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Background
Neck pain is one of the most common causes of emergency room (ER) visits in the United States. Its annual prevalence is reported to be up to 50% in the general population, with 16.3 million health care visits. Most neck pain results from a mechanical cause associated with facet joints, intervertebral discs, muscles, or fascia and does not warrant further workup. Potential underlying serious conditions, including cancer, infection, fracture, and myelopathy, can be encountered in a minority of patients. A high level of clinical suspicion with imaging studies done in a timely fashion significantly impacts patient management and prognosis in these patients. Thus, the American College of Radiology (ACR) describes red flags in neck pain (adapted from the “Bone and Joint Decade 2000 - 2010 Task Force on Neck Pain and Its Associated Disorders) to identify patients who may have a serious underlying condition that warrants an imaging study. This educational exhibit reviews these red flags with associated imaging manifestations of possible serious neck pain causes with ER presentation.

Educational Goals / Teaching Points
This exhibit includes overview of neck pain associated conditions in the ER, describe the imaging indications for neck pain in the ER, guide the radiologists about choosing the appropriate imaging modality in neck pain, and review the imaging manifestations of possibly serious neck pain causes with ER presentation.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
This exhibit includes overview of normal imaging anatomy of the cervical spine, red flags in the management of neck pain and possible imaging indications per ACR Appropriateness Criteria in the ER, multimodality imaging examples of neck pain with complicated underlying conditions, infection (osteomyelitis/discitis, paraspinal abscess, epidural abscess), neoplasia (metastatic carcinoma, multiple myeloma, lymphoma), fractures (flexion teardrop fracture, extension teardrop fracture, facet fracture with dislocation, fractures in the systemic inflammatory diseases), myelopathy and associated diseases (degenerative herniated disc, spinal canal stenosis, epidural hematoma), and other diseases that can cause neck pain (retropharyngeal abscess, acute calcific tendinitis of the longus colli muscle, etc.).

Conclusion
Patients with neck pain may present to the ER with serious underlying conditions that may necessitate an emergent intervention and rapid treatment. Imaging studies done in a timely fashion significantly impact the patient prognosis and outcome. A high level of clinical suspicion with the application of ACR red flags may expedite obtaining imaging studies in these serious neck pain cases. The radiologists should be aware of the imaging manifestations of spinal malignancies, infections, fractures, and causes that may result in myelopathy.