Approach to neck stiffness in children

INTRODUCTION — This topic will review the approach to neck stiffness in children.

The evaluation of acquired and congenital torticollis in children is discussed separately:

●(See "Acquired torticollis in children".)

●(See "Congenital muscular torticollis: Clinical features and diagnosis" and "Congenital muscular torticollis: Management and prognosis".)

DEFINITIONS — Neck stiffness is a common complaint in pediatrics, and it presents to both the emergency and primary care provider. The term refers to either an abnormal preferred position of the neck or a normal position associated with restricted range of motion. A broad range of conditions from benign to life-threatening may present with neck stiffness as a primary complaint or accompanying other concerns.

Torticollis and meningismus describe specific types of neck stiffness:

●Torticollis – Torticollis (from the Latin for twisted neck, also referred to as wry neck) is a subset of neck stiffness. In torticollis, the child holds his or her head tilted to one side with the chin rotated in the opposite direction. Neck stiffness and torticollis may present with or without accompanying neck pain.

●Meningismus – Meningismus is another important subset of neck stiffness that defines neck stiffness in association with meningeal irritation. With meningismus, the child typically has fever, restriction of neck movement (of neck flexion in particular), and pain. Conditions presenting with meningismus require emergency evaluation and management. Causes include meningitis and infection of adjacent structures such as spinal epidural abscesses. Deep space neck infections can occasionally present with meningismus but are more commonly associated with restriction of extension. (See "Retropharyngeal infections in children" and "Retropharyngeal infections in children", section on 'Clinical manifestations'.)

CAUSES — Neck stiffness is best considered as traumatic or non-traumatic, recognizing that in children, trauma may be unwitnessed, or unreported in the setting of child abuse (table 1). In a single center series of 170 children evaluated for neck complaints in an emergency department, neck stiffness was most commonly caused by trauma (62 percent) and localized infection (20 percent) [1]. In any child with neck stiffness, the presence of neurologic signs or symptom warrants emergency evaluation.

Life-threatening conditions

Traumatic

Cervical spine injury — Cervical spine fractures and subluxations are rare in children under the age of eight years. When present, they typically involve the upper cervical spine, and occur in the setting of high kinetic energy mechanisms such as motor vehicle collisions and falls. Similar to adults, older children and adolescents are vulnerable to lower cervical spine trauma caused by motor vehicle collisions and sports injuries. Caution should always be exercised in patients with high-energy mechanisms and/or axial load injuries. Signs of cervical spine injury can include neck pain, tenderness, and stiffness, but these may be absent or subtle in patients with altered mental status. While some children with fractures of the cervical spine are unresponsive at the time of evaluation, many are awake, alert and verbal, complaining of neck pain, and have no demonstrable neurologic deficit. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

SCIWORA — Spinal cord injury without radiographic abnormality (SCIWORA) occurs in children due to the ligamentous laxity and hypermobility of the pediatric cervical spine. Various mechanisms, including longitudinal distraction, hyperflexion, hyperextension, and ischemia to the spinal cord, may result in SCIWORA syndrome. Younger children (<8 years) are likely to have lesions higher in the cervical spine due to age-related changes in the location of the fulcrum for maximal flexion. Children with SCIWORA may develop significant or progressive paralysis within 48 hours of a traumatic injury; a latency of up to four days has been reported. Some children, however, may have transient neurologic symptoms that remit and then recur, often within the next day, with worsening neurologic abnormalities. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Terminology'.)

It should be noted that the term radiographic abnormality has historically been used with reference to plain radiographs and computed tomography (CT), but not magnetic resonance imaging (MRI). Many patients with neurologic findings in the setting of trauma will have radiographic abnormalities of the spinal cord or surrounding soft tissue structures on MRI.

Subluxation — Traumatic subluxation of the cervical spine is more common than fracture and typically occurs in the setting of severe trauma. Spinal subluxation may present with or without accompanying neurologic deficit.

Rotary (or "rotatory") atlantoaxial subluxation is the most common subluxation of the cervical spine in the pediatric age group. It generally does not compromise the spinal canal because the transverse ligament of the atlas remains intact. Rotary subluxation typically causes neck pain and torticollis. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)

Atlantoaxial subluxation with compromise of the spinal canal results from ligamentous laxity or rupture and resultant anterior movement of the atlas on the axis. Children with Down syndrome, Morquio syndrome, juvenile idiopathic arthritis and connective tissue disorders are susceptible to atlantoaxial subluxation with minor trauma. In contrast to congenital or acquired muscular torticollis, the head tilts away from the involved sternocleidomastoid muscle and the chin towards the muscle in patients with atlantoaxial subluxation. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete", section on 'Atlantoaxial rotary subluxation' and "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)

Spinal epidural hematoma — Epidural hematoma of the cervical spine is rare but may occur even after apparently minor trauma, or in the absence of trauma. It should be considered in patients with the abrupt onset of unexplained neck pain. The hematoma may compress the spinal cord, leading to progressive neurologic signs and symptoms. Emergency neurosurgical consultation and surgical decompression are indicated.

Subarachnoid hemorrhage — Subarachnoid hemorrhage (SAH) is accompanied by headache or other physical findings of head trauma. Note that subarachnoid hemorrhage can also occur in the absence of trauma, usually associated in these cases with aneurysm and hemorrhage. It may be associated with exertion. Classically, it presents as the sudden onset of severe headache. Neck stiffness usually occurs after a few hours. More rarely, it presents with seizures, changes in mental status, cranial nerve six palsy due to increased intracranial pressure, other focal neurologic findings, ocular hemorrhage, nausea, or vomiting. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management".)

Nontraumatic

Meningitis — Bacterial meningitis is the most important infectious cause of neck stiffness and is almost always accompanied by fever. Older children with meningitis commonly have findings of neck stiffness on physical examination. This finding may be nonspecific or absent in young infants and in children who lack an inflammatory response. Etiologies vary by age. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical features'.)

