhance the efficiency of cervical differential diagnosis. We propose classifying the aforementioned conditions causing neck pain into seven clinical groups based on simple clinical, laboratory, and imaging criteria (Table 1). These clinical groups or syndromes are often discernible from the initial patient encounter. For didactic purposes, we begin with referred pain, as non-spinal etiologies are sometimes overlooked:
- (i) Referred pain from extracervical sources (cranium, chest, abdomen): These conditions present with neck pain originating outside the cervical spine. Diagnosis relies on recognizing associated symptoms and signs indicative of the primary pathology. For example, a patient with neck and jaw pain, chest discomfort, and shortness of breath warrants immediate cardiac evaluation.
- (ii) Neck pain with signs of infection: This category includes conditions with neck pain accompanied by systemic signs of infection such as fever, chills, malaise, and elevated inflammatory markers (leukocytosis, CRP, ESR). Infections of the cervical spine, meningitis, and systemic infections with neck involvement fall into this group. Further investigations include blood cultures, imaging (CT or MRI), and potentially cerebrospinal fluid analysis.
- (iii) Neck pain with nerve root compression (cervical radiculopathy): Characterized by neck pain radiating into the arm, often following a dermatomal pattern, accompanied by sensory, motor, or reflex deficits in the affected extremity. Cervical disc herniation, foraminal stenosis, and nerve root tumors are common causes. Diagnosis is confirmed by physical examination, imaging (MRI or CT myelography), and electrodiagnostic studies (EMG/NCV).
- (iv) Neck pain with spinal cord compression (cervical myelopathy): This represents a serious category characterized by neck pain with signs of spinal cord dysfunction, including gait disturbance, upper extremity weakness and numbness, bowel or bladder dysfunction, and hyperreflexia. Cervical spinal stenosis, disc herniation with cord compression, tumors, and trauma are potential etiologies. Urgent imaging (MRI) is essential.
- (v) Mechanical neck pain: This is the most common category, characterized by neck pain related to movement and posture, typically relieved by rest. Cervical spondylosis, facet joint arthritis, muscle strains, and ligament sprains are frequent causes. Diagnosis is often clinical, supported by plain radiographs or CT scans to assess for structural abnormalities.
- (vi) Inflammatory/Rheumatic neck pain: This group encompasses conditions with neck pain due to inflammation, often persistent at rest and potentially worsening at night, with morning stiffness and improvement with activity or NSAIDs. Rheumatoid arthritis, ankylosing spondylitis, polymyalgia rheumatica, and other inflammatory arthropathies are included. Diagnosis involves clinical criteria, inflammatory markers (ESR, CRP, rheumatoid factor, etc.), and imaging.
- (vii) Neck pain with other characteristics: This heterogeneous group includes conditions that do not fit neatly into the other categories. Examples include tumors without significant compression, metabolic bone diseases, psychogenic pain, and idiopathic neck pain syndromes. Diagnosis often requires a detailed history, physical examination, targeted investigations, and exclusion of other categories.
