Serious cervical spine conditions (Red Flags)

These include (See referral guidelines):

Suspected cervical myelopathy
Suspected vertebral fragility fractures
Suspected spinal infection
Suspected malignancy
Suspected metastatic spinal cord compression
Suspected vascular pathologies of the neck
Deteriorating cervical radiculopathy with motor deficit grade 3 or less (Oxford scale)
Widespread neurology – features not in keeping with cervical radiculopathy or myelopathy
Traumatic onset neck pain
Suspected inflammatory spinal conditions

Condition	Symptoms	Signs	Further info
Cervical myelopathy	Stiff neck or legs Altered sensation in the legs Altered balance and staggering when walking Bilateral hand numbness Loss of dexterity (difficulty doing up buttons/holding a pen) Clumsiness in the hands.	Hyper-reflexia Abnormal pathological reflexes (e.g. positive Hoffman, plantar response, ankle clonus) Increased tone Motor deficits Atrophy of intrinsic hand muscles A broad-based unstable, ataxic gait Bowel and bladder dysfunction	Cervical Myelopathy – RefHelp
Suspected vertebral fragility fractures	Sudden onset of severe central spinal pain which is relieved by lying down There may be a history of trauma (such as road traffic collision or fall from height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids Identified risk factors	There may be point tenderness over a vertebral body.	Suspected vertebral fragility fractures – RefHelp
Suspected spinal cord compression (MSCC)	Localised neck pain with a current diagnosis of cancer (particularly: breast, lung, prostate, kidney, thyroid) Severe, intractable progressive pain, especially thoracic New spinal nerve root pain (burning numb, shooting) Any new difficulty walking Bowel/ bladder disturbance.	Reduced power/ altered sensation in limbs	See Malignant Spinal Cord Compression – RefHelp
Suspected malignancy	Aged over 50 years Gradual onset of symptoms Severe unremitting pain that remains when the person is supine Aching night pain that prevents or disturbs sleep Pain aggravated by straining (e.g. bowel movements, coughing, sneezing) thoracic pain No symptomatic improvement after 4-6 weeks of conservative therapy Unexplained weight loss Current/Previous history of cancer (breast, lung, gastrointestinal, prostate, renal, thyroid cancers are more likely to metastasize to the spine)	Localised spinal tenderness	If clinical assessment by GP leads to a very strong suspicion of suspected underlying malignancy, consider recommendations and referral options GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp
Traumatic onset neck pain	Central neck pain Loss of sensation or paralysis in the body, arms, and/or legs Pain that radiates from the neck into the arms and/or shoulders	Patients with traumatic neck pain are typically managed through A&E. However, prior to completing a physical examination, it is important to apply the Canadian C Spine Rule if appropriate.	Traumatic onset neck pain – RefHelp
Suspected spinal infection	Fever in a patient with new neck pain Recent infection (especially skin or urinary tract) Cervical osteomyelitis and cervical epidural abscesses arise from haematogenous spread in most cases About one third of cases of cervical epidural abscesses arise from contiguous spread from the skin Tuberculosis Diabetes History of IV drug use HIV infection, use of immunosuppressants, or the person is otherwise immune-compromised	Fever in a patient with new neck pain	See referral guidelines section
Axial Spondyloarthritis	Back pain > 3months with onset <45yrs of age Does not improve on resting Insidious onset Pain at night improving on rising Early morning stiffness improving with exercise Good response to NSAID Other associated features – see Axial Spondyloarthritis – RefHelp	Reduced range of spine movements	see Axial Spondyloarthritis – RefHelp

Other considerations:

Vascular pathologies of the neck

There are a range of potential vascular pathologies of the neck which have the potential to mimic musculoskeletal problems (vascular masqueraders).

Typically in addition to neck pain clinical features may include headache, facial pain, cranial nerve deficits, TIA/ wider neurological symptoms will form part of the clinical picture.

