Mammals have seven cervical vertebrae, a number that remains remarkably constant. I propose that the lack of variation is caused by developmental constraints: to wit, changes in Hox gene expression, which lead to changes in the number of cervical vertebrae, are associated with neural problems and with an increased susceptibility to early childhood cancer and stillbirths. In vertebrates, Hox genes are involved in the development of the skeletal axis and the nervous system, among other things. In humans and mice, Hox genes have been shown also to be involved in the normal and abnormal (cancer) proliferation of cell lines; several types of cancer in young children are associated with abnormalities in Hox gene expression and congenital anomalies. In these embryonal cancers the incidence of a cervical rib (a rib on the seventh cervical vertebra, a homeotic transformation of a cervical vertebra towards a thoracic-type vertebra) appears to be increased. The minimal estimate of the selection coefficient acting against these mutations is about 12%. In birds and reptiles variations in the number of cervical vertebrae have frequently occurred and there is often intraspecific variability. A review of the veterinary literature shows that cancer rates appear lower in birds and reptiles than in mammals. The low susceptibility to cancer in these classes probably prevents the deleterious pleiotropic effect of neonatal cancer when changes in cervical vertebral number occur. In mammals there is, thus, a coupling between the development of the axial skeleton and other functions (including the proliferations of cell lines). The coupling of functions is either a conserved trait that is also present in reptiles and birds, but without apparent deleterious effects, or the coupling is new to mammals due to a change in the functioning of Hox genes. The cost of the coupling of functions in mammals appears to be an increased risk for neural problems, neonatal cancer, stillbirths, and a constraint on the variability of cervical vertebral number.