Initial Evaluation and Management of Unilateral Neck Stiffness in Children Upon Awakening
A child who wakes up with unilateral neck stiffness most likely has benign acute torticollis from sleeping in an awkward position, but you must systematically exclude serious pathology including vertebral artery dissection, atlanto-axial subluxation, epidural abscess, and malignancy before attributing symptoms to a benign cause. 1
Immediate Red Flag Assessment
Perform a focused evaluation looking specifically for these critical red flags that mandate emergency imaging:
- Fever - suggests infection (epidural abscess, discitis, osteomyelitis, retropharyngeal abscess) 2, 3, 4
- Neurologic deficits - motor weakness, sensory changes, asymmetric reflexes, or gait abnormalities indicate nerve root or spinal cord compromise 2, 1, 3, 5
- Severe headache with photophobia - raises concern for meningitis or intracranial pathology 1
- Pain with forward neck flexion - suggests meningeal irritation rather than benign torticollis 1
- History of recent trauma - even minor or unrecognized trauma from trampolines, sports, or rough play can cause vertebral artery dissection or atlanto-axial subluxation 1
- Constant or night pain lasting >4 weeks - concerning for malignancy 2, 3
- Unintentional weight loss or lymphadenopathy - suggests malignancy 2, 3, 5
- Tachycardia - may indicate systemic infection or inflammatory process 2, 3
Critical Pitfall: Vertebral Artery Dissection
Do not assume absence of reported trauma excludes serious injury. Vertebral artery dissection can occur 12-24 hours after neck hyperextension/rotation injury during sleep and may present with only torticollis or neck pain initially, but can progress to devastating stroke from intramural thrombus and intracranial emboli. 1 Children aged ≥7 years are at particularly high risk for occult neck injuries from activities like trampoline use or sports. 1
Imaging Algorithm
If ANY Red Flags Are Present:
Obtain MRI cervical spine without contrast immediately. 1 This is the definitive imaging modality with:
- 100% sensitivity for detecting osseous injury in children 2, 1
- Superior detection of vertebral artery dissection, ligamentous injury, epidural pathology, spinal cord compression, and soft tissue abnormalities 2, 1
- Direct visualization of spinal cord, ligaments, and intervertebral discs that plain radiographs cannot provide 2
Do not obtain plain radiographs if serious pathology is suspected - they have only 73-90% sensitivity for cervical spine injury in children and completely miss soft tissue pathology, vertebral artery dissection, and epidural processes. 2, 1
If No Red Flags But History Is Concerning:
Arrange same-day physician evaluation with detailed neurologic examination. 1 Consider MRI if any abnormalities are found or clinical suspicion remains high despite normal examination. 1
If Benign Examination and Low Suspicion:
Conservative management is appropriate:
- Analgesia: Acetaminophen and/or NSAIDs if no contraindications 1
- Activity modification: Avoid extreme neck movements 4
- Close observation: Most benign torticollis resolves within 2 weeks 4
Specific Clinical Context: "Wry Neck" or Acute Torticollis
The most common benign cause in children who wake with unilateral neck stiffness is acute torticollis from sleeping in a prolonged incurved position, which causes strangulation of vascularized tissue in the uncovertebral zones at C2-C3 or C3-C4, leading to tissue edema that irritates the posterior longitudinal ligament. 6 This typically presents as:
- Triangle or oblong high-intensity zone on MRI near external edges of C2-C3 or C3-C4 discs 6
- Always on the side where pain is felt 6
- Resolves within days 6
However, you cannot make this diagnosis clinically without excluding serious pathology first. 1
Return Precautions - Instruct Immediate Return If:
- Fever develops 1
- Neurologic symptoms appear (weakness, numbness, gait changes) 1, 5
- Severe headache with photophobia develops 1
- Pain with forward neck flexion occurs 1
- Symptoms worsen or fail to improve within 7-14 days 4
Common Pitfalls to Avoid
Do not rely on current activity level to exclude serious pathology - children with vertebral artery dissection or atlanto-axial subluxation may appear active initially before deterioration. 1
Do not assume all pediatric neck stiffness is benign - while trauma and infection are most common causes in emergency settings (81% combined), malignancy and vascular injury can present identically. 4
Do not delay evaluation based on absence of reported trauma - occult injuries occur frequently, especially in children ≥7 years. 1
Do not use plain radiographs alone if any concern exists - their inadequate sensitivity misses the majority of serious soft tissue and vascular pathology. 2, 1