Textbook of Urgent Care Medicine, Chapter 30, Neck Pain

Published on October 26, 2026

Original authors: Kent Erickson and John Shufeldt

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

INTRODUCTION

Neck pain is a common presenting complaint in urgent care centers. The challenge is to distinguish minor muscular pain from fracture, spinal cord or nerve root compression, infection, malignancy, and vascular disease.

During the aging process, the incidence of cervical disc prolapse, spinal spondylosis, and spinal stenosis increases.

Care must be exercised to identify those patients at risk for significant comorbidity.

Risk assessment begins with the mechanism of injury, vital signs, and a focused neurologic examination. When cervical spine injury or another emergency condition is suspected, the priority in urgent care is stabilization and transfer, not an extended onsite work-up.

PRESENTATION

In elderly patients, seemingly minor injuries and accidents can result in significant anatomical disruptions (i.e., compression fractures, ligamentous injuries).

• Myelopathy if the disc or osteophyte compresses the spinal cord
• Radiculopathy if the disc or osteophyte compresses the nerve root

Neck pain may follow a collision, fall, axial-loading injury, repetitive activity, or arise without trauma. Symptoms in the extremities may indicate cervical radiculopathy; imbalance, clumsy hands, and bowel or bladder dysfunction raise concern for myelopathy.

Sharp pain or a feeling like electricity radiating down one arm immediately after an impact may represent a “stinger.” Symptoms that persist, recur, involve both arms, or include weakness require assessment for cervical spine or cord injury.

• Musculoskeletal pain, cervical strain, cervical disc pain, and cervical spondylosis are common nonemergency causes.
• Severe headache, unilateral neck pain after trauma or neck manipulation, focal neurologic findings, or partial Horner syndrome may indicate cervical artery dissection and warrant emergency evaluation.
• Consider referred pain from shoulder, cardiac, and other nonspinal conditions when the history and examination do not fit a cervical source.

TRIAGE PEARLS

At the scene of the accident, or if a patient presents at your urgent care center after an accident, immobilize the patient’s spine if there is a potential spinal injury, as indicated by any of the following:

• Altered mental status
• Evidence of intoxication
• A distracting injury
• Focal neurologic deficit
• Spinal pain or tenderness

Use spinal motion restriction appropriate to the suspected injury and local EMS protocol. Minimize unnecessary neck movement, use a properly fitted collar when indicated, and activate EMS. A long backboard is not routinely required for a patient who can safely be transferred to an EMS stretcher; it is primarily an extrication/transfer device.

• Progressive weakness, abnormal gait, bilateral neurologic symptoms, new bowel or bladder dysfunction, or signs of cord compression require emergency department (ED) evaluation.
• Fever, recent bacteremia, immunosuppression, injection drug use, recent spinal procedure, or severe focal spinal pain should raise concern for infection, including epidural abscess. Absence of fever does not exclude infection.
• Traumatic neck pain with severe headache, transient neurologic symptoms, or signs of vascular injury requires EMS/ED evaluation.

HISTORY PEARLS

Mechanism of injury:

• Axial-loading injury, such as from diving into a shallow swimming pool
• Ejection from a motor vehicle at any speed
• Any injury sustained in an accident involving a motorized recreational vehicle
• Being struck by a vehicle while on a bike or as a pedestrian

A dangerous mechanism, paresthesias, or age 65 years or older are high-risk features in the Canadian C-Spine Rule (for eligible alert, stable adults). Do not use arbitrary speed thresholds alone to clear or transfer a patient. The decision rule must be applied in full and in an appropriate population.

Neck pain with neurologic signs such as incontinence, clumsiness, and gait difficulties suggest myelopathy.

Neck pain associated with fever or chills, particularly with a history of IV drug use or recent infection, suggests spinal epidural abscess.

• Ask about previous spine surgery, rheumatoid arthritis or ankylosing disease, osteoporosis, cancer, immunosuppression, anticoagulant use, and recent infection or procedures.
• Ask whether the pain is midline or paraspinal, whether it radiates to an arm, and whether paresthesias or weakness are progressive.
• Document headache, dizziness, visual change, speech disturbance, facial symptoms, or recent neck manipulation when a vascular cause is possible.

PHYSICAL EXAM PEARLS

Document a neurovascular exam before and after cervical spine immobilization.

Radicular neck pain, pain on extension of the neck, and pain that radiates to one dermatome suggest a cervical radiculopathy (Table 1). Signs of radiculopathy include the following:

• Sharp, stabbing pain, worse with cough
• Paresthesia(s)
• Weakness
• Muscle wasting

Hypertonicity or lack of coordination may indicate a more serious neurologic process.

Neck pain with positive findings on the Babinski test and gait difficulties suggest myelopathy.

Radicular pain from herpes zoster can precede the typical accompanying rash.

Limited range of motion is often from muscle spasm and associated pain.

Perform a baseline neurologic assessment on any patient with suspected spinal injury or spinal cord injury (SCI).

