CCFP priority topic 68 of 105
Neck Pain on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Neck Pain. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Serious causes
In neck pain without injury, find the dangerous causes, including pain sent from elsewhere.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, diagnosis
On the exam
A 74-year-old woman has neck and arm pain after a new pillow. Expect a short menu (pick several from a list) of causes to rule out.
Pick the history that finds a serious cause.
Common mistakes
Chasing artery tears or giant cell arteritis when she has none of their signs. Missing heart pain or meningitis by calling every sore neck a strain is wrong too.
Approach
- Ask about fever, weight loss, night sweats and pain at night. Feel for lumps in the neck. Think of infection, cancer and lymphoma.
- Neck pain with new headache, a droopy eyelid, a small pupil or stroke signs: think of dissection. This is a tear in the carotid or vertebral artery wall.
- Neck or jaw pain with effort, sweating or shortness of breath: think of the heart. Get an electrocardiogram (ECG).
- Fever, headache and a stiff neck: think of meningitis.
- Headache worse lying down, blurred vision and swollen optic discs: think of raised pressure in the skull (idiopathic intracranial hypertension).
- An older adult with new headache, jaw pain on chewing or stiff shoulders each morning: think of giant cell arteritis (inflamed head arteries). Also think of polymyalgia rheumatica (stiff, aching shoulders and hips). Check the sedimentation rate (ESR) and C-reactive protein (CRP).
- No red flags: treat it as mechanical pain. No blood tests, no imaging.
| Clue | Think of | First step |
|---|---|---|
| Droopy eyelid, small pupil, headache, stroke signs | Artery dissection | Urgent imaging of the neck arteries |
| Pain with effort, sweating, short of breath | Heart attack or angina | ECG now |
| Fever, weight loss, night sweats, neck lumps | Lymphoma, cancer or infection | Examine the nodes, blood work, imaging |
| A child with fever, drooling and a stiff, painful neck | Deep neck abscess | Emergency assessment |
Key feature 2 of 5
Root or cord
In neck pain without injury, tell nerve or cord pressure from simple muscle pain.
CFPC skill Clinical reasoningPhase History, physical
On the exam
A 74-year-old woman has neck pain, thumb tingling and full strength. Expect a short menu (pick several from a list) of exam findings.
Pick the findings that change what you do.
Common mistakes
Reading her reduced reflex at one level, numb thumb or arm pain on neck turning as cord signs, and ordering urgent imaging. These mark one nerve root. Skipping a cord exam is wrong too.
Approach
- Muscle pain: a local ache, tender muscles, no arm symptoms, a normal nerve exam. Tenderness says nothing about nerve pressure.
- Nerve root pressure (radiculopathy): arm pain or tingling in one strip of skin, a reduced reflex at one level, weakness in one muscle group.
- Arm pain on turning and tilting the head back toward the sore side (Spurling test) points to a root, not the cord.
- Map the root. C6: thumb and index finger, biceps and brachioradialis (forearm, at the wrist) reflexes. C7: middle finger, triceps. C8: little finger.
- Cord pressure (myelopathy): clumsy hands, trouble with buttons, unsteady walking, bladder change. Look for brisk reflexes, upgoing toes and a Hoffmann sign (the thumb flexes when the middle fingertip is flicked).
- Cord signs or weakness that is getting worse: urgent magnetic resonance imaging (MRI) and a spine referral.
- Root pain with full strength: treat and reassess. Image only if it persists or gets worse.
- Pain on a painful arc of the shoulder points to the rotator cuff. Thumb tingling at night can be carpal tunnel syndrome.
| Nerve root | Spinal cord | |
|---|---|---|
| Symptoms | Pain and tingling down one arm | Clumsy hands, unsteady walking, bladder change |
| Reflexes | Reduced at one level | Brisk, Hoffmann sign, upgoing toes |
| Strength | Weak in one muscle group, or normal | Weak or stiff in arms and legs |
| Next step | Treat and reassess; MRI if weakness worsens | Urgent MRI and spine referral |
Key feature 3 of 5
Chronic neck pain
Treat long-lasting neck pain with a plan that combines several kinds of care.
CFPC skill Clinical reasoningPhase TreatmentSources Choosing Wisely Canada
On the exam
A woman of 74 with arthritic neck pain takes an angiotensin-converting enzyme (ACE) inhibitor and a diuretic. Expect a short menu (pick several from a list) of treatments.
Pick the parts of her plan.
Common mistakes
Rest, a soft collar, or an anti-inflammatory (NSAID) with stomach protection. The stomach pill does not protect her kidneys. Swapping to codeine brings falls and confusion.