Viral or Lyme meningitis also may cause neck pain and stiffness accompanied by cerebrospinal fluid pleocytosis with a negative culture. Fever is commonly but not always presents in these cases. (See "Viral meningitis in children: Clinical features and diagnosis", section on 'Common features' and "Lyme disease: Clinical manifestations in children", section on 'Meningitis'.)

Peritonsillar and neck space abscesses — Stiff neck with fever can be caused by infection or abscess in the peritonsillar, retropharyngeal, parapharyngeal, submandibular, and submental spaces, as well as the anterior or posterior triangles. The prevalence of each type of infection varies by age. A rare but serious neck infection is Lemierre syndrome, a suppurative thrombophlebitis of the internal jugular vein; these patients are febrile and ill appearing with clinical and laboratory features of serious infection. (See "Peritonsillar cellulitis and abscess" and "Retropharyngeal infections in children" and "Lemierre syndrome: Septic thrombophlebitis of the internal jugular vein".)

Limitation of neck extension, with use of eye movement for upward gaze, is particularly suggestive of retropharyngeal abscess. Other clinical features may include sore throat, cervical lymphadenopathy, rhinorrhea, and non-specific findings such as irritability, lethargy, and poor oral intake. Trismus is a hallmark of peritonsillar or less commonly retropharyngeal abscess. It may sometimes be clinically difficult to differentiate a deep neck space infection from meningitis without a lumbar puncture, especially in a toxic-appearing younger patient. Imaging may be indicated prior to lumbar puncture when the clinical picture is more suggestive of a neck infection. In these cases, the clinical presentation and severity of illness should be considering regarding the need to initiate antibiotics prior to definitive diagnosis. Procedural sedation, which is often required for adequate radiographic examination, should be undertaken with caution given the potential for airway compromise.

Factors that impact the choice of imaging are discussed separately. (See "Retropharyngeal infections in children", section on 'Imaging' and "Deep neck space infections in adults", section on 'Clinical suspicion and urgent imaging'.)

Epidural abscess — Although uncommon, a cervical spine epidural abscess is important to consider in patients with fever, pain, and a stiff neck. Cervical spine abscesses are associated with severe neurologic deficits and mortality. Risk factors including but not limited to immunodeficiency, recent trauma, and intravenous drug use should be elicited to help raise the index of suspicion for this infrequent diagnosis, as prompt recognition and surgical drainage are essential to optimize outcomes. (See "Spinal epidural abscess".)

Central nervous system lesions — Regardless of histological and metastatic features, these lesions are potentially life-threatening because of the potential for intracranial pressure elevation and the associated brain and spinal cord compression. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis", section on 'Physiology'.)

●Brain tumors – Brain tumors located in the posterior fossa may present with head tilt, neck stiffness, or torticollis. Associated symptoms may include vomiting, headache, ataxia, vision disturbances, papilledema, or cranial nerve deficits. Head tilt may result from attempts to compensate for diplopia. However, neck stiffness is believed to result from irritation of the accessory nerve by the cerebellar tonsils trapped in the occipital foramen or by tonsillar herniation. Thus, any patient with torticollis should have a thorough neurologic examination, and a posterior fossa tumor should be considered in a patient with headache, vomiting, focal neurological deficits, or torticollis that does not resolve over several days with conservative measures. (See "Clinical manifestations and diagnosis of central nervous system tumors in children".)

●Spinal cord tumors – Torticollis may be seen rarely in patients with tumors of the spinal cord. Spinal cord tumors are infrequent and typically cause pain at the site of the tumor along with neurologic defects (sensory and motor defects, impaired bowel and bladder function). Symptoms may be very slow to develop, often leading to delay in diagnosis. Patients may also hold their heads in a forward flexed position ("hanging head") sign. (See "Clinical manifestations and diagnosis of central nervous system tumors in children".)

●Other head and neck space-occupying lesions – Nasopharyngeal carcinoma is an uncommon tumor in children, but it may present with epistaxis, neck pain, and cervical adenopathy. Other tumors of the head and neck that may present with neck stiffness include orbital tumors, vestibular schwannomas (acoustic neuromas), osteoblastomas, Ewing sarcomas, and tumors metastatic to the spine.

●Other space-occupying lesions of the spinal cord – Other uncommon space-occupying lesions of the cervical spine such as neurenteric cysts, arteriovenous malformations, spontaneous spinal epidural hematomas, and syringomyelia may also cause neck pain and stiffness; neurologic findings are commonly present.

●Vascular anomalies – Congenital berry aneurysms and acquired cerebral aneurysms associated with sickle cell disease may rupture spontaneously and result in life-threatening SAH. As for traumatic SAH, classic features are the abrupt onset of severe headache, nausea and vomiting, and sometimes photophobia. Fever can also be present. The abruptness of onset of these symptoms distinguishes this presentation from meningitis, although the distinction may be difficult. Occasionally, milder symptoms thought to represent leaking from an aneurysm whose rupture is imminent are the earliest presenting features. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

●Arnold-Chiari malformation – This malformation may also cause neck pain and/or stiffness, and frequently occurs in patients with myelomeningocele; stridor is a classic clinical feature. (See "Chiari malformations", section on 'Chiari II clinical features'.)

Common conditions

Traumatic

Clavicle fracture — Fracture of the clavicle in children is common and may cause neck stiffness because of decreased movement secondary to pain, or due to sternocleidomastoid muscle spasm. The diagnosis of clavicle fracture is usually clear because pain and tenderness are noted over the fracture site. A history of trauma is usually elicited, but it may be absent in the case of unwitnessed minor trauma. The acute symptoms associated with clavicle fracture may on occasion mask an associated cervical spine injury or atlantoaxial rotatory subluxation. Thus, careful examination of the spine is warranted in patients presenting with clavicle fracture, especially if a high-energy mechanism is present. Medial clavicle fractures are also associated with neurovascular and lung injuries and careful evaluation, often with dedicated additional imaging, is necessary to exclude them. (See "Clavicle fractures", section on 'Clinical presentation and examination'.)

