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Neck Pain Care Pathway

Date of last update: February, 2024

Differential Diagnosis for Neck Pain

Clinical Cornerstone:

  • Diagnosing neck pain requires a patient-centered approach that integrates physical, psychological, and social aspects of pain. A comprehensive diagnostic strategy integrates clinical findings with patient narratives and risk factor evaluations for a complete understanding of the patient's condition.

  • Neck pain is broadly categorized as non-specific, where pain or symptomology is not attributed to a distinct pathology, or specific, where it is linked to an underlying condition (e.g., cancer, fracture) or referred from other organs. Cervical disc herniation causing neck pain with radiculopathy is a common specific cause. Further diagnostic testing is often required to confirm a specific diagnosis of neck pain.

Differential Diagnosis for Neck Pain

1. Non-specific Neck Pain (NAD I-III)

  • Cervical strain/sprain, WAD I-III, mechanical cervicalgia

  • Degenerative changes/osteoarthritis (e.g., degenerative disc disease, facet arthropathy)

  • Cervicogenic headache, whiplash-associated headache

2. Specific Neck Pain

a) Neck Pain with Radiculopathy:

  • Herniated nucleus pulposus (disc protrusion or herniation causing nerve root compression)

  • Cervical spinal stenosis (narrowing of the spinal canal or foramen l  eading to nerve compression)

  • Cervical spondylotic myelopathy (associated with upper extremity weakness, numbness or tingling, decreased fine motor abilities, spasticity, hyperreflexia, poor balance)

  • Thoracic outlet syndrome (neurogenic or vascular) / Plexopathy

  • Peripheral neuropathy (e.g. diabetic neuropathy)

b) Fracture:

  • Compression fracture from osteoporosis

  • Trauma or minor trauma  with immediate onset of pain or associated with midline tenderness

  • Trauma or minor trauma  from a dangerous mechanism (e.g. a fall from elevation, axial blow to the head, high speed collision or roll-over)

c) Inflammatory Causes:

  • Ankylosing spondylitis

  • Rheumatoid arthritis

d) Infectious Causes:

  • Osteomyelitis (bone infection)

  • Discitis (intervertebral disc infection)

  • Epidural abscess

e) Neoplastic Causes:

  • Primary spinal tumors

  • Metastatic spinal tumors


f) Referred Pain:

  • Shoulder pathology (e.g., rotator cuff injuries)

  • Referral from visceral diseases (e.g. a cardiac event, pulmonary or gallbladder conditions)


g) Other Causes:

  • Fibromyalgia

Conduct patient assessment

Red flags present

Red flags present

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Refer to appropriate emergency or healthcare provider

  • Structured patient education

  • Exercise (strength, range of motion)

  • Manual therapies (e.g., spinal manipulation or mobilization, massage)

  • Low-level laser therapy

  • Psychological / social support

  • Medicines

  • Referral

Major symptom/sign change

Goals not achieved


Adjust treatment and management plan or refer

References or links to primary sources

  • Bussières A.E, et al. The treatment of neck pain -associated disorders and whiplash-associated disorders: A clinical practice guideline. J Man Phys Ther. 2016; 39(8):P523-564.


  • Bussières AE, Taylor JAM, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. Journal of manipulative and physiological therapeutics. 2008;31(1):33-88. doi:10.1016/j.jmpt.2007.11.003


  • Berman, Daniel MD; Holtzman, Ari MD; Sharfman, Zachary MD, MS; Tindel, Nathaniel MD. Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States. Journal of the American Academy of Orthopaedic Surgeons 31(2):p 64-70, January 15, 2023. | DOI: 10.5435/JAAOS-D-22-00517


  • Côté P, et al. Management of neck pain and associated disorders: A clinical practice guidelines from the Ontario Protocol for Traffic Injury (OPTIMa) Collaboration. Eur Spine J. 2016; 28:2000-2022.



  • Shearer HM, Carroll LJ, Côté P, Randhawa K, Southerst D, Varatharajan S, Wong JJ, Yu H, Sutton D, van der Velde G, Nordin M. The course and factors associated with recovery of whiplash-associated disorders: an updated systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Physiotherapy. 2021 Sep 3;23(5):279-94.


  • 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

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