What are the causes of a stiff neck?

Causes of Stiff Neck

The primary causes of a stiff neck include mechanical pain from the spine and supporting structures, followed by serious conditions such as tumor, infection, inflammation, autoimmune disorders, and vascular causes. 1

Common Causes

• Mechanical/Musculoskeletal Issues - Represent the majority of nontraumatic cervical or neck pain cases 1

  • Muscle strain or spasm
  • Cervical degenerative disc disease (DDD) 2
  • Poor posture leading to cervical proprioception impairment 3
  • Cervical radiculopathy (nerve root compression) 4

• Inflammatory Conditions - Often associated with elevated inflammatory markers 2

  • Cervical arthritis
  • Inflammatory myopathies
  • Systemic inflammatory conditions affecting the neck 2

Serious Causes (Red Flags)

• Infections 1

  • Meningitis - characterized by significant neck stiffness that worsens with neck flexion 5, 6
  • Cervical epidural abscess
  • Soft tissue infections of the neck

• Neoplastic Conditions 1

  • Primary or metastatic tumors affecting cervical spine 7
  • Extradural cervical tumors may present with stiff neck as the only initial symptom 7

• Vascular Causes 1

  • Vertebral artery dissection
  • Carotid artery pathologies

• Neurological Disorders 8

  • Pseudotumor cerebri - can present with stiff neck and torticollis, especially in children 8
  • Subarachnoid hemorrhage 6
  • Posterior fossa tumors 8

Red Flag Symptoms Requiring Urgent Evaluation

• Constitutional Symptoms 1

  • Fever
  • Unexplained weight loss

• Laboratory Abnormalities 1, 2

  • Elevated inflammatory markers (WBC, ESR, CRP)
  • Abnormal laboratory values suggesting infection or inflammation

• Neurological Signs 1

  • Spinal cord injury or deficit
  • Radicular symptoms with progressive neurological deficits 4

• Risk Factors 1

  • History of malignancy
  • Immunosuppression
  • Intravenous drug use
  • Recent trauma
  • Coagulopathy

Diagnostic Approach

• Clinical Assessment for Red Flags 1, 2

  • Presence of any red flags warrants immediate further investigation
  • Absence of fever, neck stiffness, and altered mental status together makes bacterial meningitis unlikely 6

• Imaging Considerations 1, 2

  • No imaging recommended for acute neck pain (<6 weeks) without red flags 1
  • MRI without contrast is preferred when red flags are present 2
  • CT may be useful for assessing osseous structures when MRI is contraindicated 4

Clinical Pearls

• Neck pain is one of the top 5 leading causes of global years lost to disability 1
• Nearly 50% of individuals with neck pain experience recurrent or persistent symptoms 1
• Cervical proprioception impairment is a key factor in many cases of chronic neck pain 3
• MRI findings should always be interpreted in combination with clinical findings due to high rates of abnormal findings in asymptomatic individuals 4
• In children with unexplained stiff neck or torticollis, examination of optic discs is important to exclude pseudotumor cerebri 8