Muscular injury — Blunt trauma to the neck may result in neck pain as a result of muscular contusion or spasm. This is a diagnosis of exclusion, however, and should not be entertained until a detailed physical including neurologic examination and radiographs of the cervical spine exclude the possibility of a more serious injury. The possibility of associated vascular injury must also be considered. Similarly, acceleration/deceleration injuries may result in muscle strain causing neck stiffness, but bony and ligamentous injuries must be excluded before making this diagnosis. It is not always possible to differentiate among these entities at the time of an acute injury based upon plain radiographs alone. Further imaging and care should be guided by the specific mechanism and physical findings. (See "Overview of musculoskeletal neck injuries in the child or adolescent athlete", section on 'Muscular injuries' and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Nontraumatic

Lymphadenitis — Cervical lymphadenitis, either acute or chronic, is a common cause of neck stiffness. The child with this condition typically has tender swelling over the lateral aspect of the neck, with or without fever. Most cases of cervical lymphadenitis are due to Staphylococcus aureus or Group A streptococcus. Other bacteria (eg, Bartonella henselae, the cause of cat-scratch disease) and mycobacteria are less common causes. Occasionally, severe reactive but not primarily infected cervical lymphadenopathy, as with infectious mononucleosis or other pharyngeal infections, may cause mild neck stiffness. The generalized lymphadenopathy associated with Kawasaki’s disease may also present with neck stiffness; in these cases, other stigmata of Kawasaki’s should be present. (See "Kawasaki disease: Clinical features and diagnosis" and "Cervical lymphadenitis in children: Etiology and clinical manifestations".)

Muscle spasm — Mild torticollis due to sternocleidomastoid muscle spasm is a frequent presentation. It is characterized by mild neck stiffness, usually associated with a twisting of the head toward the sternocleidomastoid muscle and the chin away from the muscle, with or without pain, in a well-appearing child. It may result from minor irritation or an awkward sleeping position. No fever, trauma, or intercurrent illness is present. Torticollis that does not resolve with conservative measures should be re-evaluated for other causes of neck stiffness. (See "Acquired torticollis in children".)

Other infections — Pneumonia, pyelonephritis, otitis media, and mastoiditis may cause neck pain, stiffness or torticollis secondary to compensatory muscle spasm, or referred pain. Systemic viral processes may present with myalgias, and myositis can cause neck pain and stiffness, but these are typically accompanied by muscular symptoms beyond the neck alone. Similarly, Lyme disease may present with cervical myalgias even in the absence of Lyme meningitis; other stigmata of Lyme disease are typically present. (See "Lyme disease: Clinical manifestations in children".)

Dystonic reaction — Certain drugs with dopamine-2 receptor antagonism can cause acute dystonic reactions with torticollis. These include many neuroleptic and antiemetic agents, such as haloperidol, prochlorperazine, and metoclopramide. Treatment with intravenous diphenhydramine may be diagnostic and therapeutic. (See "Acquired torticollis in children", section on 'Dystonic reaction'.)

Uncommon conditions

Infectious

●Vertebral osteomyelitis – Vertebral osteomyelitis occurring in the cervical spine may lead to neck stiffness and is typically accompanied by localized pain and fever. It is usually bacterial, most commonly Staphylococcus aureus, but it may be caused by mycobacteria as well. The average age of presentation is approximately eight years [2]. It may present insidiously, and it should be considered in patients with fever of unknown origin and neck symptoms. (See "Hematogenous osteomyelitis in children: Clinical features and complications", section on 'Children older than three months'.)

●Infectious discitis – Infectious discitis is uncommon in children. This disease is thought to be caused by infection with Staphylococcus aureus, although bacterial cultures from the blood, and even from the disc, are commonly negative. The cause has been debated. Most children with infectious discitis are younger than three years of age. Disease is usually in the lumbar or thoracic vertebrae rather than in the cervical spine. However, it can occur at any vertebral level and present with percussion tenderness over the involved cervical spine and neurologic findings such as weakness and decreased reflexes. Fever may be present as well, though less commonly than in osteomyelitis. MRI confirms the diagnosis. (See "Back pain in children and adolescents: Causes", section on 'Discitis'.)

Congenital

●Congenital muscular torticollis – Congenital muscular torticollis is the most common cause of torticollis in infancy. The etiology of this condition is unclear but is believed to be related to birth trauma that causes an injury to the SCM muscle with hematoma formation, followed by fibrous contracture of the muscle. Many patients will have a history of breech presentation. On examination, a palpable mass can often be detected in the inferior aspect of the SCM. The mass is generally not present at birth but appears in the neonatal period. The head is held in the characteristic position, with the patient's chin pointing away from the affected, contracted SCM muscle. Radiographs of the cervical spine are necessary to exclude other congenital causes of torticollis. (See "Congenital muscular torticollis: Clinical features and diagnosis".)

●Branchial cleft cyst abscess – The hypopharynx is the source for the third and fourth branchial pouches, each arising in the pyriform sinus. Cysts of third or fourth branchial origin present as recurrent abscesses in the lateral neck that cause redness, swelling, and neck pain with stiffness similar to cervical lymphadenitis. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Third and fourth branchial arch'.)

●Thyroglossal duct cyst abscess – Thyroglossal duct cysts are usually within two cm of the midline but can be somewhat more lateral. Cysts with associated abscesses cause midline or lateral neck redness, swelling, and pain with stiffness. The typical cyst maintains a close relationship to the hyoid, thyrohyoid membrane, or thyroid cartilage. Classically, thyroglossal duct cysts move up with swallowing or protrusion of the tongue, emphasizing their close relationship with the hyoid/larynx complex. (See "Thyroglossal duct cyst, thyroglossal duct cyst cancer, and ectopic thyroid", section on 'Clinical manifestations'.)

●Atlantoaxial instability – Several congenital conditions may be associated with atlantoaxial instability and predispose the patient to cervical subluxation. In addition to Down and Klippel-Feil syndromes, these include other skeletal dysplasias and os odontoideum (aplasia or hypoplasia of the odontoid). Children with these conditions should be screened for atlantoaxial instability. Morquio syndrome is a mucopolysaccharidosis resulting in flattening of the vertebrae and multiple skeletal dysplasias. The odontoid process of the axis is underdeveloped and may lead to atlantoaxial subluxation. (See "Mucopolysaccharidoses: Clinical features and diagnosis".)