Assess vital signs; palpate for midline cervical tenderness or deformity; and record shoulder and neck range of motion only when serious injury has been reasonably excluded. Examine upper extremity strength, light touch, reflexes, gait, balance, and hand dexterity. Upper motor neuron findings (hyperreflexia, clonus, Hoffmann or Babinski signs) suggest cord involvement.

The Spurling maneuver may reproduce radicular symptoms in a stable patient without suspected trauma, fracture, instability, or myelopathy. Do not apply axial compression or forced neck movement when serious pathology is possible. A negative provocative test does not exclude radiculopathy.

Table 1. Cervical radiculopathy findings (updated)

Root	Common sensory distribution	Typical weakness	Reflex
C5	Lateral shoulder and upper arm	Deltoid/shoulder abduction; biceps	Biceps may decrease
C6	Lateral forearm, thumb and index finger	Wrist extension and biceps	Brachioradialis, sometimes biceps
C7	Posterior arm/forearm and middle finger	Triceps, wrist flexion	Triceps
C8	Medial forearm, ring/little fingers	Finger flexion and grip	No consistently reliable deep tendon reflex
T1	Medial forearm/arm	Finger abduction and intrinsic hand muscles	No consistently reliable deep tendon reflex

TESTING PEARLS

The National Emergency X-Radiology Utilization Study (NEXUS) validated clinical criteria to identify patients with very low probability of spinal cord injury; the more precise target is clinically important cervical spine injury following blunt trauma.

NEXUS low-risk criteria: no posterior midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful distracting injury. All five must be satisfied before imaging may be omitted in the validated clinical setting. The Canadian C-Spine Rule uses a separate sequential approach: high-risk features, low-risk features permitting assessment, and active 45-degree neck rotation only when safe.

Do not mix components of the two rules or rely on an abbreviated checklist. The Canadian C-Spine Rule was developed for alert, stable patients age 16 years or older; age 65 years or older is a high-risk criterion. NEXUS and the Canadian C-Spine Rule come from emergency-care cohorts, and should not be presented as independently validated urgent-care discharge rules.

If imaging is indicated after blunt cervical trauma in an adult, CT of the cervical spine without IV contrast is the preferred initial study. Plain radiographs have poor sensitivity and should not substitute for CT in a patient who meets criteria for imaging. In most urgent care centers this means ED transfer rather than delaying care for local x-rays.

A patient with new neurologic abnormalities after trauma may require MRI after CT, even if CT shows no fracture. Suspected cord compression, infection, malignancy, or an epidural process generally calls for MRI arranged urgently at the receiving hospital or through appropriate specialty care.

In acute atraumatic neck pain without neurologic findings or red flags, routine imaging is generally unnecessary. For persistent or progressive radicular symptoms, MRI without contrast is often appropriate when specialist evaluation or intervention is being considered. Suspected spinal infection is generally assessed with MRI with and without contrast.

Table 2. Imaging and transfer decisions in urgent care

Presentation	Recommended urgent care approach
Low-risk blunt trauma, reliable examination	Apply a validated decision rule in full and only to an eligible patient; no imaging if low-risk criteria are met and clinical concern is absent.
Blunt trauma meeting imaging criteria or unreliable examination	Spinal motion restriction as indicated; ED transfer for cervical CT without contrast.
Trauma with weakness, paresthesias, or cord findings	EMS/ED transfer. CT is usually initial; MRI may be needed for neurologic/ligamentous injury.
Acute atraumatic pain without red flags	No routine imaging. Symptom-directed treatment and reassessment.
Persistent radiculopathy without progression	Follow-up; consider cervical MRI without contrast when symptoms persist or intervention is contemplated.
Suspected spinal infection, cancer, or cord compression	Urgent ED/specialist evaluation; MRI protocol tailored to indication. Do not delay transfer for onsite radiographs.

DIAGNOSIS PEARLS

For patients who are immunocompromised or have a history of IV drug abuse, diabetes, or cancer, epidural abscess should be high on the differential diagnosis list; note that fever is not always present in these patients.

Use these rules to guide trauma imaging decisions, not to diagnose a strain. The diagnosis of mechanical neck pain is clinical after serious disease is excluded. Distinguish unilateral lower motor neuron findings of radiculopathy from gait disturbance, hyperreflexia, and hand dysfunction of cervical myelopathy.

The Quebec Task Force grading system remains a useful description of whiplash-associated disorders: grade I, pain without physical signs; grade II, pain with musculoskeletal signs; grade III, neurologic signs; and grade IV, fracture or dislocation. Grades III–IV warrant particular attention to neurologic examination and imaging/disposition.

Severe abrupt neck pain or headache with focal neurologic symptoms or partial Horner syndrome suggests cervical artery dissection. Suspected epidural abscess, malignancy, cord compression, and dissection exceed the diagnostic capacity of routine urgent care and warrant immediate escalation.

