Stiff Neck

Chapter 25 Stiff Neck



Nicholas Tsarouhas, MD, Marla J. Friedman, DO



1 What is the pathophysiology of meningismus?


Flexion of the neck stretches the inflamed nerve roots and meninges of the cervical region. The patient’s protective muscle spasm manifests as neck stiffness, or meningismus.



2 Is meningismus usually seen in neonates with meningitis?


Neonates rarely manifest meningismus or nuchal rigidity. The most common symptoms of meningitis in young infants are fever, lethargy, irritability, and poor feeding.


Pong A, Bradley JS: Bacterial meningitis and the newborn infant. Infect Dis Clin North Am 13:711–733, 1999.



3 At what age is meningismus or nuchal rigidity reliable in evaluation of children for meningitis?


While this is controversial, most experts feel that after 18–24 months this finding becomes more useful. It may be a late finding in meningitis in younger infants.



4 What are Kernig’s and Brudzinski’s signs?


These are physical examination maneuvers to evaluate for the presence of meningeal inflammation. Kernig’s sign refers to extension of the patient’s leg causes neck pain and flexion. Brudzinski’s sign involves flexion of the patient’s neck and produces flexion at the knees and hips.



5 What are the indications for lumbar puncture (LP) in a child with stiff neck?


Consider performing an LP to rule out meningitis in any febrile child with a stiff neck and no other obvious source of infection. This is especially important in children who are not well appearing.


Ostenbrink R, Moons KGM, Theunissen, CCW, et al: Signs of meningeal irritation at the emergency department: How often bacterial meningitis? Pediatr Emerg Care 17:161–164, 2001.



6 What are the contraindications to doing an LP?


LP may be dangerous in an unstable, critically ill child. “Curling” the young patient into position for the LP may limit ventilation and lead to respiratory arrest in an already compromised infant. If the child is unstable, draw a blood culture and administer antibiotics. Defer the LP until the child is more stable. Other contraindications to LP include increased intracranial pressure and lumbosacral cutaneous infection.


Cronan K, Wiley J: Lumbar puncture. In Henretig FM, King C (eds): Textbook of Pediatric Emergency Procedures. Baltimore, Williams & Wilkins, 1997, p 542.



7 Describe some possible complications of LP


While complications are rare, they do occur. Examples include hematomas, persistent cerebrospinal fluid (CSF) leaks, radiculopathies, nerve injuries, epidermoid cysts, post-LP headache, and infection. Headaches after LP in children are uncommon because a small needle is used for the procedure and minimal CSF leak occurs. Life-threatening and extremely rare complications include herniation, respiratory arrest, and cardiac arrest.


Cronan K, Wiley J: Lumbar puncture. In Henretig FM, King C (eds): Textbook of Pediatric Emergency Procedures. Baltimore, Williams & Wilkins, 1997, p 542.



8 What other spinal infections may present with a stiff neck?


Osteomyelitis, epidural abscess, and discitis may occur in the cervical region. Focal spine tenderness in the presence of fever should raise suspicion for these infections. Conventional radiography is sometimes helpful, but radionuclide bone scanning or magnetic resonance imaging are more diagnostic.



9 Which serious deep neck infection can present with stiff neck?


Retropharyngeal abscess. Retropharyngeal infections (cellulitis, adenitis, abscess) can develop in the potential space between the anterior border of the cervical vertebrae and the posterior wall of the esophagus. These infections generally occur in infants and toddlers and are rarely seen in children older than 5 years. They are usually caused by group A streptococcus, Staphylococcus aureus, or anaerobes. These ill-appearing children may present with fever, respiratory distress, drooling, difficulty swallowing, stridor, or meningismus. Obtain a lateral neck radiograph to investigate for widening of the upper cervical prevertebral tissues. Computed tomography is confirmatory. Management includes IV antibiotics and, sometimes, surgical drainage.


Harries PG: Retropharyngeal abscess and acute torticollis. J Laryngol Otol 111:1183–1185, 1997.



10 What are the most common causes of torticollis in well-appearing, afebrile children?


Minor irritation, muscle spasm, and awkward sleep malposition are quite common in young children. The onset is usually sudden, often occurring after waking from sleep. These children have no history of fever or trauma, and should have a completely normal neurologic examination. Supportive care and analgesics/anti-inflammatories are usually the only therapies indicated.



11 What are some common causes of stiff neck in well-appearing, febrile children?


Cervical adenitis. A large, tender node can often be visualized and palpated in the examination of a child with a stiff neck. Most are febrile. Group A streptococcus or S. aureus are the most likely organisms responsible, but Bartonella henselae (cat scratch disease), and mycobacterial disease should also be considered. Pharyngitis/tonsillitis and upper respiratory tract infections may also be associated with stiff neck.



KEY POINTS: COMMON INFECTIOUS CAUSES OF STIFF NECK




1 Meningitis: Ill appearance, irritability, lethargy; fever; neck held stiffly or pain with flexion


2 Tonsillitis/pharyngitis: Red, inflamed tonsils, but not always exudative; consider peritonsillar abscess


3 Cervical adenitis: Single, enlarged, tender cervical node; fever common, but not universal


4 Viral myositis/myalgia: Cervical muscles diffusely tender to palpation; other viral symptoms present


5 Upper respiratory tract infection: Similar to viral myositis, with prominent upper respiratory tract symptoms

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Sep 1, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Stiff Neck

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