Vascular pathologies of the neck are rare, but are an important consideration in patients presenting with neck and head pain. Occurrences of vascular pathologies of the neck are complex and multifactorial. Rarely is an event associated with a single causal factor.

It is important to note that there is a different risk profile for dissection and non-dissection events.

Dissection events most commonly present with a history of trauma, with cardiovascular factors being less common
Non-dissection events most commonly occur in the presence of cardiovascular factors

An absence of risk factors does not necessarily rule out the risk of serious neuro-vascular event.

Guidance: The International Federation of Musculoskeletal Physical Therapists have produced an international framework and resource to help improve clinician awareness of the range of potential vascular pathologies which may masquerade as MSK pain and dysfunction- see here IFOMPT cervical framework final 2020.pdf

Relevant Resources

Headaches: Headache – RefHelp Page (includes guide to differentiating primary headache disorders, headache as a new complaint including adult assessment
Facial pain: Facial Pain-Neurology – RefHelp Page
Transient ischaemic attack (TIA) and stroke: Transient Ischaemic Attack (TIA) And Stroke – RefHelp Page
Vertigo and dizziness: Vertigo and dizziness – RefHelp Page

M.A & P.A – 14-05-26

Who can refer:

GPs other primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
Secondary care consultants and associated teams
MSK physiotherapists within Lothian who identify patients with suspected serious spinal condition or inflammatory spinal pain should follow agreed pathways and processes Lumbar spine pathways | Right Decisions and NHS Lothian Integrated Spinal Service

Who & How to refer:

Suspected cervical myelopathy-
- Patients with moderate / severe myelopathy or progressive features- Discuss with On call Neurosurgical registrar via switchboard 0131 242 1000
- Patients with mild and stable symptoms – Refer to neurosurgery – the urgency of the referral is based on the clinical presentation.
- If the patient has an existing diagnosis of cervical myelopathy, from a specialist team, and there is no change in their presentation, aim to optimise function and conservative management- Keep clinical presentation under review, review management if any progressive features develop as above, safety net the patient about disease progression, consider a referral to MSK physiotherapy
Suspected vertebral fragility fractures– follow (VFF Pathway)
Suspected metastatic spinal cord compression– see Malignant Spinal Cord Compression – RefHelp
Deteriorating cervical radiculopathy with motor deficit grade 3 or less– Discuss with on call neurosurgical registrar via switchboard 0131 242 1000
Suspected infection– Discuss with on call neurosurgical registrar via switchboard 0131 242 1000
Traumatic neck pain –
- High risk patient (Canadian C-Spine Rule) – Do not physically assess the patient- Discuss with On call Neurosurgical registrar via switchboard 0131 242 1000
- Low risk on Canadian C-Spine Rule: See Neck Pain section of pathway, However, if still have a moderate or high level of clinical concern refer to Neurosurgery
Suspected vascular pathology – If there are features of concern refer/direct to the appropriate service considering urgency. Further advice of relevance include;
- Headaches: Headache – RefHelp Page (includes guide to differentiating primary headache disorders, headache as a new complaint including adult assessment
- Facial pain: Facial Pain – Neurology – RefHelp Page
- Transient ischaemic attack (TIA) and stroke: Transient Ischaemic Attack (TIA) And Stroke – RefHelp Page
- Vertigo and dizziness: Vertigo and dizziness – RefHelp Page
Widespread neurological symptoms –Neurology – RefHelp
Suspected malignancy – If clinical assessment by GP leds to a very strong suspicion of suspected underlying malignancy, consider recommendations and referral options GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp
Suspected inflammatory spinal condition – Refer to Rheumatology – the urgency of the referral is based on the clinical presentation. See Rheumatology Axial Spondyloarthritis RefHelp Page

Who not to refer:

Do not refer patients to MSK Physiotherapy who have presence of significant red flags/ suspicion of a serious spinal condition or have suspected inflammatory spinal pain.