Stiff Neck

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

TorticollisCervical SpondylosisURTIWhiplashMeningism
Other SymptomsNoPossibleYesPossibleYes
Enlarged lymph NodesNoNoYesNoPossible
Neck AsymmetricalYesPossibleNoPossibleNo

Possible Investigations


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.

Published: 2nd August 2022 Updated: 10th April 2024

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