●Klippel-Feil syndrome – Klippel-Feil syndrome is characterized by congenital fusion of a variable number of cervical vertebrae, which may result in atlantoaxial instability [3]. Genetic analysis indicates heterogeneous inheritance, including autosomal dominant, autosomal recessive, and sporadic occurrence. It is often associated with other bony abnormalities, and significant scoliosis develops in more than 50 percent of affected children. Limitation in range of motion of the neck is the most common physical sign. In addition to limited neck motion, the classic triad, seen in less than half of patients, also includes a low hairline and a short neck. Deafness, genitourinary abnormalities, and cardiovascular abnormalities are also associated findings in these patients.

●Sprengel deformity – Sprengel deformity is characterized by congenital failure of the scapula to descend to its correct position. The scapula rests in a high position in relation to the neck and thorax. In its most severe form, the scapula may be connected to the cervical spine by a congenitally anomalous ossification, the omovertebral bone, and limit neck movement. Patients with Sprengel deformity should undergo evaluation for associated bony and spinal cord abnormalities (eg, absent ribs, fused ribs, congenital scoliosis, Klippel-Feil syndrome, diastematomyelia).

●Hemiatlas – Hemiatlas is a malformation of the first cervical vertebra, which may cause severe, progressive torticollis. In time, the deformity becomes fixed; therefore, posterior fusion is recommended.

●Basilar impression – Basilar impression is a condition resulting from anomalies at the base of the skull and vertebrae which lead to a short neck, headache, neck pain, and cranial nerve palsies due to compression of the cranial nerves. Many congenital conditions, including Klippel-Feil syndrome, achondroplasia, and neurofibromatosis, may cause basilar impression.

●Occipitocervical synostosis – Commonly associated with basilar impression is occipitocervical synostosis, a condition in which fibrous or bony connections between the base of the skull and the atlas cause neck pain, torticollis, high scapula, and several neurologic conditions.

Neurologic

●Benign paroxysmal torticollis – Benign paroxysmal torticollis of infancy presents as recurrent episodes of torticollis in association with pallor, agitation, and vomiting and is a diagnosis of exclusion once the child has been evaluated for causes of increased intracranial pressure or repeated neurologic episodes (eg, seizures). The typical onset is between two and eight months of age; the condition tends to remit by two to three years. (See "Acquired torticollis in children", section on 'Benign paroxysmal torticollis'.)

●Ophthalmologic, neurologic, and/or vestibular causes – Head tilt or neck malposition may result from abnormalities of vision (strabismus, cranial nerve palsies, extraocular muscle palsies, or refraction errors) or of the vestibular apparatus. The child attempts to correct for the disturbance through changes in neck position. Careful ophthalmologic and neurologic examinations of the child with head tilt are necessary to exclude these possibilities. Torticollis has also been reported in patients with migraine headaches. (See "Approach to the pediatric patient with acute vision change".)

●Myasthenia gravis – Patients with myasthenia gravis may develop torticollis, although ptosis, impairment of extraocular muscular movement, and other cranial nerve palsies are often earlier signs. (See "Clinical manifestations of myasthenia gravis".)

●Guillain-Barré syndrome – Isolated neck stiffness is a rare presentation of Guillain-Barré syndrome [4]. Associated weakness, ataxia, and areflexia are expected. (See "Guillain-Barré syndrome in children: Epidemiology, clinical features, and diagnosis".)

●Idiopathic intracranial hypertension (Pseudotumor cerebri) – Stiff neck and torticollis have also been reported in children with pseudotumor cerebri. While they may be the presenting signs of idiopathic intracranial hypertension, its clinical presentation is usually characterized by headache, vomiting, and papilledema. (See "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis", section on 'Symptoms'.)

●Spasmus nutans – Spasmus nutans is an acquired condition of childhood, characterized by nystagmus, head nodding, and torticollis. Children with these findings typically become symptomatic in the first two years of life. The condition is generally benign and self-limited. However, some children with the symptoms of spasmus nutans have underlying brain tumors. (See "Acquired torticollis in children", section on 'Spasmus nutans'.)

Other

●Grisel syndrome – Grisel syndrome is neck pain or stiffness secondary to inflammatory atlantoaxial subluxation that causes ligamentous laxity. Predisposing events include otolaryngological procedures or infection, including upper respiratory infections. The subluxation is rotary, with or without displacement of the atlas. Fever and dysphagia are common. Most commonly, the condition is mild and there is no anterior displacement of the axis. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)

●Intervertebral disc calcification – Intervertebral disc calcification (IDC) in children is an uncommon, generally self-limited condition in which the nucleus pulposus of one or more intervertebral discs calcifies. The cause of the condition and its acute symptoms are unknown. It is generally believed that acute symptoms are secondary to some inciting event (eg, mild trauma, viral infection) that results in an inflammatory response, possibly because of the release of calcium crystals.

Children typically present with 24 to 48 hours of neck pain associated with neck stiffness or torticollis; fever is often present as well. The disease is generally benign and self-limited, although disc protrusion and cord compression may uncommonly occur. Distinguishing features of infectious discitis as opposed to IDC include the lack of disc calcification and the single disc involvement of acute infectious discitis. Infectious discitis is most common in the lumbar spine, whereas IDC in children most commonly involves the cervical spine.

●Rheumatologic causes – Collagen vascular disease in children may involve the cervical spine and lead to neck stiffness and/or pain. Although isolated cervical disease is unusual, neck stiffness or torticollis may be the presenting sign of juvenile idiopathic arthritis. Cervical involvement in ankylosing spondylitis is a late finding, as it is in other spondyloarthropathies. Girls with psoriatic arthritis, however, may have cervical involvement preceding sacroiliac and lumbar involvement. (See "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis" and "Spondyloarthritis in children".)

