A 14-year-old female came to clinic with a 3-day history of increasing neck stiffness. The pain was mainly left-sided and got worse as the day went on. She was also having generalized headaches in the evening that would resolve with sleep. She denied fevers, chills, nausea, emesis, or photophobia or other pain. She denied numbness or tingling in shoulders or arms. The past medical history showed that she was fully vaccinated and had 3 migraine headaches since the age of 12 that were controlled with sleep and ibuprofen. The family history was positive for migraine headaches and a paternal grandfather with a replaced knee. The review of systems was non-contributory.
The pertinent physical exam showed a female in no distress who was alert and oriented x 4. Vital signs were normal including temperature. HEENT was normal except for pain of the left trapezius and sternocleidomastoid muscles. This became worse with stretching of these muscles, but there was complete range of motion in the neck. Muscle palpation showed tense, spasmed muscles. The left occipitalis muscle also had some minor pain near the posterior insertion. Movement of the shoulder also caused mild pain when these muscles were engaged. Neurological examination was normal with good tone, strength and normal sensation in the face, neck, arm and shoulder. The diagnosis of muscle spasms of the left neck muscles was made. The physician noticed a large backpack in the room and asked the patient about it. She had started the school year that week and was carrying several large textbooks all day with her. She carried the backpack on her left shoulder only. The physician herself could barely lift the backpack, and talked with the patient about ways to decrease the weight (e.g. use online books if available, take only the books necessary at one time) and to wear the backpack on both shoulders or to use a pull-type, roller backpack on the ground if excessive weight was necessary. The patient was told how to use anti-inflammatory medications, heat and gentle exercise and massage to help eliminate the spasm. “You should be careful about your posture too.” she said. “People sitting in chairs or working at computers for a long time can make this worse. You need to get up and move frequently and stretch even for a minute. Then come back and do your work.”
The complaint of neck stiffness always makes the clinician a little concerned until he/she understands the whole history because of the potential diagnosis of meningitis/encephalitis. While this potential is always concerning, there are many other causes of neck stiffness or pain to consider that are much more common. Normal wear and tear, injury or overuse that occur in daily activities and work can cause neck stiffness or pain. Often, even in adults, the cause of the pain is not recognized. Good examples are the adolescent above, or an innocent stumble, particularly if carrying something that may cause a person to be off-centered, twist their body to regain balance and only later cause a stiffness or soreness. The little stumble is not recognized as the cause of the neck stiffness.
Meningitis is an inflammation of the meninges. The most feared causes are rapidly growing bacteria such as meningococcus. Aseptic meningitis is usually caused by nonbacterial organisms and other diseases including enteroviruses, measles, mumps, and mycoplasma. Organisms colonize the person usually in the nasopharyngeal mucosa, spread to the blood stream and eventually reach the meninges by the blood-brain barrier and cerebrospinal fluid after evading the person’s immunological defenses. Lumbar puncture is needed to help determine if meningitis is present and the potential organism. To review what are the initial cerebrospinal fluid findings for meningitis, click here.
Meningismus that is associated with meningitis is neck pain with flexion of the neck, not lateral movement. In a seated upright position with the neck fully extended, the neck is flexed and resistance may be felt throughout the movement or just at the end of the movement.
The differential diagnosis of stiff neck includes:
- Abscess – retropharyngeal, parapharyngeal or peritonsilar
- Lymphadenitis, cervical
- Herpes zoster
- Cerebral palsy
- Epidural hematoma
- Intracranial hemorrhage
- Post-lumbar puncture
- Vertebral anomaly
- Arthritis – with prominent symptoms in the neck joints
- Deconditioning or overuse of muscles
- Trauma to neck – whiplash where the muscles and ligaments are stretched with pain and inflammation
- Torticollis – spasm of the sternocleidomastoid muscle or hemorrhage
- Tumor – primary or metastatic
Questions for Further Discussion
1. What bacterial organisms cause meningitis?
2. How much weight is recommended to be carried in a backpack?
3. What are indications for radiological evaluation of a patient with neck stiffness?
- Disease: Neck Stiffness | Neck Disorders and Injuries
- Symptom/Presentation: Neck Stiffness
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Neck Injuries and Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Sheldon SH, Levy HB. Pediatric Differential Diagnosis. 2nd Edit. Second Edition. Raven Press: New York. 1985:153-154.
Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:250-252.
Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010 Nov;126(5):952-60.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital