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addition to the neck stiffness are present, appropriate studies should be obtained.
For example, the patient with neck stiffness and headache may have a
subarachnoid hemorrhage for which a head CT scan would be indicated. The
patient with a clavicular fracture may have spasm of the SCM muscle and
torticollis; however, tenderness is noted over the injured clavicle. Radiographs
will confirm the diagnosis. Of note, rotary atlantoaxial subluxation may be
associated with clavicle fracture.
Fever in the setting of neck stiffness suggests the presence of an infectious,
inflammatory, or neoplastic process. Meningitis must be excluded either clinically
or with a lumbar puncture (see Chapter 94 Infectious Disease Emergencies ). On
examination, neck pain and resistance to flexion should be sought, and a lumbar
puncture should be strongly considered. Supporting findings may include
Brudzinski sign (flexion of the neck elicits flexion of the knee and hip) and
Kernig sign (with the hip flexed, pain occurs with extension of the leg). Other
conditions (e.g., subarachnoid hemorrhage) may also present with fever and neck
stiffness, and a lumbar puncture is helpful in evaluating these conditions as well.
After meningitis has been excluded in the febrile patient with neck stiffness,
the examination should focus on the presence or absence of a cervical mass. If a
cervical mass is identified, a history of head or neck infections, contact with cats
suggestive of Bartonella, or constitutional symptoms suggestive of malignancy
should be elicited. If the cervical mass is tender and clinically consistent with
lymph nodes, a trial of antibiotics directed at the most common bacterial
pathogens may be all that is necessary. Tuberculosis screening should be
performed if risk factors are present. If the cervical mass does not respond to an
appropriate trial of antibiotics, cat-scratch disease, atypical mycobacterial
infection, or malignancy may be the cause. Imaging may be useful if the cervical
mass is not consistent with lymphadenitis or is not responding to treatment as
expected.
If no palpable cervical mass is present in the febrile child with neck pain and/or
stiffness, a more in-depth evaluation may be necessary based on the history and
physical examination. Radiographic imaging of the neck may suggest

retropharyngeal abscess in the child with drooling and neck stiffness, and stridor
with more severe disease. Imaging of the cervical spine may detect atlantoaxial
subluxation due to Grisel syndrome in the child with otolaryngologic disease or a
recent otolaryngologic procedure. Additionally, advanced imaging (including CT,
MRI, and nuclear medicine scans) may be useful in detecting other diseases
involving the cervical spine, including vertebral osteomyelitis, discitis, IDC,
spinal epidural abscess, and neck stiffness from collagen vascular disease.