●Gastroesophageal reflux – Sandifer syndrome is torticollis and other abnormal posturing in the setting of gastroesophageal reflux disease. Additional symptoms and complications of gastroesophageal reflux may or may not be present. These include regurgitation, anorexia, hematemesis, irritability, anemia, failure to thrive, asthma, chronic cough, or hoarseness. (See "Acquired torticollis in children", section on 'Sandifer syndrome'.)

●Benign tumors of the head and neck – Osteoid osteoma is a benign bone tumor that typically affects older children and adolescents. If the osteoma is in the cervical spine, neck pain results. Pain is the typical presenting symptom, often worse at night. Eosinophilic granulomas and bone cysts are rare, benign lesions of the spine that may cause neck pain and/or stiffness. (See "Nonmalignant bone lesions in children and adolescents", section on 'Osteoid osteoma' and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

●Pneumomediastinum – Spontaneous pneumomediastinum may present with neck pain and torticollis. A history of severe coughing and/or retching and palpable neck crepitus are often present. (See "Spontaneous pneumomediastinum in children and adolescents".)

●Psychiatric etiologies – Psychogenic torticollis may occur rarely and is a diagnosis of exclusion.

EVALUATION — After immobilization of the cervical spine as indicated, the clinician should perform a careful history and physical examination to guide further evaluation and management.

Cervical spine trauma — Children with neck stiffness and possible cervical spine injury should be immobilized before the clinician proceeds with evaluation. Indications for cervical spine immobilization in the setting of known or possible trauma include (see "Evaluation and acute management of cervical spine injuries in children and adolescents"):

●Mechanism concerning for potential c-spine injury (eg, motor vehicle collision, motor vehicle-pedestrian, motor vehicle-bicycle, fall from a considerable height)

●Anatomic predisposition to neck injury (eg, Down syndrome), prior neck injury, or history of cervical spine surgery

●GCS <13

●Altered mental status or intoxication

●Neck pain and/or guarding of the neck

●Neurologic deficit

●Distracting injury that may mask cervical spine instability because of pain. To qualify as a distracting injury, the trauma must be sufficiently severe as to make the otherwise alert, verbal child unaware of neck pain.

History — A comprehensive history helps narrow the extensive list of possible causes in the child with neck stiffness (table 1). In patients with acute onset of neck stiffness or torticollis, three concerns take priority:

●Trauma – The clinician should elicit any history of trauma requiring cervical spine immobilization, before proceeding with a complete history and physical. Recall that patients with cervical spine injury may be ambulatory at presentation. If trauma has occurred, details should be elicited, including the height and speed involved. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

●Fever – Fever in an ill-appearing child with stiff neck requires prompt evaluation and management of possible meningitis. In patients with fever and neck pain without meningitis or obvious source of infection on head, ear, throat, or neck examination, the possibility of more occult infections, such as retropharyngeal abscess, vertebral osteomyelitis, discitis, or spinal epidural abscess should be considered. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation' and "Bacterial meningitis in children older than one month: Treatment and prognosis".)

●Neurologic abnormality – Symptoms of vision change (eg, diplopia, blurry vision), ataxia, gait abnormality, paresthesias or other sensory changes in the extremities, and functional abnormalities of the bowel or bladder, along with any neurologic sign or symptom, raise concern for an intracranial or intraspinal space occupying lesion. (See "Clinical manifestations and diagnosis of central nervous system tumors in children".)

Other historical features of importance include:

●Headache – Any patient with fever, neck stiffness, and a history of headache should be assessed for the possibility of meningitis. An abrupt onset of severe headache should raise the suspicion of subarachnoid hemorrhage (SAH). A more indolent course should raise concern for intracranial mass, as well as idiopathic intracranial hypertension (previously known as pseudotumor cerebri), especially in a patient on a medication known to precipitate this condition (eg, doxycycline), or with associated ophthalmologic symptoms (eg, vision loss). (See "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis", section on 'Symptoms' and "Emergency department approach to nontraumatic headache in children".)

●Throat pain – Complaints of sore throat, sometimes accompanied by mild headache, should prompt consideration of Streptococcal infection, viral pharyngitis (eg, infectious mononucleosis), or neck space infections as a complication of pharyngitis, especially in the ill-appearing patient. Drooling or difficulty managing oral secretions in association with trismus may manifest in patients with retropharyngeal or peritonsillar abscess.

●Ear or dental pain – Ear or dental pain accompanies a focal infection in these regions such as dental abscess, otitis media, or mastoiditis.

●Painful neck mass – A history of a painful neck mass with or without fever raises the possibility of cervical lymphadenitis or abscess, branchial cleft cyst abscess, or infected thyroglossal duct cyst, or other neck mass.

●Respiratory symptoms – Cough or respiratory distress suggest an upper lobe pneumonia.

A review of systems should assess for symptoms of systemic disease that may present in the cervical region, particularly joint or skin findings suggestive of a rheumatologic disorder.

Weight loss or failure to thrive, fatigue, night sweats, or fevers and chills should raise the possibility of an oncologic process or tuberculosis.

Neurologic symptoms with vomiting should raise the possibility of a brain tumor or other central nervous system (CNS) process. Generalized weakness can be associated with myasthenia gravis or Guillain-Barré syndrome.

The past medical history should be reviewed with particular emphasis on the presence of a congenital disorder such as cervical skeletal malformations, myelomeningocele (associated with Arnold Chiari malformation), Down syndrome, and connective tissue disorders (eg, Morquio syndrome). (See 'Causes' above.)

A history of ingestion of dopaminergic antagonists (eg, haloperidol, risperidone, metoclopramide) suggests a dystonic reaction.

Physical examination — As with history, assessment for evidence of trauma, meningitis, and/or neurologic deficits takes priority. The clinician should look for signs of trauma suggesting the need for cervical spine immobilization before proceeding with the remainder of the exam. (See "Pediatric cervical spinal motion restriction".)

●Meningitis – Fever, toxic appearance, meningismus, and/or evidence of photophobia should prompt a swift evaluation for meningitis. Although meningeal signs are present at the time of admission in the majority of patients with bacterial meningitis, they are not invariably present. Nuchal rigidity may not be elicited in comatose patients or those with focal or diffuse neurologic deficits and may be subtle in infants and young children. In addition, nuchal rigidity may occur late in the course, particularly in infants and young children. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical findings'.)

