Management of Suspected Viral Torticollis in a 24-Year-Old Female
For this 24-year-old female with acute neck pain, negative LP, and normal CT imaging, conservative management with NSAIDs, muscle relaxants, and gentle range-of-motion exercises is the appropriate treatment approach, as the workup has already excluded serious pathology and most cases of acute viral torticollis resolve spontaneously within days to weeks. 1
Clinical Context and Diagnosis Confirmation
Your clinical suspicion of viral torticollis is reasonable given the presentation, but the extensive workup already performed (LP and CT head/neck) has effectively ruled out the critical "red flag" conditions that would alter management:
- Meningitis has been excluded by the negative LP, which was the most important differential diagnosis requiring urgent intervention 1
- Structural abnormalities, fractures, and mass lesions have been excluded by the normal CT imaging 2
- No red flags are present based on the information provided - specifically no trauma, malignancy history, immunosuppression, neurological deficits, or constitutional symptoms beyond the acute neck pain 2
The 2-day history places this in the acute phase (<6 weeks duration), where spontaneous resolution is expected in the majority of cases 2.
Conservative Management Protocol
Symptomatic treatment is the cornerstone of management:
- NSAIDs for pain control and anti-inflammatory effect 1
- Muscle relaxants (such as cyclobenzaprine) for muscle spasm relief 1
- Gentle active range-of-motion exercises as tolerated to prevent stiffness - avoid aggressive manipulation in the acute inflammatory phase 1
- Heat application may provide symptomatic relief
- Activity modification - avoid positions that exacerbate pain, but encourage gradual return to normal activities
Expected Clinical Course
- Most cases resolve within 1-2 weeks with conservative management 1
- Nearly 50% of acute neck pain cases may have residual or recurrent symptoms up to 1 year, though this is typically mild 2
- Improvement should be evident within 3-5 days - lack of improvement warrants reassessment
Follow-Up Strategy
Schedule follow-up in 2-4 weeks if symptoms persist 3:
- If pain persists beyond 4-6 weeks despite conservative therapy, consider physical therapy referral 3
- If symptoms worsen or new neurological deficits develop, obtain MRI cervical spine without contrast to evaluate for soft tissue pathology not visible on CT 2
Critical Pitfalls to Avoid
Do not order additional imaging at this point - the patient has already had comprehensive imaging that excluded serious pathology, and further imaging in acute uncomplicated neck pain rarely changes management 2, 3:
- MRI is not indicated in acute neck pain without red flags, as it has high false-positive rates showing degenerative changes in asymptomatic individuals 2
- Radiographs would add no value given the normal CT already obtained 2
Do not pursue invasive diagnostic procedures such as cervical facet blocks or provocative discography - there is no evidence supporting these in acute neck pain 4
Watch for development of red flags that would require urgent re-evaluation 2:
- Fever or constitutional symptoms suggesting infection (though LP was negative)
- Progressive neurological deficits
- Intractable pain despite appropriate therapy
- Vertebral body tenderness on palpation
Special Consideration for Viral Etiology
The viral etiology suggested by your clinical impression aligns with the case literature showing that acute viral torticollis presents with sudden onset neck pain, antalgic posturing, and may be associated with fever, headache, nausea, and malaise 1. The inflammatory process irritates cervical muscles and nerves, causing the characteristic presentation 5. The negative LP confirms this is not bacterial meningitis, and the self-limited nature supports a viral process 1.