Neck injuries
Use the Canadian C-spine rule in order, and never test neck rotation before excluding the high-risk factors.
A 40-year-old driver was hit from behind at low speed while waiting at a signal. He walked into the department. His neck started hurting this morning, mostly at the sides. No midline tenderness, no tingling. He can turn his head 45° to each side.
An hour later, a 72-year-old woman tripped and hit her forehead on the floor. She has neck pain and tingling in both hands.
Who needs imaging, and what are you worried about in the second patient?
- Protect the spine if high riskManual in-line stabilisation or collar until assessed.
- Neurological symptomsTingling, weakness or numbness in arms or legs: CT and senior.
- Canadian C-spine ruleFor alert, stable adults (GCS 15).
- Press each spinous processMidline tenderness needs imaging. Paraspinal tenderness alone doesn't.
- Neuro examUpper and lower limbs: power, sensation, reflexes.
- Low risk and can rotate 45° both waysNo imaging.
- Whiplash adviceKeep moving, simple analgesia, recovery usually in weeks. No collar.
- Return ifWeakness, numbness, severe headache, dizziness, visual or speech change.
- Any neurological deficit
- Midline tenderness or a step
- Dangerous mechanism
- Age 65 or over with neck pain after a fall
- Neck pain with severe headache, dizziness or stroke-like symptoms
- Cervical fracture
- Spinal cord injury (central cord syndrome in elderly with neck extension)
- Vertebral or carotid artery dissection
- Odontoid fracture in elderly after a fall
- Head injury
| High risk (image) | Age 65 or over, dangerous mechanism, or tingling in the limbs |
| Dangerous mechanism | Fall from over 1 m or 5 stairs, axial load to the head, high-speed or rollover crash, ejection, motorbike or bicycle collision |
| Imaging | CT cervical spine for most adults |
| Rotation test | Can actively rotate 45° left and right: safe without imaging if low risk |
| Paracetamol | 1 g 4 times daily |
| Ibuprofen | 400 mg 3 times daily with food for a few days |
Check every dose against a current drug reference and your hospital protocol.
On this page
History
- Mechanism: speed, rollover, ejection, fall height, diving, axial load, hyperextension (face-first fall in the elderly).
- When did the neck pain start? Immediately or later (delayed onset is low risk)?
- Tingling, numbness, weakness, bladder problems.
- Headache, dizziness, vision or speech problems (dissection).
- Arthritis, ankylosing spondylitis, osteoporosis: stiff spines fracture easily.
Examination
- Keep the neck still while you assess if high risk.
- Press each spinous process in the midline, then the muscles at the sides.
- Full neurological examination of arms and legs.
- Only test rotation if the Canadian rule allows it.
Canadian C-spine rule
- Any high-risk factor?Age 65 or over, dangerous mechanism, tingling in the limbs: image.
- Any low-risk factor that allows assessment?Simple rear-end collision, sitting up in the department, walking at any time, delayed onset of neck pain, no midline tenderness. None: image.
- Can they actively rotate 45° left and right?Yes: no imaging. No: image.
Paraspinal muscle tenderness is expected in whiplash and isn't a reason to scan. Midline bony tenderness is.
What else could it be?
| Condition | Clues |
|---|---|
| Whiplash (soft tissue) | Delayed onset, paraspinal tenderness, normal neurology |
| Cervical fracture | High-risk mechanism, midline tenderness |
| Spinal cord injury | Neurological signs, priapism, low BP with slow pulse (neurogenic shock) |
| Central cord syndrome | Older, hyperextension, arms weaker than legs |
| Vertebral artery dissection | Neck pain with headache, dizziness, visual, speech or balance problems |
| Torticollis (wry neck) | No trauma, woke with it |
Older people
- Stiff, arthritic and osteoporotic necks fracture with minor falls, especially face-first.
- Odontoid (C2) fractures are common and easily missed.
- Central cord syndrome: hyperextension in an arthritic neck causes weakness worse in the arms than the legs, often without a fracture.
- Low threshold for CT in anyone over 65 with neck pain after a fall.
Treatment of whiplash
- Keep the neck moving. Soft collars slow recovery.
- Heat packs and gentle exercises.
- Most improve within weeks; some take a few months.
- No driving or riding until able to turn the head fully.
Common mistakes
- Scanning everyone with paraspinal tenderness (or not scanning midline tenderness).
- Testing rotation before checking for high-risk factors.
- Missing an odontoid fracture in an elderly patient after a fall.
- Putting a whiplash patient in a soft collar.
- Missing vertebral artery dissection in a young person with neck pain and dizziness.
Come back if
- Numbness, tingling or weakness in arms or legs.
- Severe headache, vision, speech or balance problems.
- Problems passing urine.
