Evaluation and Management of Neck Stiffness in an 11-Year-Old Male
This presentation is most consistent with benign torticollis or atlantoaxial rotatory subluxation, and imaging is not immediately indicated given the absence of trauma, fever, and pain with forward flexion—clinical observation with symptomatic management is appropriate as first-line management.
Key Clinical Features That Guide Management
The absence of specific red flags in this case is critical for risk stratification:
- No fever: This significantly reduces concern for infectious causes like meningitis or epidural abscess 1
- No pain with forward flexion: This is particularly reassuring, as meningeal irritation typically causes pain with neck flexion rather than lateral rotation 1, 2
- No trauma history: Eliminates the need for trauma-based imaging protocols 1
- Lateral neck stiffness pattern: Suggests mechanical rather than inflammatory etiology 3
Most Likely Diagnosis
Atlantoaxial Rotatory Subluxation or Acute Torticollis
In pediatric patients aged 5-14 years presenting with acute neck stiffness without trauma, MRI studies demonstrate characteristic findings of tissue strangulation in the uncovertebral zones at C2-C3 or C3-C4 levels 3. This occurs from:
- Rapid head movements or prolonged neck positioning during sleep 3
- Vascular tissue entrapment causing edema and irritation of the posterior longitudinal ligament 3
- Results in antalgic head positioning and, in severe cases, rotational blocking 3
These MRI findings (triangle or oblong high-intensity zones near disc edges) typically resolve within days 3.
Initial Management Approach
Conservative Management (First-Line)
Immediate imaging is NOT indicated given the benign clinical presentation 1. Instead:
- Analgesia: Acetaminophen and/or NSAIDs if no contraindications 1
- Observation period: 24-48 hours for spontaneous resolution 3
- Activity modification: Avoid extreme neck movements
- Reassurance: Most cases resolve spontaneously within days 3
Red Flags Requiring Urgent Evaluation
Immediate hospital referral and imaging are mandatory if any of the following develop 1:
- Fever (suggests meningitis, epidural abscess, or discitis) 1, 2
- Altered mental status 1
- Severe headache with photophobia 1
- Pain with forward neck flexion (meningeal sign) 1, 2
- Neurological deficits (weakness, numbness, bowel/bladder dysfunction) 1
- Progressive worsening despite conservative care 1
When to Consider Imaging
Indications for Advanced Imaging
MRI cervical spine without contrast is the preferred modality if imaging becomes necessary 1:
- Symptoms persisting beyond 7-10 days without improvement 1
- Development of neurological symptoms 1
- Concern for atlantoaxial instability (torticollis with severe pain) 1
- Need to exclude soft tissue pathology 1
Plain radiographs have limited utility but may be considered if:
- Evaluating for congenital abnormalities in recurrent cases 1
- Assessing for osseous pathology if MRI unavailable 1
CT is NOT recommended as first-line imaging for non-traumatic neck stiffness in children 1
Specific Considerations for This Age Group
Trampoline and Sports-Related Injuries
Even without reported trauma, occult neck injuries can occur from trampoline use or sports activities 1:
- Cervical hyperflexion/hyperextension injuries may present with delayed neck stiffness 1
- Atlantoaxial subluxation has been reported in previously normal children after trampoline use 1
- Any neck pain or torticollis after trampoline activity warrants prompt medical evaluation 1
Text Neck Syndrome
In adolescents with chronic smartphone use, consider:
- Cervical kyphosis and muscle hypertonicity from prolonged forward head posture 4
- However, this typically presents with chronic rather than acute onset 4
Critical Pitfalls to Avoid
Do not assume all neck stiffness is benign: While most cases in children are self-limited, serious pathology must be excluded through careful history and examination 1
Do not rely on Kernig's or Brudzinski's signs: These have poor sensitivity for meningitis and should not be used to rule out serious infection 1
Do not delay antibiotics if meningitis is suspected: If fever, altered mental status, or meningeal signs develop, administer empiric antibiotics immediately—even before imaging or lumbar puncture 1, 5
Do not miss vertebral artery dissection: Though rare, this can present 12-24 hours after neck injury with initially mild symptoms 1
Do not overlook the timing of symptom onset: Neck stiffness developing >24 hours after any vaccination requires full evaluation and should not be attributed to the vaccine 5