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Neck stiffness is defined as limited cervical range of motion caused by muscle spasm. This limitation can occur with flexion, extension, rotation, or lateral bending and may or may not be associated with pain. Nuchal rigidity, on the other hand, is pain with limitation through all ranges and is typically caused by significant meningeal irritation in the same manner peritonitis causes abdominal rigidity. Meningismus describes signs of meningeal irritation, typically pain with limited cervical flexion, in the absence of true meningitis.1

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The differential diagnosis is extensive (Table 12–1). Nearly all infectious causes of neck pain and/or stiffness present acutely (≤7 days) and with fever. The most common infectious causes of neck pain and stiffness are cervical lymphadenitis, meningitis, deep neck space infections, and cervical osteomyelitis.

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Table 12–1. Differential Diagnosis of Neck Stiffness and/or Pain 
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It is important to note that up to 20% of children with meningitis have no cervical signs of meningeal irritation.2 Index of suspicion should be high, however, in the febrile, ill-appearing child who also has one or more associated signs or symptoms of meningitis. In the infant, these can be nonspecific and include irritability, inconsolable crying, and lethargy. The older child may complain of headache and photophobia and display altered mental status. Vomiting, seizures, and upper respiratory tract symptoms are also common.3

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The child with a deep neck space infection can also present with fever, stiff neck, and toxic appearance. However, they may also have torticollis, neck mass, drooling, trismus, or stridor along with intraoral findings, such as tonsillitis and uvular deviation. Superficial neck infections, such as adenitis and cellulitis, less commonly cause toxic appearance, stiffness, and drooling. The presence of these should prompt an evaluation for a deep neck space infection.4,5

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Children with cervical osteomyelitis are not toxic appearing and typically present with neck pain and stiffness. Fever may be present. Diskitis ...

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