Stiff Neck

Neck stiffness is not a diagnosis; it is a symptom, a form of neck pain.  Up to 50% of people may experience neck pain at some time.  Trauma and overuse are common factors in young adults.  Muscle spasm usually lasts only 1-4 days; torticollis (unilateral neck muscle spasms causing a twisting of the head) should prompt a work up for a serious underlying problem.  Many nonspecific infections may produce an “achy” neck; neck rigidity, however, suggests meningitis and is a medical emergency. 

History

• When did the pain begin?  

• Ask about trauma and occupation (i.e., overhead work).  Be aware that injuries, including whiplash, may not result in pain until 24 hours later.  

• Where else is the pain felt?  Pain on motion of the shoulder suggests the problem is in the shoulder, not the neck.  

• Decreased sensation in the hands indicates nerve compression.   

Physical Exam

Provided there is no acute trauma, put the patient’s neck through passive and then active range of motion.  

• Pain on motion of the neck helps localize the problem.  

• Referred pain is suggested by an absence of tenderness on palpation.  

• Soft tissue infections, osteomyelitis, metastatic disease, tendinitis, and neuritis may manifest as point tenderness.  

• Spasm may be felt on palpating the posterior neck muscles; unilateral spasm produces torticollis.  

• A neurologic exam may be indicated (reflexes, strength, sensation).  

• Increased lower extremity reflexes, or a positive Babinski sign, suggests cord compression.  

• A patient with meningitis is febrile but awake, and has true meningismus (nuchal rigidity); the neck is as stiff as a board.  

• An altered mental status suggests (meningo)encephalitis.

Labs

X-rays are not needed, unless there has been an inadequate response after two weeks of therapy.  A complete set of cervical spine x-rays is indicated if there has been recent trauma or if there is an abnormal neurologic exam.  View C1 through C7 (with oblique and odontoid views) to look for a fracture or metastatic disease.  Note: degenerative changes (DJD) are common, and do not correlate well with symptoms and signs.     

Differential Diagnosis

• Arthritis (DJD)

• Disc disease (DDD)

• Infection (lymphadenitis, meningitis, osteomyelitis, pharyngitis)

• Malignancy

• Neuritis

• Sprain (whiplash, tendinitis)

• Strain (exertion, cold weather)

• Thyroiditis

• Trauma

• Vasculitis

• Pain may be referred from headaches, sinus or TMJ problems, or diaphragmatic irritation.

Plan

• Meds: Analgesics include acetaminophen, aspirin (3-6 g per day), or ibuprofen. 

• Activities: A soft cervical collar only limits motion by 10-25%, but reminds the patient to restrict neck motion.  In the field this may be fashioned out of clothes or towels. Cervical traction is not practical in the field.  Heat may relieve spasms.  Certain activities may relieve spasm or prevent recurrences.  At night, a small pillow should be placed under the nape of the neck (to maintain the normal lordotic curve).  Encourage the patient to keep the chin in (not hyperextend), and to avoid reaching above their chin.  Range of motion exercises performed twice daily, in a hot shower, may rehabilitate the neck.

• Medevac: a patient with suspected meningitis must be medevaced ASAP to the nearest medical facility; give whatever antibiotics you have, in the highest doses possible, ASAP (do not worry about cultures).  Medevac cases of acute neck trauma; stabilize the neck first.  Nerve root signs should be evaluated by a neurologist, a neurosurgeon, or an orthopedic surgeon. 

This section provided by: CDR Wesley Emmons, MC, USNR

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