Nuchal rigidity is manifest by the inability to place the chin on the chest, limitation of passive neck flexion, and Kernig and Brudzinski signs. These may be present in any combination.

•Kernig sign – Kernig sign is present if the patient, in the seated position with the hip and knee flexed at 90 degrees, cannot extend the knee more than 135 degrees and has pain in the hamstrings. In addition, flexion of the opposite knee may occur.

•Brudzinski sign – Brudzinski sign is present if the patient, while in the supine position, flexes the lower extremities at the hips and knees during attempted passive flexion of the neck.

Signs of meningeal irritation are present in 60 to 80 percent of children with bacterial meningitis at the time of presentation. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Clinical findings'.)

●Neurologic deficit – Physical exam for neurologic deficits should include an assessment of mental status, cranial nerves, muscle strength, sensation, cerebellar function, gait, deep tendon reflexes, the Babinski reflex, and rectal tone. Extra vigilance must be used if the patient is too young or incapacitated to provide an accurate history.

●HEENT – Careful attention should be paid to any focus of infection that could be presenting as neck stiffness. This includes evidence of a superficial abscess or cellulitis of the scalp, middle ear effusion or purulent collection in otitis media, mastoiditis, dental infection, infection in the floor of the mouth of submental region (Ludwig angina) or pharyngitis. Drooling, trismus, or exquisite anterior neck tenderness suggest retropharyngeal abscess or other deep neck infection. (See "Retropharyngeal infections in children".)

The presence of craniofacial asymmetry often indicates congenital or long-standing torticollis.

Evidence of ocular abnormalities, including abnormal movements or ptosis, may indicate a neurologic etiology. Fundoscopic exam should be performed looking for papilledema as the presenting sign of increased intracranial pressure or pseudotumor cerebri. Papilledema may be subtle; consider ophthalmology consultation if clinical suspicion if high. (See "Evaluation and management of strabismus in children", section on 'Evaluation' and "Fourth cranial nerve (trochlear nerve) palsy" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".)

●Neck – The neck itself should be carefully examined for abnormal positioning, which may provide a clue to the type of torticollis, and for the erythema and edema of cervical lymphadenitis, branchial cleft cyst abscess, or thyroglossal duct cyst infection. Palpation of the cervical spine identifies and localizes bony tenderness. Point tenderness over the cervical spine may indicate underlying fracture, subluxation, discitis, or osteomyelitis. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

A short neck with a low posterior hair line may indicate a bony cervical spine anomaly (eg, occipitocervical synostosis).

In patients who do not require cervical spine immobilization, the active range of motion of the neck should be assessed; the normal child should be able to flex the chin to the chest, extend the neck superiorly, touch the ear to the ipsilateral shoulder, and turn the head 90 degrees to the right or left to touch the chin to the contralateral shoulder. Passive range of motion testing should be generally not be performed because of the risk of vertebral subluxation.

●Pulmonary – Thorough pulmonary exam in the febrile child may reveal an upper lobe pneumonia, which can rarely present with meningismus.

●Abdominal exam – The abdominal exam may show signs of occult trauma; vomiting accompanied by a normal abdominal exam elevates suspicion for a central nervous system (CNS) process. Unilateral costovertebral tenderness suggests pyelonephritis.

●Musculoskeletal and dermatologic exams – Joint and skin examination may reveal signs of arthritis, rash, or nail changes consistent with a systemic rheumatologic process.

ANCILLARY STUDIES — The laboratory and radiographic evaluation of neck stiffness is based upon the suspected underlying etiology.

Laboratory studies

●Inflammatory markers – An elevated white blood cell (WBC) count and differential, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) or procalcitonin provide supportive evidence when an occult infectious process such as osteomyelitis, epidural abscess, or discitis is suspected.

●Blood cultures – Blood cultures are indicated in the evaluation of invasive infectious causes of neck stiffness, including meningitis, neck space infections and epidural abscesses, osteomyelitis, and cellulitis. Blood cultures are frequently negative but are still suggested in the evaluation of discitis.

●Lumbar puncture – – In cases of suspected meningitis, the patient should undergo lumbar puncture (LP). Children with elevated intracranial pressure (ICP) are at risk for cerebral herniation when LP is performed. Consequently, CT of the head should be obtained before LP for all patients with clinical suspicion for increased ICP (eg, papilledema, focal neurologic deficits, or altered mental status) or in any atypical presentation. Magnetic resonance imaging (MRI) may be considered to evaluate for increased ICP or intracranial lesion in the afebrile patient in whom evaluation is considered urgent but not emergent.

Appropriate cerebrospinal fluid (CSF) studies include cell count and differential, glucose and protein, Gram stain, and bacterial culture. Viral culture or targeted viral PCR (especially for enterovirus and herpes simplex) may be indicated as well. If Lyme meningitis is suspected, serum Lyme antibodies but not polymerase chain reaction testing may be useful. (See "Nervous system Lyme disease", section on 'Meningitis'.)

CSF analysis can also be useful in diagnosing CT-negative SAH, recognizing that xanthochromia may be absent in the first 12 hours.

An opening pressure should be obtained if idiopathic intracranial hypertension is a possibility; removal of spinal fluid may be therapeutic in this setting. (See "Lumbar puncture in children".)

Radiographic imaging

●Plain radiographs – Cervical spine films are essential in the evaluation of children with suspected cervical spine injury, and suspected congenital abnormalities of the cervical spine. They may be necessary in other unclear presentations, and the possibility of occult trauma should always be considered. Plain films do not always detect rotary atlantoaxial subluxation or atlantoaxial subluxation. It is typically impractical to obtain odontoid views in children under five years. If a fracture is found or suspected, CT scanning can better define an injury. MRI is useful to evaluate for suspected spinal cord or ligamentous injury, and in cases of suspected cervical spine epidural hematoma or vertebral osteomyelitis. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Plain radiographs' and "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation' and "Overview of musculoskeletal neck injuries in the child or adolescent athlete", section on 'Atlantoaxial rotary subluxation'.)

