Neck pain with any of the following signs and symptoms may indicate a more serious pathology such as spinal cord compression, spinal fracture or malignancy and require referral:14

·       fever

·       generalised neck stiffness

·       severe neck tenderness or swollen glands (lymphadenopathy)

·       nausea or vomiting

·       pain that is getting worse, unremitting or disturbing sleep

·       skin reddening, wounds or exudate

·       unexplained weight loss

·       neurological problems including disturbed cognitive status, muscle tone, or movement; sharp pains when moving the head; headache; sensitivity to light or sound; visual loss, weakness or loss of dermal sensation

·       a history of inflammatory arthritis, cancer, TB, immunosuppression, drug abuse, HIV or other infections

·       previous significant trauma

·       osteoporosis risk factors or a history of minor trauma in someone at risk of osteoporosis

·       previous neck surgery

·       new symptoms appearing before the age of 20 years or after the age of 55 years.

Age-related factors which may be associated with something more serious than non-specific neck pain include:14

·       for people over 50 years – a history of cancer or vascular disease

·       for people under 20 years – altered hair distribution, birthmarks, congenital abnormalities, skin tags, infections related to substance misuse or family history.