TREATMENT AND DISPOSITION PEARLS

Significant pain alone does not always require transfer, but pain associated with trauma risk factors, abnormal vital signs, neurologic deficit, infection, vascular symptoms, or inability to function safely requires prompt escalation. Use a low threshold for ED transfer when examination or imaging needs exceed the urgent care center’s capability.

The vast majority of patients with neck pain secondary to minor trauma can be treated effectively with a nonsteroidal anti-inflammatory (NSAID) medication for 5 to 7 days.

NSAIDs may be used briefly at the lowest effective dose when appropriate; consider renal disease, peptic ulcer or GI bleeding, anticoagulants, cardiovascular risk, and pregnancy. Acetaminophen is an alternative when NSAIDs are unsuitable, within appropriate daily limits and with hepatic risk in mind.

Routine diazepam or other benzodiazepines are not recommended for uncomplicated neck strain because evidence of benefit is limited and sedation, dependence, falls, and dangerous combinations with opioids or alcohol are important risks. If a muscle relaxant is considered, use individual risk assessment and a brief course; avoid sedating combinations.

Physical therapy may also be prescribed; discharged patients should be encouraged to resume normal activities as quickly as possible.

For uncomplicated whiplash or mechanical neck pain, encourage gentle active range of motion and early return to tolerated activity, rather than prolonged bed rest or routine soft-collar immobilization. Home exercise and physical therapy are reasonable for persistent pain or functional limitation. Avoid cervical manipulation when instability, myelopathy, vascular disease, or fracture is suspected.

Close follow-up with a primary-care physician is warranted.

Most stable patients with nonprogressive radiculopathy can begin conservative care, with reassessment for new weakness or myelopathic signs. Consider advanced imaging and spine referral for persistent symptoms, especially beyond approximately 4 to 6 weeks, or earlier for objective motor deficit.

Table 3. Disposition pearls

Clinical findings	Disposition
Suspected fracture/instability, high-risk mechanism with imaging indication, or unreliable trauma examination	Spinal motion restriction and ED transfer; EMS when indicated.
Progressive deficit, myelopathy, acute cord symptoms, new bowel/bladder dysfunction	Emergency ED transfer for imaging and specialist evaluation.
Suspected epidural abscess, vascular dissection, or other life-threatening cause	EMS/ED evaluation; do not delay for urgent care testing.
Stable uncomplicated strain/whiplash, no red flags	Brief symptom-directed treatment, early movement, primary-care follow-up.
Stable nonprogressive radiculopathy	Conservative management with documented strength/reflex assessment, close follow-up, and referral if persistent or worsening.

MEDICOLEGAL PEARLS

Although patients with significant mechanisms of injury do not often present to urgent care centers, a high index of suspicion must be maintained for those patients who are at risk for spinal cord involvement even with minor injuries.

Performance of a neurovascular exam before and after cervical spine immobilization should be documented in the medical record.

Patients with midline cervical tenderness, neurologic deficit, distracting injuries, or abnormal mental status should be immobilized and transported to an emergency department with a hard cervical collar in place.

Document the basis for using (or not using) a cervical spine decision rule, including the patient’s eligibility and each required element. Record the presence or absence of focal weakness, gait or hand dysfunction, bowel or bladder change, infection red flags, and concerning headache or vascular symptoms.

If serious pathology is suspected, document why the patient was transferred, the receiving facility or EMS handoff, and measures used to restrict spinal motion. A negative plain radiograph, absence of fever, or temporary improvement with analgesia should not be used to exclude an important spinal condition.

REFERENCES

1. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. doi:10.1056/NEJM200007133430203.
2. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. doi:10.1001/jama.286.15.1841.
3. Hassankhani A, Freeman CW, Banks J, et al. ACR Appropriateness Criteria Acute Spinal Trauma: 2024 Update. J Am Coll Radiol. 2025;22(5 suppl):S48-S66. doi:10.1016/j.jacr.2025.02.013.
4. American College of Radiology. ACR Appropriateness Criteria: Cervical Pain or Cervical Radiculopathy. Revised 2024.
5. Murphy S. Clearing the C-Collar in the Emergency Department: A Practical Guide. American College of Emergency Physicians; August 6, 2025.
6. National Institute for Health and Care Excellence. Spinal Injury: Assessment and Initial Management. NG41. 2016.
7. Côté P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: a clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(7):2000-2022. doi:10.1007/s00586-016-4467-7.
8. American Academy of Orthopaedic Surgeons. Cervical Radiculopathy (Pinched Nerve). OrthoInfo.
9. US Food and Drug Administration. FDA Requiring Boxed Warning Updated to Improve Safe Use of Benzodiazepine Drug Class. September 23, 2020.
10. Tande AJ, Currier BL, Osmon DR. Spinal epidural abscess. N Engl J Med. 2026;394:1621-1633. doi:10.1056/NEJMra2412728.
11. Reliability and Diagnostic Accuracy of Standard Dermatomes and Myotomes for Determining the Pathologic Level in Surgically Verified Patients With Cervical Radiculopathy. 2022. PubMed Central article PMC9816603.