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
| 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.