Trauma Fracture of the cervical spine Subluxation of the cervical spine Epidural hematoma of the cervical spine Subarachnoid hemorrhage Muscular contusions/spasm of the neck Clavicular fracture Infectious/inflammatory conditions Bacterial meningitis Retropharyngeal abscess Infections of the spine (osteomyelitis, tuberculosis, epidural abscess, discitis) Minor irritation, malposition, and muscle spasm Rotary atlantoaxial subluxation as a result of local inflammation and/or otolaryngologic procedure (Grisel syndrome) Primary or reactive cervical lymphadenitis/lymphadenopathy Intervertebral disc calcification Collagen vascular diseases (juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, and other spondyloarthropathies) Upper lobe pneumonia Acute suppurative thyroiditis Otitis media and mastoiditis Viral myositis Pharyngotonsillitis Upper respiratory tract infection Tumors, vascular lesions of the central nervous system, and other spaceoccupying lesions Brain tumor Spinal cord tumor Subarachnoid hemorrhage (aneurysm rupture) Other tumors of the head and neck (rhabdomyosarcoma, Ewing sarcoma, lymphoma, nasopharyngeal carcinoma, orbital tumor, acoustic neuroma, osteoblastoma, and metastatic tumors) Other space-occupying lesions of the head and neck (Arnold–Chiari malformation) Other space-occupying lesions of the spinal cord (neurenteric cyst, arteriovenous malformation, syringomyelia) Congenital conditions Congenital muscular torticollis Skeletal malformations (Klippel–Feil syndrome, Sprengel deformity, hemiatlas, basilar impression, occipitocervical synostosis) Atlantoaxial instability secondary to congenital conditions (Down syndrome, Marfan syndrome, Klippel–Feil syndrome, os odontoideum, Morquio syndrome) Miscellaneous Ophthalmologic, neurologic, and/or vestibular causes (strabismus, cranial nerve palsy, extraocular muscle palsy, refractive error, migraine headache, myasthenia gravis, Guillain–Barré syndrome, idiopathic intracranial hypertension) Benign paroxysmal torticollis of infancy Sandifer syndrome Spontaneous pneumomediastinum Spasmus nutans Dystonic reaction Psychogenic disorder TABLE 49.2 COMMON CAUSES OF NECK STIFFNESS OR MALPOSITION Trauma Cervical muscular contusion, strain, and spasm Clavicular fracture Traumatic rotary atlantoaxial subluxation Infectious/inflammatory conditions Minor irritation, malposition, and muscle spasm Cervical lymphadenitis Pharyngotonsillitis and other upper respiratory tract infections Viral myositis/myalgias Congenital conditions Congenital muscular torticollis Miscellaneous Dystonic reaction Neck Stiffness Associated With Infectious/Inflammatory Conditions Potentially Life-Threatening Causes Bacterial meningitis has become a very uncommon childhood disease in the United States; however, it is still the most important infectious cause of neck stiffness (see Chapter 94 Infectious Disease Emergencies ) In the era of Haemophilus influenzae type B and conjugated pneumococcal vaccinations, the most common bacterial pathogens causing meningitis after the neonatal period are Streptococcus pneumoniae (including nonvaccine-type strains) and Neisseria meningitidis Children with meningitis typically present with fever and headache with neck stiffness on physical examination These findings may not be apparent in young infants or conditions with less inflammatory response (i.e., meningococcal meningitis) Distinguishing viral from bacterial meningitis in children is assisted by high-quality prediction rules Torticollis has also been reported in patients with bacterial meningitis, although less commonly TABLE 49.3 LIFE-THREATENING CAUSES OF NECK STIFFNESS OR MALPOSITION Trauma Injuries to the cervical spine (fracture, subluxation, epidural hematoma) Subarachnoid hemorrhage Infection Bacterial meningitis Retropharyngeal abscess Infections of the spine (osteomyelitis, epidural abscess, discitis) Tumors, vascular lesions of the central nervous system, and other spaceoccupying lesions Brain tumor Spinal cord tumor Subarachnoid hemorrhage (aneurysm rupture) Other tumors and space-occupying lesions of the head, neck, and spinal cord Congenital conditions Atlantoaxial instability secondary to congenital conditions Retropharyngeal Abscess Several other important infectious processes usually present with neck stiffness and fever Retropharyngeal abscess is an infection occupying the potential space between the posterior pharyngeal wall and the anterior border of the cervical vertebrae Most commonly caused by Staphylococcus aureus, group A streptococcus, and oral anaerobes, these infections typically present with clinical toxicity, drooling, and rarely stridor Neck pain and/or stiffness are the presenting clinical findings in approximately two-thirds of these children Limitation of neck extension and torticollis are common Lateral radiographs of the neck can be helpful in making the diagnosis and will reveal soft tissue swelling anterior to the upper cervical vertebral bodies Lateral neck radiographs may be nondiagnostic due to inadequate neck extension or failure to obtain the image during inspiration When radiographs are nondiagnostic, when a widened prevertebral space is noted, or when clinical suspicion is high, CT imaging with contrast is indicated Infections of the Spine Infectious processes of the spine (e.g., osteomyelitis, epidural abscess, discitis) in children can involve the cervical region, although