In a patient with a retropharyngeal abscess, but not lateral or parapharyngeal abscesses, lateral radiographs of the neck may reveal soft tissue swelling anterior to the upper cervical vertebral bodies. CT with intravenous contrast is helpful in equivocal cases, especially those with an apparently widened retropharyngeal space seen on plain neck radiographs that may be due to inadequate neck extension or inadequate inspiration. (See "Retropharyngeal infections in children", section on 'Imaging'.)

Plain radiography of the appropriate region is usually diagnostic in patients with osteoid osteoma, clavicle fracture, or upper lobe pneumonia.

●Ultrasonography – In infants in whom congenital muscular torticollis is suspected, ultrasonography of the sternocleidomastoid muscle can confirm that the palpable mass is of muscular origin. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Diagnosis'.)

●Computed tomography (CT) – As noted above, neck CT with IV contrast is useful in identifying a retropharyngeal, lateral, or parapharyngeal abscess, as well as infectious thrombophlebitis, although it may not always distinguish accurately between abscess, cellulitis and phlegmon. The use of CT for the diagnosis of retropharyngeal infections in children is discussed in detail separately. (See "Retropharyngeal infections in children", section on 'Imaging'.)

Spine CT with IV contrast can also be useful to diagnose an epidural abscess of the spinal cord. (See "Spinal epidural abscess", section on 'Diagnosis'.)

Head CT can aid in diagnosing subarachnoid hemorrhage or posterior fossa mass. However, MRI is required to adequately image the posterior fossa. The sensitivity of modern head CT for detecting SAH is highest in the first six hours after SAH and then progressively declines over time. Other diagnostic testing may be indicated beyond this six-hour window. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Head CT scan'.)

Radiographic findings of atlantoaxial subluxation may include a widened predental space and prevertebral soft tissue swelling. In Grisel syndrome (nontraumatic atlantoaxial subluxation), routine radiographs of the neck may or may not reveal asymmetry between the facet joints and increased space between the dens of the axis and the anterior arch of the atlas. Dynamic or high-resolution CT scan with three-dimensional reconstruction is the best way to visualize the subluxation. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation' and "Overview of musculoskeletal neck injuries in the child or adolescent athlete", section on 'Atlantoaxial rotary subluxation'.)

●Magnetic resonance imaging – An emergency MRI of the spine should be obtained for any child with signs and symptoms suggestive of a spinal cord tumor, hemorrhage, ischemia, or compression. It is also the study of choice for the detection of spinal epidural hematoma, spinal epidural abscess, vertebral osteomyelitis, and infectious discitis. (See "Spinal epidural abscess", section on 'Diagnosis' and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Advanced imaging' and "Back pain in children and adolescents: Causes", section on 'Discitis'.)

MRI is also warranted in patients without neurologic deficits whose symptoms have failed to resolve as expected over time in response to conservative measures.

●Radionuclide scanning – Radionuclide scanning (bone scan, scintigraphy) will reveal uptake at areas of increased metabolic activity of the spine before bony destruction is visible on radiography of the spine in osteomyelitis or infectious discitis and is also useful for the diagnosis of osteoid osteoma. It is less sensitive and specific than MRI for diagnosing these diseases. Multiple nuclear medicine imaging procedures are available to evaluate for osteomyelitis. The three-phase bone scan, utilizing technetium 99m (99mTc), usually is performed initially. Scans using inflammation imaging tracers, such as gallium or indium, can be helpful when results of the initial 99mTc study are equivocal, but involve additional exposure to radiation. MRI is therefore generally preferred when further imaging is required. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Scintigraphy'.)

Radionuclide scanning is useful when:

•MRI is not available and imaging other than plain radiography is needed to make the diagnosis

•The area of suspected infection cannot be localized

•Multiple areas of involvement are suspected

APPROACH

Neck stiffness with trauma — In any patient with a history of trauma, cervical spine immobilization should proceed without delay, if not already in place on presentation (algorithm 1A). Imaging should be used to evaluate and differentiate amongst cervical spine fracture, subluxation, ligamentous injury and muscle strain, or contusion; computed tomography (CT) angiography may be indicated for suspected vascular injury. Cervical muscle strain and contusion are diagnoses of exclusion. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

Clavicular tenderness should prompt plain radiographic evaluation for clavicular fractures in addition to imaging of the cervical spine.

Findings of spinal cord injury — In a patient with neurologic symptoms suggesting spinal cord impingement and a history of trauma, immediate attention must be turned to immobilization of the cervical spine, appropriate imaging (emergent cervical spine films and computed tomography or magnetic resonance imaging) and further management with emergent neurosurgical consultation. Children with predisposition to atlantoaxial instability (eg, Down syndrome, mucopolysaccharidosis, juvenile idiopathic arthritis) may develop spinal cord injury despite sustaining only minor trauma. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation' and "Evaluation and acute management of cervical spine injuries in children and adolescents" and "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)

Headache — Headache should prompt consideration of intracranial hemorrhage, including subarachnoid hemorrhage and epidural or subdural hematoma. Non-contrast head CT is the mainstay for prompt diagnosis and helps guide management. Head CT is highly accurate within six hours of onset of symptoms, but some patients with a normal head CT but persistent neck pain and stiffness or high clinical suspicion for subarachnoid hemorrhage may require lumbar puncture or other testing for detection of subarachnoid hemorrhage. (See "Intracranial epidural hematoma in children" and "Intracranial subdural hematoma in children: Clinical features, evaluation, and management" and "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis".)

Neck stiffness without trauma — In a patient with no history of trauma, the patient should first be evaluated for signs of spinal cord impingement suggesting a space-occupying spinal cord lesion (eg, spinal epidural abscess, spinal cord tumor) (algorithm 1B). Neurologic symptoms in an ill-appearing patient with a fever should prompt concern for a spinal or cranial epidural abscess. Spinal cord tumors and other space-occupying lesions should be considered if the development of symptoms is gradual and not associated with trauma or fever. (See "Clinical manifestations and diagnosis of central nervous system tumors in children".)