Frequently asked questions
Does a neck injury need an X-ray or CT?
Use the Canadian C-spine rule: anyone with a high-risk factor (age 65+, dangerous mechanism, limb tingling), no low-risk factor, or who can't rotate the neck 45° each way needs a CT.
Should I wear a neck collar for whiplash?
No. Collars slow recovery; keep the neck moving.
How long does whiplash last?
Most people improve within a few weeks; some take a few months.
What is central cord syndrome?
A spinal cord injury, usually in older people with arthritic necks after a hyperextension injury, causing weakness worse in the arms than the legs.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 40-year-old after a low-speed rear-end crash has paraspinal neck pain, no midline tenderness and can rotate his neck 45° each way. What imaging is needed?
Answer: None. Low-risk patients who can rotate 45° each way need no imaging.
- Flexion-extension films: No.
- CT cervical spine: Low risk by the Canadian rule.
- MRI: Not indicated.
- X-ray of the whole spine: No.
2. Which factor makes a neck injury high risk under the Canadian C-spine rule?
Answer: Age 65 or over. High-risk factors: age 65+, dangerous mechanism, limb paraesthesia.
- Sitting in the department: Low-risk factor.
- Simple rear-end crash: Low-risk factor.
- Delayed onset of neck pain: Low-risk factor.
- Paraspinal tenderness: Low-risk sign.
3. A young man has neck pain after a gym session, then a severe headache, dizziness and slurred speech. What is suspected?
Answer: Arterial dissection. Neck pain with posterior circulation symptoms suggests dissection: CT or MR angiography.
- Muscle strain: No.
- Migraine: Not with stroke signs.
- Whiplash: Doesn't cause stroke signs.
- Cervical rib: No.
4. A man stabbed in the neck between the cricoid and the angle of the mandible has an expanding haematoma, bruit and stridor. He is haemodynamically unstable. What is the next step?
Answer: Airway, then theatre now. Penetrating neck injury: zones I (clavicle–cricoid), II (cricoid–angle of mandible), III (above angle). Hard signs (expanding/pulsatile haematoma, active bleeding, bruit/thrill, airway compromise, shock, neurological deficit, air bubbling) → immediate airway control (early intubation — distortion risk; surgical airway if needed) and operative exploration. Stable patients without hard signs → CT angiography (‘no-zone’ approach). Never probe wounds; don’t remove impaled objects in ED; platysma breach defines penetrating injury.
- CT angiography first: Hard signs in an unstable patient mean theatre, not CT.
- Probe the wound in ED: Probing dislodges clot.
- Observe and re-examine: Observation is unsafe.
5. A conscious 30-year-old after a car crash has neck pain and tenderness over the midline cervical spine. He is intoxicated. What is the correct imaging?
Answer: CT cervical spine. Canadian C-spine/NEXUS rules: patients with midline tenderness, intoxication, altered consciousness, focal neurology or a distracting injury cannot be clinically cleared and need imaging. CT is the imaging of choice in adults with high risk (sensitivity much higher than plain films). Maintain spinal precautions until cleared; MRI if neurological deficit or suspected ligamentous injury.
- Clinical clearance: Intoxication prevents reliable clinical clearance of the cervical spine.
- Lateral X-ray, remove collar: Plain films miss many cervical injuries; CT is the imaging of choice in adults.
- MRI brain: MRI of the brain does not image the cervical spine.
6. A stab wound cuts the left half of the spinal cord at T10. What is found below the level of injury?
Answer: Left weakness; right pain loss. Brown-Séquard syndrome. The corticospinal tract and dorsal columns cross in the medulla, so their loss is on the same side as the injury. The spinothalamic tract crosses within one or two segments of entering the cord, so pain and temperature are lost on the opposite side.
- Right weakness; left pain loss: Weakness is on the same side as the lesion.
- Loss of all sensation on both sides: Seen with complete transection.
- Bilateral weakness, sensation intact: Seen with anterior cord syndrome (sensation partly lost).
- Left pain and temperature loss alone: Pain loss is on the opposite side.
7. From which spinal roots does the phrenic nerve arise?
Answer: C3, C4 and C5. The phrenic nerve (mainly C4) supplies motor fibres to the diaphragm and sensory fibres to the central diaphragm, pericardium and mediastinal pleura. Irritation of the diaphragm (blood, pus) refers pain to the shoulder tip (C4 dermatome). It descends on scalenus anterior.
- C1, C2 and C3: Cervical plexus branches, not phrenic.
- C5, C6 and C7: Brachial plexus.
- C2, C3 and C4 only: Misses C5.
- T1 and T2: Upper thoracic roots.
References and dose sources
- NICE NG232 — Head injury (incl. cervical spine)
- Canadian C-spine rule
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.