Stiff Neck
The most common causes of acute neck stiffness are benign and easily managed in general practice. However, this symptom causes disproportionate panic in parents of febrile children thanks to extensive media coverage of meningitis. This anxiety can spill over into adult illness behaviour, with the result that a troublesome but harmless symptom may be misinterpreted as the harbinger of serious pathology.
Differential diagnosis
Common Diagnoses
- Acute Torticollis
- Cervical Spondylosis
- Viral URTI with Cervical Lymphadenitis
- Whiplash Injury
- Meningism Due to Systemic Infection (e.g. Pneumonia)
Occasional Diagnoses
- Tension/Stress (Common, but Usually Causes an Ache or Muscle Tenderness Rather than Stiffness)
- Other Forms of Arthritis (e.g. Rheumatoid [RA] and Ankylosing Spondylitis)
- Abscess in the Neck
- Functional Neurological Disorder
- Intracerebral Haemorrhage
- Cerebral Tumour
Rare Diagnoses
- Meningitis
- Vertebral Fracture
- Bone Tumour (Primary or Secondary)
- Atypical Infections: Tetanus, Leptospirosis, Sandfly Fever, Psittacosis
- Brain Abscess
Ready reckoner
Key distinguishing features of the most common diagnoses
| Torticollis | Cervical Spondylosis | URTI | Whiplash | Meningism | |
|---|---|---|---|---|---|
| Other Symptoms | No | Possible | Yes | Possible | Yes |
| Recurrent | No | Yes | No | Possible | No |
| Enlarged lymph Nodes | No | No | Yes | No | Possible |
| Neck Asymmetrical | Yes | Possible | No | Possible | No |
| Fever | No | No | Yes | No | Yes |
Possible investigations
Likely: None.
Possible: FBC, Paul–Bunnell test, ESR/CRP, rheumatoid factor, HLA-B27.
Small Print: Bone biochemistry, X-ray cervical spine, bone scan, other hospital-based tests.
- FBC and Paul–Bunnell: In unresolved or resistant URTI, check these parameters if glandular fever suspected.
- ESR/CRP, rheumatoid factor and HLA-B27: Will help in the diagnosis of possible RA and ankylosing spondylitis in the young and middle-aged with unresolving neck stiffness.
- Neck X-ray: For possible fracture (at hospital); of limited value in cervical spondylosis – symptoms do not correlate well with X-ray findings. May reveal serious bone pathology, but bone scan more useful for this.
- Bone biochemistry: Consider this if bony secondaries or myeloma are possible diagnoses.
- Hospital-based tests: These might include lumbar puncture (for meningitis) and scans for cerebral lesions.
Top Tips
- Neck tenderness due to cervical lymphadenopathy in an URTI is infinitely more common than meningitis, but is often misreported as ‘neck stiffness’.
- Only advise soft collars in the majority of stiff necks for a maximum of 48 hours. Though comfortable, they tend to delay resolution. Instead, suggest adequate analgesia, heat and mobilisation.
- Warn patients with whiplash injury that symptoms may take many months to settle completely – this saves repeated futile and frustrating consultations.
Red Flags
- Meningococcal petechiae are usually a late sign and can be missed unless the febrile child with a stiff neck is undressed and examined.
- Pain and stiffness may be the only symptoms of vertebral fracture or subluxation, which can occur without cord involvement – significant trauma merits A&E referral.
- Thunderclap headache preceding neck stiffness suggests subarachnoid haemorrhage – admit straight away.
- Consider serious bony pathology if pain and stiffness are relentless and wake the patient at night – especially if there are other worrying symptoms, or the patient has a past history of carcinoma.
- Pain onset in whiplash is usually delayed. Immediate onset may mean significant bony injury.