What are the differential diagnoses for neck stiffness?

Differential Diagnoses for Neck Stiffness

Neck stiffness requires immediate systematic screening for life-threatening conditions—particularly meningitis, subarachnoid hemorrhage, and spinal infection—before attributing symptoms to benign mechanical causes. 1

Critical Life-Threatening Diagnoses (Immediate Evaluation Required)

Infectious Etiologies

• Bacterial meningitis is the most urgent consideration; absence of all three findings (fever, neck stiffness, altered mental status) effectively excludes bacterial meningitis, but presence of any one warrants immediate lumbar puncture 2
• Vertebral osteomyelitis or discitis presents with constitutional symptoms (fever, night sweats), elevated inflammatory markers (ESR, CRP, WBC), and history of IV drug use or immunosuppression 3, 1
• Epidural abscess should be suspected in patients with IV drug use history, even if currently denied, as this represents a neurosurgical emergency 1

Vascular Emergencies

• Subarachnoid hemorrhage (SAH) can present with isolated neck stiffness in alert patients without focal deficits; neck stiffness evaluated ≤6 hours after symptom onset has 90% positive predictive value but only 69% negative predictive value, meaning absence does NOT rule out SAH early 4
• Carotid or vertebral artery dissection should be considered in patients >50 years with vascular disease risk factors 1

Malignancy

• Metastatic disease to cervical vertebrae presents with intractable pain, constitutional symptoms (unexplained weight loss), and vertebral body tenderness on palpation 1
• Primary spinal tumors cause progressive symptoms refractory to conservative treatment 1

Spinal Cord Pathology

• Cervical myelopathy from spinal cord compression presents with progressive weakness, gait disturbance, bowel/bladder dysfunction, and myelopathic signs on examination 1

Mechanical/Degenerative Causes (After Excluding Red Flags)

Nerve Root Compression

• Cervical radiculopathy from herniated disc or osteophyte compression is the primary mechanical neuropathic cause, affecting 83 per 100,000 persons annually; 75-90% resolve with conservative therapy 5
• Positive Spurling's test is highly specific for nerve root compression 1

Arthritic Conditions

• Facet joint arthropathy causes localized mechanical pain that may be unilateral 1
• Cervical osteoarthritis/spondylosis affects 53.9% of adults aged 18-97, though degenerative changes correlate poorly with symptoms in isolation 5
• Inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis) causes persistent pain with elevated inflammatory markers 1

Disc Pathology

• Intervertebral disc degeneration is extremely common but often asymptomatic; 65% of asymptomatic patients aged 50-59 show significant cervical degeneration on imaging 1

Algorithmic Diagnostic Approach

Step 1: Red Flag Screening (Mandatory for Every Patient)

Screen systematically for the following—presence of ANY red flag mandates urgent MRI cervical spine without contrast: 3, 1

• Constitutional symptoms: fever, unexplained weight loss, night sweats
• Elevated inflammatory markers: ESR, CRP, leukocytosis
• History of malignancy or immunosuppression
• IV drug use (current or past)
• Neurological deficits: progressive weakness, sensory changes, gait disturbance, bowel/bladder dysfunction
• Intractable pain despite appropriate conservative therapy
• Vertebral body tenderness on palpation
• Coagulopathy
• Trauma history

Step 2: If Red Flags Present

• Order MRI cervical spine without contrast immediately to evaluate for infection, malignancy, inflammatory processes, spinal cord compression, or vascular pathology 1
• Do NOT delay imaging or treatment while awaiting specialist consultation 3
• For suspected meningitis: perform lumbar puncture (CT head first only if focal deficits, papilledema, immunocompromised, or altered consciousness); initiate empiric ceftriaxone immediately without waiting for imaging 2

Step 3: If No Red Flags Present (Acute Neck Pain <6 Weeks)

• Defer imaging and pursue conservative management with reassurance, physical therapy, NSAIDs, and activity modification 1
• Most acute neck pain resolves spontaneously, though approximately 50% have residual or recurrent symptoms at 1 year 3, 5
• Plain radiographs are NOT routinely indicated as they rarely change management and show degenerative changes in most asymptomatic adults 1

Step 4: If Symptoms Persist Beyond 6-8 Weeks Without Red Flags

• Consider MRI cervical spine without contrast to evaluate for structural causes requiring intervention 1
• Document specific dermatomal distribution of pain and any sensory/motor deficits to localize affected nerve root level 1

Critical Pitfalls to Avoid

• Do NOT assume mechanical cause without red flag screening—missing spinal infection or SAH can be catastrophic 1, 4
• Do NOT rely on absence of neck stiffness to exclude SAH, especially if evaluated ≤6 hours after symptom onset (only 69% NPV early) 4
• Do NOT order immediate imaging for acute neck pain without red flags—this leads to overdiagnosis of incidental degenerative changes present in 85% of asymptomatic individuals over 30 years 1
• Do NOT interpret degenerative changes on imaging as causative without clinical correlation—spondylotic changes correlate poorly with symptoms 1, 5
• Do NOT delay antibiotics for suspected meningitis while awaiting CT or specialist consultation 2

Special Considerations for Specific Presentations

Neck Stiffness with Normal Mental Status

• In alert patients without focal deficits, neck stiffness may be the ONLY clue for SAH or meningitis 4
• Maintain high index of suspicion and low threshold for lumbar puncture or neuroimaging 2, 4

Elevated CRP with Neck Pain

• Elevated inflammatory markers constitute a red flag requiring immediate MRI to exclude infection or inflammatory arthritis 1, 6
• Minimal response to NSAIDs combined with elevated CRP suggests serious underlying pathology beyond mechanical pain 6