referral criteria from primary care - cervical spondylosis or cervical disc prolapse

Last edited 06/2018

• isolated neck pain is best managed conservatively and surgical review is not indicated
  
  
• in consideration of clinical features secondary to possible disc herniation
  • it is important for patients to understand that such clinical features can resolve spontaneously, and usually do so in most people. Thus, in general, even in those where a disc herniation is thought highly likely on clinical grounds a period of conservative treatment, with brief rest (about 3-5 days) followed by careful remobilisation, should be allowed before surgical referral is contemplated (1)
    
    
  • where intractable brachialgia and/or clinical signs due to herniation persist or progress despite conservative management, neurosurgical opinion is warranted, as such patients would be likely to benefit from decompressive surgery (1)
    
    
    • the presence of neurological deficit, such as loss of dexterity or co-ordination, weakness and wasting, is not necessarily an indication for surgery, although a neurosurgical referral is indicated
    • constant upper limb numbness or paraesthesia, with or without objective neurological signs, is suggestive of nerve root compromise and requires further investigation, so neurological referral is required
      
      
  • when considering neck pain it is important to exclude 'red flags'(that suggest a serious spinal abnormality)
    • if present, refer urgently for investigations and further assessment (1,2,3,4)
      • Red flags for neck pain:
        • trauma, preceding neck surgery, osteoporosis risk, myelopathy, history of cancer, unexplained weight loss, fever, history of infections (e.g. TB, HIV), history of inflammatory arthritis, and any of the following signs and symptoms:
          • new symptoms below age 20 or above age 55 years
          • constant, progressive, non-mechanical pain
          • signs of spinal cord compression
            • neurological symptoms should prompt a neurological examination to exclude spinal cord compression or cervical myelopathy (such as clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function)
            • cord compression can present with upper motor neurone signs in the lower limbs (upper going plantars, hyper reflexia, spasticity and clonus) and lower motor neurone signs in the upper limbs (atrophy and hyporeflexia).
          • Lhermitte's sign (flexion of the neck producing an electric shock sensation down the spine and into the limbs)
            • can suggest an underlying serious cause such as myelopathy or demyelination
          • dizziness, drop attacks, blackouts
            • may indicate vascular insufficiency, which is more common in older patients
          • vertebral body tenderness
            • localized "exquisite" tenderness when palpatation of verterbral body (3)
          • lymphadenopathy/cervical rib
            • examination - in supraclavicular region for cervical rib, and anteriorly for cervical lymph nodes, which may indicate infection or cancer
          • pulsatile mass
            • indicate carotid artery aneurysm, especially after neck manipulation or trauma
            • requires urgent referral
              
              
    • Management
      • a history of substantial preceding trauma and cervical spine tenderness should prompt consideration for immediate immobilisation, A&E referral and imaging to exclude fracture or instability
      • immediate referral is indicated if spinal cord compression is suspected
      • consider urgent referral, imaging or specialist opinion if any of these red flags are present (4)
        

Notes:

• the urgency of the referral depends on the mode of onset, severity of the neurological deficit and the rate of progression
  • traumatic cervical disc herniation will require an A+E review - features suggestive of spinal cord compression require an immediate surgical review
• the need for surgical intervention would be assessed on the basis of further investigations

Reference:

1. ARC (January 2002). Rheumatic Disease in Practice.
2. ARC (Issue 8 (Hands On Series 6) Spring 2011), Neck pain: management in primary care
3. CKS. Neck pain - cervical radiculopathy (Accessed June 17th 2018).
4. GP Online. Neck pain - red flag symptoms (Accessed June 17th 2018).