Neck Stiffness/Pain

Neck stiffness may be caused by inflammation, infection, or trauma. True nuchal rigidity is characterized by the inability to actively or passively touch the chin to the chest and is due to inflammation of the brain and spinal cord. A positive Brudzinski's sign is spontaneous flexion at the hips in response to passive neck flexion. A positive Kernig's sign is an inability to extend at the knee with the hip in flexion.

Differential Diagnosis

• Trauma
  –Paraspinal neck stiffness: Commonly due to motor vehicle collisions (“whiplash”) or abnormal sleep posture
  –Cervical spine fracture with spasm of neck muscles
  –Subarachnoid hemorrhage: Most commonly due to ruptured cerebral aneurysm
  –Epidural hematoma
  –SCIWORCA: Spinal Cord Injury Without Radiographic Abnormality occurs in pediatric patients with ligamentous laxity and hypermobility of the cervical spine
  –Rotary atlantoaxial subluxation: Subluxation of the cervical spine at C1-C2 level, resulting in sternocleidomastoid spasm with tilting of the head toward the affected side and chin pointed toward the ipsilateral side
• Infection
  –Meningitis: Often bacterial (e.g., Neisseria meningitidis, Streptococcus pneumoniae) or viral (e.g., HIV, Epstein-Barr virus, enterovirus, herpes simplex virus)
  –Cervical lymphadenitis
  –Tonsillopharyngitis
  –Epiglottitis
  –Retropharyngeal abscess
  –Epidural abscess
  –Discitis
• Torticollis: Idiopathic sternocleidomastoid spasm, resulting in tilting of the head toward the affected side with the chin pointed to the contralateral side
• Inflammatory
  –Rheumatoid arthritis
  –Ankylosing spondylitis
  –Degenerative joint disease
• Tumors (especially leptomeningeal metastases)
• Dystonic reaction: Idiosyncratic drug reaction, often to psychiatric medications (e.g., haloperidol, prochlorperazine)

Workup and Diagnosis

• History and physical examination focusing on evidence of trauma and infection
  –All patients with possible traumatic injury should be maintained in a cervical collar and backboard until diagnostic workup is complete
• Initial labs may include CBC, electrolytes, BUN/creatinine, calcium, glucose, and ESR
• Blood cultures are indicated if infectious etiologies are suspected
• Lumbar puncture with CSF analysis is useful in cases of suspected infection or subarachnoid hemorrhage
• Cervical spine radiographs are indicated in trauma or neck infection (may reveal prevertebral soft-tissue swelling)
• Head CT scan without contrast may show bleeding in cases of subarachnoid hemorrhage (fails to reveal subarachnoid blood in 10% of cases)
• Neck CT scan may be indicated in suspected soft tissue disease (e.g., retropharyngeal abscess) or occult vertebral fracture if not adequately visualized on plain films
• MRI of the spine may be indicated in suspected epidural abscess or epidural hematoma

Treatment

• Trauma: Soft-collar immobilization is no longer routinely recommended
  –Cervical spine fractures may be treated with surgical fixation, halo brace immobilization, or careful observation
  –Soft-tissue injuries to the neck and torticollis are treated symptomatically with NSAIDs and muscle relaxants (e.g., benzodiazepines, cyclobenzaprine)
  –Subarachnoid hemorrhage is often treated surgically
• Infection
  –Bacterial meningitis requires immediate broad-spectrum antibiotics (e.g., ceftriaxone and vancomycin); steroids may decrease the morbidity associated with the inflammatory response to infection
  –Viral meningitis is treated supportively (IV fluids, NSAIDs)
  –Abscess requires antibiotics and drainage
• Inflammatory arthropathies typically respond to NSAIDs, steroids, or antirheumatic agents

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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