What are the causes and treatment options for a stiff neck?

Stiff Neck: Causes and Treatment

Immediate Clinical Priority: Rule Out Life-Threatening Causes

The first priority when evaluating a stiff neck is to identify "red flag" symptoms that indicate serious underlying pathology requiring urgent intervention, including meningitis, cervical epidural abscess, metastatic disease, or vascular dissection. 1

Red Flag Symptoms Requiring Urgent Evaluation

• Constitutional symptoms: Fever, unexplained weight loss, night sweats 1, 2
• Neurological deficits: Weakness, sensory changes, gait disturbance, myelopathic signs 1, 2
• Laboratory abnormalities: Elevated ESR, CRP, or WBC count 1, 2
• History factors: Malignancy, immunosuppression, IV drug use 1, 2
• Meningeal signs: Stiff neck combined with headache and altered mental status 3
• Intractable pain: Pain unresponsive to appropriate conservative therapy 2
• Vertebral body tenderness: On palpation, suggesting infection or metastatic disease 2

Common Causes of Stiff Neck

Mechanical/Musculoskeletal (Most Common)

• Mechanical issues represent the majority of nontraumatic neck pain cases 1
• Cervical degenerative disc disease is a common cause 1
• Cervical radiculopathy from nerve root compression (herniated disc or osteophyte) 1, 2
• Facet joint arthropathy causing localized mechanical pain 2
• In children, acute stiff neck may result from strangulation of vascularized tissue in uncovertebral zones at C2-C3 or C3-C4 levels, often triggered by head movement or prolonged neck positioning during sleep 4

Serious Causes Requiring Urgent Intervention

• Infections: Meningitis, cervical epidural abscess, vertebral osteomyelitis/discitis 1, 2
• Neoplastic conditions: Primary or metastatic tumors affecting the cervical spine 1, 2
• Vascular causes: Vertebral artery dissection, carotid artery pathologies 1
• Inflammatory conditions: Cervical arthritis, inflammatory myopathies with elevated inflammatory markers 1, 2
• Grisel syndrome: Nontraumatic atlantoaxial subluxation following ENT infections or surgery in children 5
• Pseudotumor cerebri: Can present as stiff neck and torticollis in prepubertal children 6

Treatment Algorithm

For Acute Neck Pain WITHOUT Red Flags

Conservative management without imaging is the appropriate initial approach for acute neck pain (<6 weeks) in the absence of red flags, as most cases resolve spontaneously. 3, 2, 7

Conservative Management Components:

• Observation period: 6-8 weeks of conservative therapy before considering imaging 2
• Exercise therapy: Appears beneficial for neck pain 8
• Muscle relaxants: Some evidence supports use in acute neck pain associated with muscle spasm 8
• Analgesics and anti-inflammatory medications: For symptom control 5
• Physical therapy referral: If pain persists beyond 2-4 weeks 7
• Cervical collar: May be used in specific cases like Grisel syndrome 5

Follow-up Strategy:

• Reassess in 2-4 weeks if symptoms persist 7
• Consider imaging if symptoms persist beyond 6-8 weeks, progressive neurological deficits develop, or severe pain is unresponsive to treatment 2

For Acute Neck Pain WITH Red Flags

Immediate MRI cervical spine without contrast is the preferred imaging modality when red flags are present, as it is most sensitive for detecting soft tissue abnormalities, inflammatory processes, infection, tumor, or vascular pathology. 1, 2, 7

Urgent Evaluation Steps:

• MRI cervical spine without contrast: First-line imaging for suspected serious pathology 1, 2, 7
• Laboratory testing: ESR, CRP, WBC count if infection or inflammatory process suspected 1, 2
• Lumbar puncture: Following neuroimaging if meningeal signs present (stiff neck with headache) to measure intracranial pressure and evaluate for meningitis 3
• Temporal artery biopsy: If elderly patient with scalp tenderness, jaw claudication, or pain suggesting giant cell arteritis 3
• Immediate treatment initiation: For confirmed infections (antibiotics), inflammatory conditions (corticosteroids if giant cell arteritis), or other identified serious pathology 3, 5

For Chronic Neck Pain (>12 weeks)

• Comprehensive evaluation including imaging and laboratory tests is warranted 2
• Plain radiographs: Useful for initial screening of spondylosis, degenerative disc disease, and malalignment 3
• MRI without contrast: Preferred for evaluating persistent symptoms, though not first-line in absence of red flags 3
• Interventional options: Conflicting evidence for epidural corticosteroid injections for radiculopathy; weak positive evidence for cervical facet joint radiofrequency denervation 8
• Surgery: More effective than nonsurgical therapy in short term for radiculopathy or myelopathy, but not in long term for most patients 8

Critical Pitfalls to Avoid

• Do not order imaging immediately in absence of red flags: This leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 2
• Do not interpret degenerative changes as causative without clinical correlation: Spondylotic changes are present in 85% of asymptomatic individuals over 30 years 2
• MRI findings must be interpreted with clinical context: High rates of abnormal findings occur in asymptomatic individuals 3, 1
• In children with unexplained stiff neck or torticollis, examine optic discs: To exclude pseudotumor cerebri 6
• Do not miss Grisel syndrome in children following ENT procedures: Diagnosis requires focused history and neuroradiological findings 5

Special Populations

Elderly Patients with Vasculopathic Risk Factors

• Without temporal tenderness, jaw claudication, or scalp pain: Evaluation may be limited to blood pressure, serum glucose, and hemoglobin A1c 3
• Follow-up necessary to determine spontaneous resolution: If no improvement, MRI brain with and without contrast may be indicated 3
• With history of scalp tenderness, jaw claudication, or pain: Check ESR and CRP immediately; perform temporal artery biopsy if results suggest giant cell arteritis 3

Pediatric Patients

• Thorough assessment for red flags including trauma, infection signs, and neurological deficits 7
• Conservative management without imaging if no red flags present 7
• Consider MRI if red flags present, with follow-up in 2-4 weeks if symptoms persist 7
• Acute stiff neck in children may resolve spontaneously within days as hydropic tissue resolves 4