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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 that peritonitis causes abdominal rigidity. Meningismus describes signs of meningeal irritation, typically pain with limited cervical flexion, in the absence of true meningitis.1


The differential diagnosis is extensive (Table 16-1). 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.

TABLE 16-1Differential Diagnosis of Neck Stiffness and/or Pain

Not all children who have meningitis will present with neck stiffness. 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 and seizures may also occur.2

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, ...

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