Table 1. Clinical Grouping for Cervical Differential Diagnosis
| 1. Referred Pain | 2. Pain with Infection | 3. Pain with Nerve Root Compression | 4. Pain with Spinal Cord Compression | 5. Mechanical Pain | 6. Inflammatory/Rheumatic Pain | 7. Pain with Other Characteristics |
|---|---|---|---|---|---|---|
| Myocardial Infarction, Aortic Dissection, Pancoast Tumor, Esophageal Spasm, Cholecystitis, Cervical Lymphadenitis | Cervical Osteomyelitis, Discitis, Epidural Abscess, Meningitis, Tuberculous Spondylitis, Fungal Infections, Brucellosis | Cervical Disc Herniation, Foraminal Stenosis, Nerve Root Tumors, Spondylosis, Facet Joint Disease | Cervical Spinal Stenosis, Disc Herniation with Cord Compression, Tumors, Trauma, Atlantoaxial Subluxation, Syrinx | Cervical Spondylosis, Facet Joint Arthritis, Muscle Strain, Ligament Sprain, Whiplash, Poor Posture | Rheumatoid Arthritis, Ankylosing Spondylitis, Polymyalgia Rheumatica, Crowned Dens Syndrome, SLE, Inflammatory Arthropathies | Fibromyalgia, Myofascial Pain Syndrome, Psychogenic Pain, Metabolic Bone Diseases (Osteoporosis, Paget’s), Idiopathic Torticollis, Tumors without Compression, Medication-Induced Pain |
| Diagnostic Tools: ECG, Chest X-ray, Abdominal Exam, Consider origin-specific tests | Diagnostic Tools: Blood Counts, CRP, ESR, Blood Cultures, Imaging (CT/MRI), CSF Analysis if Meningitis suspected | Diagnostic Tools: Neurological Exam, MRI, CT Myelography, EMG/NCV | Diagnostic Tools: Neurological Exam, MRI (urgent), CT Scan | Diagnostic Tools: Clinical Exam, Radiographs, CT Scan | Diagnostic Tools: Inflammatory Markers (ESR, CRP, RF, etc.), Rheumatoid Factor, HLA-B27, Imaging | Diagnostic Tools: Clinical Exam, Targeted Blood Tests (Calcium, Vitamin D, Thyroid function), Psychological Evaluation, Exclusion of other categories |
ECG, Electrocardiogram; CRP, C-reactive protein; ESR, Erythrocyte sedimentation rate; CSF, Cerebrospinal fluid; EMG/NCV, Electromyography/Nerve Conduction Velocity; MRI, Magnetic Resonance Imaging; CT, Computed Tomography; RF, Rheumatoid Factor; HLA-B27, Human Leukocyte Antigen B27; SLE, Systemic Lupus Erythematosus
Discussion
The necessity for a systematic approach to neck and back pain, including cervical differential diagnosis, has been long recognized in primary care and specialist settings [3, 49]. Underwood and others have highlighted the limitations of relying solely on “red flags” for back pain due to their low specificity and sensitivity. Instead, focusing on early identification of serious conditions like cauda equina syndrome, spinal infections, and fractures has been advocated [50]. For the majority of neck and back pain cases, a more longitudinal diagnostic approach, allowing for observation and response to initial treatment, is often appropriate.
Singleton and Edlow similarly emphasized risk stratification and systematic diagnosis of severe spinal pathology in emergency medicine [1]. Our proposed approach aligns with these frameworks by incorporating a mental model that distinguishes between benign musculoskeletal conditions, spinal pathologies causing neurological compromise, and non-spinal sources of neck and back pain.
Bardin et al. proposed a “diagnostic triage” system for low back pain, starting with excluding non-spinal causes and then categorizing patients into specific spinal pathology, radicular pain, or non-specific low back pain [6]. Our approach expands on these models by providing a more granular classification system (seven groups) applicable to the entire spine, with a specific focus on cervical differential diagnosis.
While existing diagnostic frameworks are valuable, particularly for low back pain, our review offers a more comprehensive and inclusive overview of spinal pathologies from the cervical to sacral regions. This broader perspective enhances the diagnostic acumen of clinicians managing axial pain. The expansion to seven pain syndromes, compared to simpler classifications, makes this review particularly useful in non-emergency settings and for specialists managing complex cervical pain presentations. We believe that utilizing this seven-syndrome classification system can effectively guide clinicians in the accurate diagnosis of axial pain, minimizing unnecessary investigations and referrals, and improving patient care. For automotive repair professionals, understanding these categories can facilitate better communication with customers and healthcare providers regarding neck pain complaints potentially related to driving or vehicle accidents.
Author Contribution
EK: Conceptualization, Methodology, Writing; HS: Methodology, Writing; NS: Methodology, Writing; AT: Methodology, Writing; EB: Methodology, Writing.
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The authors declare no competing interests.
Footnotes
This article is part of the Topical Collection on Differential Diagnosis in Clinical Practice.
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Elisha Krasin and Haggai Schermann contributed equally to this work.
References
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