Approach
- Keep her active, with exercise she can do at home.
- Build a plan with several parts: home exercise, physiotherapy, and hands-on care such as chiropractic or massage. Add acupuncture if she wants it.
- No nonsteroidal anti-inflammatory drugs (NSAIDs) with high blood pressure, heart failure or kidney disease. That includes selective ones such as celecoxib.
- NSAIDs raise blood pressure, weaken blood pressure pills, hold fluid and worsen kidney function. A proton pump inhibitor protects only the stomach.
- Do not start opioids long term for chronic pain. Try non-opioid medicines and physical treatment first.
- Avoid codeine bought without a prescription. In older adults it brings sleepiness, falls and memory problems.
- Surgery is for cord pressure, weakness that is getting worse, or failed care. Wear and tear on a film is not a reason.
Key feature 4 of 5
Film after injury
After a neck injury, use the exam and a decision rule to choose who needs an X-ray.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis, investigationSources Choosing Wisely Canada
On the exam
Neck pain after a car crash, in an alert patient. Expect one best answer: film or no film.
Decide whether the neck needs an X-ray.
Common mistakes
An X-ray to be safe after a minor crash when the rule is negative. Skipping the film when the rule says to image is wrong too.
Approach
- Use the Canadian C-spine rule in alert, stable patients with neck pain after an injury.
- If the rule is negative, order no neck X-ray. Very few of these patients have an injury a film would show.
- An unneeded film delays care, can add pain, and gives radiation with no benefit.
- The rule does not apply to a patient who is not alert or not stable. Keep the neck still and image.
- New weakness or numbness in the arms or legs after an injury: keep the neck still, image and call the spine team.
Key feature 5 of 5
Reading the film
On a neck X-ray after injury, make sure every vertebra can be seen clearly.
CFPC skill Clinical reasoningPhase Diagnosis, investigation
On the exam
A neck X-ray after a fall from a ladder. Expect one best answer on whether the film is good enough.
Decide if the film clears the neck.
Common mistakes
Calling a film normal when the side view stops above the top of the chest spine. Injuries hide at the very top and bottom of the neck.
Approach
- The side view must show all seven neck vertebrae and the top of the first chest vertebra (the C7 to T1 junction).
- A full series has a side view, a front view and an open-mouth view of the top two vertebrae.
- C7 to T1 not seen: repeat with the shoulders pulled down or get computed tomography (CT). Or take a swimmer's view: a side view with one arm raised over the head.
- Trace the front and back of the vertebral bodies and the back of the canal. Each line should be a smooth curve.
- A normal but incomplete film is not a normal film. Strong suspicion with a normal film still needs CT.
Flashcards
Answer it first, then check.
KF 1Neck pain, a droopy eyelid and a small pupil after a sudden twist. What do you fear?
A tear in the carotid or vertebral artery wall. Arrange urgent imaging of the neck arteries.
KF 1Neck and jaw pain with sweating, brought on by climbing stairs. Which test first?
An ECG. Heart pain can be felt in the neck and jaw.
KF 2Thumb tingling, a reduced brachioradialis reflex, full strength. Root or cord?
Root, likely C6. A reduced reflex at one level is a root sign, not a cord sign.
KF 2Name four signs of spinal cord pressure in the neck.
Any four of: clumsy hands, unsteady walking, brisk reflexes, Hoffmann sign, upgoing toes, bladder change.
KF 3A patient with high blood pressure takes an ACE inhibitor and a diuretic. Is celecoxib safe?
No. Selective NSAIDs also raise blood pressure and worsen kidney function. Source: Choosing Wisely Canada
KF 4An alert driver was rear-ended. The Canadian C-spine rule is negative. X-ray?
No. A negative rule means no neck film. It would add radiation and delay care. Source: Choosing Wisely Canada
KF 5The side view of the neck stops at C6. Can you clear the neck?
No. Get a view down to C7 and T1, such as a swimmer's view, or a CT.
FAQ
Does the Canadian C-spine rule apply to children?
It was built and tested in alert, stable adults and older teens, not in children. Do not lean on it for a child. Assess them carefully, and get advice from a paediatric or trauma centre.
Does neck pain with arm tingling need an MRI?
Not at first if strength is full and there are no cord signs. Treat and reassess. Image for cord signs, weakness that is getting worse, red flags, or pain that will not settle.
Which guideline does the exam follow for chronic neck pain?
The CFPC does not name one. The key feature wants a plan with several parts: staying active, exercise, hands-on therapies and safe pain relief. Staying active comes first: rest and a collar make the neck stiffer and slow recovery.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada