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Neck Pain Care Pathway

Date of last update: February, 2024

Signs or Symptoms of Pathology (Red Flags)


Clinical Cornerstone: Consider asking additional questions that help evaluate for the presence of red flags in neck pain. Red flags are symptoms or signs that may indicate a serious pathology and should be deliberated in the clinician’s differential diagnosis.

  • Spinal fracture

    • Red flags: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, paresthesias in extremities, inability to actively rotate the neck 45 degrees to the left and right (Canadian C-Spine Rule).

    • Action: Refer to appropriate provider for imaging especially if pain is sudden in onset and pain is severe.


  • Spinal malignancy

    • Red flags: history of cancer, unexplained weight loss, unexplained significant night sweats, pains worse at night, progressive headaches worse with exertion.

    • Action: Refer to an appropriate provider.

  • Spinal infection

    • Red flags: intravenous drug use, poor living conditions, immunosuppression, recent surgery/invasive interventions, history of TB/born in TB-endemic country, recent infection, unexplained constitutional symptoms (e.g. fever/chills).

    • Action: Immediate emergency referral.

  • Cervical myelopathy

    • Red flags: gait disturbances, hand clumsiness, non-dermatomal numbness, weakness or numbness and weakness involving  lower extremity / bowel / bladder, coordination problems.

    • Action: Immediate emergency referral.

  • Meningitis

    • Red flags: neck stiffness, severe generalized headache that is worse with flexion, neck pain or headache with fever or  vomiting or rash,  altered mental status, photophobia.

    • Action: Immediate emergency referral.

  • Vertebral / Carotid Artery Dissection

    • Red flags: severe neck pain and/or headache (described as the worst pain ever), double vision, difficulty initiating swallowing, dizziness, drop attacks,facial numbness, difficulty walking, nausea, nystagmus.

    • Action: Immediate emergency referral.

  • Intracranial / Brain Lesion

    • Red flags: sudden and intense onset headache (thunderclap headache).

    • Action: Immediate emergency referral.

  • Neurological disorders (e.g., MS, ALS, neurodegenerative disorders)

    • Red flags: upper/lower motor neuron findings, clonus.

    • Action: Refer to appropriate provider.

Orange Flags


Clinical Cornerstone: Orange Flags are symptoms or signs that may represent the presence of serious psychiatric disorder (e.g., major depression, major personality disorders, post-traumatic stress disorders [PTSD], substance addiction and abuse). In the event such disorders are present, referral to a psychiatric specialist would be indicated over usual care in the presence of non-major disorders such as anxiety. Screening can include:

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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