Nuchal Rigidity

Nuchal Rigidity: Excerpt from In A Page: Pediatric Signs and Symptoms

Nuchal rigidity is characterized by involuntary muscle spasms that limit passive neck flexion. Although it has myriad causes, meningeal irritation may occur secondary to infection, so patients must be evaluated emergently for meningitis/focal infection. Cervical muscle spasms and dystonia are common etiologies that can be treated with local therapies and pharmacologic agents that act at the neuromuscular junction.

Differential Diagnosis

• Stress
  –Causing muscles to tighten and stiffen
• Injury/whiplash secondary to trauma
• Cervical adenitis
• Meningitis
  –Presence of nuchal rigidity has 30% sensitivity, 95% specificity
• Encephalitis
• Subarachnoid hemorrhage
• Retropharyngeal abscess
  –Associated with fever, sore throat (84%)
• Epiglottitis
• Focal dystonia
• Torticollis, congenital or acquired
• Tetanus
  –Associated with trismus, risus sardonicus, opisthotonus, muscle spasms
• Dental abscess
• Pharynx/larynx spasms
• Chemical meningitis
  –After spinal anesthesia or lumbar puncture
• Parameningeal infection
  –Lesion on MRI/CT
• Posterior fossa tumor
• Thyroiditis
• Rheumatoid arthritis
• Cervical arthritis
• Pneumonia
• Cervical spine osteomyelitis
• Poliomyelitis
• Trichinosis
• Chagas disease
• Infantile Gaucher disease
• Maple syrup urine disease
• Kernicterus
• Toxins
  –Phenothiazines
  –Strychnine
  –Lead poisoning
  –Methanol poisoning
  –Hypervitaminosis A

Workup and Diagnosis

• History
  –Duration
  –Age of onset
  –Presence and location of pain
  –Trauma
  –Vomiting, headache, fever
  –History of blood clots, aneurysm
  –Decreased sensation or movement in other areas
  –Recent infection or recent dental work
  –Visual changes
  –Seizures
• Physical exam
  –Vital signs, blood pressure, pulse, temperature
  –Head circumference in infants to evaluate for progressive increase in intracranial pressure
  –Head and neck should be palpated
  –Sinus tenderness, thyromegaly, and focal lymph nodes
  –Kernig sign: Flex hip and knee, then extend knee, assess for resistance to knee straightening
  –Brudzinski sign: Flex neck/chin to chest, observe if hip and knees flex
  –Careful mental status examination
  • Evaluation
    –Lumbar puncture to identify bacterial or viral meningitis, particularly in the febrile patient
    –MRI scan if focal neurologic abnormality, seizure, mental status changes

  Treatment

  • Meningitis/encephalitis
    –Broad-spectrum antibiotics
    –Neurologic checks
    –Dexamethasone may improve neurologic outcome and lower incidence of postmeningitic deafness
  • Subarachnoid hemorrhage
    –Immediate neurosurgical evaluation
    –Consider MRA/conventional angiography
    –Surgical clipping and excision
    –Pharmacologic management of cerebral vasospasm
    –Nimodipine is often used to prevent delayed ischemia
  • Torticollis: Treat with valium, botulinum toxin type A
  • Adenitis/dental abscess: Antibiotic treatment
  • Injury: Soft collar, NSAIDs
  • Cervical muscle spasms
    –Heat, massage, soft cervical collar, analgesics

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: HEADACHE (Differential Diagnosis in Primary Care)

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• HEADACHE (Differential Diagnosis in Primary Care)
• NUCHAL RIGIDITY (Differential Diagnosis in Primary Care)
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• Brudzinski's sign (Handbook of Signs & Symptoms (Third Edition))
• Headache (Handbook of Signs & Symptoms (Third Edition))

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