What are the next steps for a 7-year-old (seven years old) who woke up screaming with neck pain but is now playing?

Immediate Medical Evaluation Required

This child requires prompt medical evaluation and diagnostic assessment today, as neck pain following nighttime screaming in a 7-year-old—even with current normal activity—may represent serious cervical spine pathology including vertebral artery dissection, atlanto-axial subluxation, or occult trauma. 1, 2

Critical Red Flags Present

The clinical scenario contains several concerning features that mandate urgent assessment:

• Acute onset with severe pain (screaming suggests significant distress) followed by apparent resolution is a classic presentation for serious cervical pathology that can present 12-24 hours after injury 1
• Age 7 years places this child in the high-risk category for occult neck injuries, particularly if any trampoline use, sports activity, or unrecognized trauma occurred 1, 2
• Current "playing" behavior does not exclude serious pathology, as children may appear deceptively well between episodes or before neurologic deterioration 2, 3

Specific Life-Threatening Conditions to Exclude

Vertebral Artery Dissection

• Presents 12-24 hours after neck hyperextension/rotation injury 1
• Can cause intramural thrombus leading to vessel dissection and intracranial emboli 1
• Results in devastating neurologic complications including stroke 1, 4
• Any neck pain associated with potential trauma (including unrecognized events during sleep) requires prompt evaluation 1

Atlanto-axial Subluxation

• Can occur in previously normal children from minor trauma 1
• May present with torticollis or neck pain 1
• Requires immediate imaging if suspected 1, 2

Occult Cervical Spine Injury

• Children can sustain significant injuries from activities like trampoline use, even without reported trauma 2
• Cervical spine injuries from hyperflexion/hyperextension can be catastrophic 1

Immediate Assessment Required

History Details to Obtain

• Any trampoline use, sports participation, or rough play in the past 24-48 hours 1, 2
• Sleeping position and any possibility of neck hyperextension during sleep 5
• Presence of fever, headache, photophobia, or altered mental status 2
• Pain with forward neck flexion versus lateral rotation 2
• Any neurologic symptoms: weakness, numbness, tingling, gait changes 3

Physical Examination Findings to Document

• Neurologic examination including strength testing in all extremities 3
• Pain with forward flexion (suggests meningeal irritation) versus lateral rotation 2
• Presence of torticollis or abnormal head positioning 1, 5
• Lymphadenopathy 3
• Vital signs, particularly fever 2

Imaging Recommendations

MRI cervical spine without contrast is the preferred imaging modality if any red flags are present or if clinical suspicion remains high 1, 6, 2

• MRI has 100% sensitivity for detecting osseous injury in children and is the reference standard for soft tissue evaluation 1
• MRI can detect vertebral artery dissection, ligamentous injury, epidural pathology, and spinal cord compression 1, 6, 3
• Plain radiographs have only 73-90% sensitivity for cervical spine injury in children and miss soft tissue pathology 1

Management Algorithm

If Red Flags Present (fever, neurologic deficits, severe headache, pain with forward flexion):

• Immediate emergency department evaluation 2, 3
• Do not delay assessment for imaging 2
• MRI cervical spine without contrast 1, 2

If No Obvious Red Flags But History Concerning:

• Same-day evaluation by physician 1
• Detailed neurologic examination 3
• Consider MRI if any abnormalities found or high clinical suspicion 1, 6

If Benign Examination and Low Suspicion:

• Conservative management with NSAIDs (ibuprofen or acetaminophen) 1
• Close observation for development of red flags 2
• Return immediately if: fever develops, neurologic symptoms appear, severe headache with photophobia, pain with forward neck flexion, or inability to control pain 1, 2

Critical Pitfalls to Avoid

• Do not assume all neck pain in children is benign simply because the child appears well or is playing 2, 3
• Do not rely on absence of reported trauma to exclude serious injury, as occult injuries occur during sleep or unrecognized activities 2, 5
• Do not delay evaluation based on current activity level, as serious pathology can have delayed presentation 1, 4
• Do not use plain radiographs alone if serious pathology is suspected, as sensitivity is inadequate 1

Bottom Line

Given the acute onset with severe pain (screaming) in a 7-year-old, this child needs medical evaluation today to exclude vertebral artery dissection, atlanto-axial subluxation, or other serious cervical pathology that can present with delayed or intermittent symptoms. 1, 2 The fact that the child is currently playing does not exclude serious underlying pathology. 2, 3