Febrile — If fever is present, the possibility of meningitis must be excluded clinically or, when necessary, by lumbar puncture (LP). Subarachnoid hemorrhage (SAH) may also present with fever and meningismus, and may be detected on LP after a negative head CT. Once the emergent concern for meningitis has been addressed, careful physical exam should identify the etiology or direct further testing. Other important causes of fever and meningismus include upper lobe pneumonia, retropharyngeal abscess, septic thrombophlebitis, cervical spine osteomyelitis, cervical discitis, and CNS lupus. Pyelonephritis rarely causes meningismus and evaluation for an infection of the urinary tract as a cause of neck stiffness is usually performed only in febrile, young children in whom no other etiology is identified. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Evaluation'.)

In a patient with fever and a neck mass, tenderness indicates cervical lymphadenitis, a branchial cleft cyst abscess, or thyroglossal duct cyst infection. In a child with diffuse lymphadenopathy, diagnosis of Kawasaki’s disease should be pursued if other typical features are present. The febrile child with no palpable mass and neck stiffness warrants evaluation for deep neck space infection, cervical spine osteomyelitis or discitis, spinal epidural abscess, or other infectious or inflammatory processes affecting the upper respiratory tract. A chest radiograph is indicated for the child with neck stiffness in association with signs of an upper lobe pneumonia (algorithm 1B). (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Third and fourth branchial arch' and "Spinal epidural abscess" and "Kawasaki disease: Clinical features and diagnosis" and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Diagnostic approach' and "Cervical lymphadenitis in children: Etiology and clinical manifestations".)

A nontender cervical mass may arise as a manifestation of tuberculosis, atypical mycobacterium infection, cat scratch disease, or malignancy (eg, lymphoma).

Afebrile — Most afebrile, well-appearing children with neck stiffness of recent onset and/or short duration have muscular spasm or muscle strain and in the absence of trauma require no imaging or laboratory evaluation. Failure of symptoms to resolve in a reasonable period of time should prompt further evaluation. Presence of a cervical mass, neurologic or ophthalmologic abnormalities, weakness, or prolonged duration of stiffness are key concerning features in the afebrile child with neck stiffness that warrant additional studies (algorithm 1C and algorithm 1D).

●A cervical mass within the sternocleidomastoid (SCM) suggests congenital muscular torticollis (in an infant) or a sternocleidomastoid muscle hematoma or tear. If the cervical mass is not within the SCM, a malignant or atypical infection may be the cause, and a complete blood count and biopsy of the mass should be considered. (See "Congenital muscular torticollis: Clinical features and diagnosis".)

●In the absence of a mass, a careful ophthalmologic and neurologic examination should be performed to exclude the possibility of a brain tumor, other space-occupying lesions of the brain, or visual or vestibular disturbance. At times, the patient does not have true neck pain but is attempting to correct for these disturbances through changes in head position.

●The child with myasthenia gravis generally has ptosis and weakness of extraocular muscles and may develop torticollis. The Miller-Fisher variant of Guillain-Barré typically presents with oculomotor abnormalities that may lead to head tilt and neck stiffness. (See "Clinical manifestations of myasthenia gravis" and "Guillain-Barré syndrome in children: Epidemiology, clinical features, and diagnosis", section on 'Miller Fisher syndrome'.)

●Abrupt onset of neck stiffness with other features of dystonia (eg, oculogyric crisis, cogwheeling) should prompt a trial of intravenous diphenhydramine. Common medications implicated in dystonic reactions in children include atypical neuroleptics (eg, risperidone) or antiemetic medications (eg, metoclopramide). (See "Hyperkinetic movement disorders in children", section on 'Dystonia'.)

●Timing of symptoms (ie, acute or chronic) may be an important factor in determining the appropriate diagnosis. For the well-appearing child with sudden onset of mild torticollis without a history of trauma, fever, or neurologic abnormalities (eg, the child who awakens with mild torticollis after sleeping in a strange position), muscle spasm is the most likely cause. Careful clinical assessment, anti-inflammatory medication, consideration of soft cervical collar, and close follow-up is all that is necessary. (See "Acquired torticollis in children".)

Infants with congenital muscular torticollis may not have SCM masses that are detectable on physical examination. Some children with neck stiffness may have dysmorphic features, suggesting specific skeletal malformation syndromes or cervical subluxation in a child with Down syndrome. (See "Congenital muscular torticollis: Clinical features and diagnosis".)

Osteoid osteoma and other benign tumors of the head and neck may occasionally be detected by plain radiography of the cervical spine, but typically require additional imaging (eg, computed tomography, bone scan, or magnetic resonance imaging).

Finally, as is frequently the case, if no cause can be identified after a complete history, detailed examination and careful radiographic and laboratory evaluation, muscle spasm may be the cause of torticollis.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Torticollis in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Causes – The table summarizes the causes of neck stiffness in children, highlighting the most common and the most life threatening conditions (table 1). (See 'Causes' above.)

●Approach – The diagnostic approach to neck stiffness in children is summarized in the algorithms (algorithm 1A-D). (See 'Approach' above.)

●Evaluation – A careful history and physical examination helps narrow the differential diagnosis of neck stiffness. In children with acute onset of neck stiffness or torticollis, three concerns take priority:

•Trauma – Children with possible cervical spine injury should be immobilized before the clinician proceeds with evaluation. (See 'Cervical spine trauma' above.)

•Fever – Fever and meningismus in an ill-appearing child with stiff neck requires prompt evaluation and management of suspected meningitis. (See 'Meningitis' above.)

•Neurologic findings – Symptoms of vision change (eg, diplopia, blurry vision), ataxia, gait abnormality, paresthesias or other sensory changes in the extremities, weakness, or functional abnormalities of the bowel or bladder raise concern for an intracranial or intraspinal space-occupying lesion. (See 'Central nervous system lesions' above and 'Spinal epidural hematoma' above and 'Epidural abscess' above.)

The laboratory and radiographic evaluation of neck stiffness depends upon the suspected underlying etiology, as summarized above. (See 'Ancillary studies' above.)