Identifying red flags for serious neck pathology: A UK nominal group study

BACKGROUND: Red flags are clinical indicators that may signal serious underlying spinal conditions, yet there is no consistently applied guidance for identifying red flags specific to serious neck pathologies. While previous studies have outlined red flags for cervical spine pain more broadly (e.g., Feller et al., 2024), there is limited empirical evidence detailing early presenting features that differentiate serious pathology from common musculoskeletal presentations, particularly in non-traumatic contexts. This gap increases the risk of missed or delayed diagnosis. OBJECTIVE: To empirically identify and prioritise red flags for serious neck pathologies to support earlier detection and appropriate management. METHODS: A qualitative study using the Nominal Group Technique was conducted with ten UK-based clinicians experienced in diagnosing and managing serious neck pathologies. Participants independently generated potential red flags, refined them through structured group discussion, and voted on their inclusion using a predefined consensus threshold. Agreed-upon indicators were then organised into thematic categories. RESULTS: Consensus was achieved on eight categories of red flags across three domains: risk factors, symptoms, and signs. Early indicators prioritised by participants included pain characteristics, functional decline, subtle neurological changes, and patient-reported difficulty supporting the head or neck. Clinicians emphasised that red flags are most informative when interpreted as clusters of evolving features rather than isolated findings. CONCLUSION: Unlike prior systematic reviews, this study empirically identifies early, clinician-prioritised red flags specific to serious neck pathologies, providing practical guidance for differentiating serious conditions from benign musculoskeletal neck pain. Recognising these early features may support timely detection and improved patient outcomes.