Pediatric neck pain spans benign torticollis to limb- and life-threatening pathology (C-spine injury, retropharyngeal abscess, meningitis, atlantoaxial instability). Use mechanism, fever, neuro exam, and age to triage. Children < 8 y have a high fulcrum (C2–C3) and proportionally large heads — different injury patterns than adults.
🚩 Red-flag clues (must not miss)
- •Trauma + midline tenderness, neuro deficit, AMS, distracting injury, or intoxication = immobilize and image (PECARN C-spine)
- •Fever + neck stiffness + ill appearance = meningitis or deep neck space infection — do not delay LP/imaging
- •Drooling, trismus, muffled voice, neck held in extension = retropharyngeal/peritonsillar abscess
- •Down syndrome, Klippel-Feil, JIA, achondroplasia, post-op = consider atlantoaxial instability before manipulation
- •Torticollis that is fixed, painful, post-URI in school-age = atlantoaxial rotatory subluxation (Grisel)
- •Night pain, weight loss, palpable mass, lymphadenopathy = malignancy (lymphoma, leukemia, bone tumor)
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Labs
Imaging
Meds
History
- Mechanism (MVC, fall, diving, sports, birth trauma in neonate)
- Fever, sore throat, recent URI, dental infection, immunization status
- Neuro symptoms — paresthesias, weakness, gait change, bowel/bladder
- Predisposing syndromes (Down, Klippel-Feil, Marfan, JIA, achondroplasia)
- Headache, photophobia, vomiting (meningitis), torticollis duration
Exam
- C-spine: midline tenderness, step-off, ROM (defer if any concern for injury)
- Full neuro — strength, sensation, reflexes, gait; cranial nerves
- Oropharynx — trismus, drooling, asymmetry, uvular deviation, posterior pharyngeal bulge
- Lymph nodes, thyroid, clavicles; skin (rash, petechiae)
- Meningeal signs — Kernig, Brudzinski, nuchal rigidity (insensitive < 18 mo)
Labs
- Febrile / infectious concern: CBC, CRP, ESR, blood cx; LP if meningitis suspected (after CT if focal deficit/AMS)
- Throat cx, rapid strep if pharyngeal source
- Lyme serology in endemic areas with arthralgia
- Trauma: type & screen if surgical; otherwise labs not routinely needed
Imaging
- PECARN low-risk c-spine criteria — clear clinically if ALL absent: AMS, focal neuro, neck pain, torticollis, substantial torso injury, predisposing condition, diving, high-risk MVC
- If imaging needed in trauma: CT c-spine (preferred for ≥ 8 y or high-energy); plain films (AP, lateral, odontoid) acceptable for low-risk < 8 y
- MRI c-spine if neuro deficit, SCIWORA suspected, or ligamentous injury concern
- Soft-tissue lateral neck (inspiration, neck extension) — retropharyngeal width > 7 mm at C2 or > 14 mm at C6 = abnormal; consider CT neck with IV contrast
- CT neck with IV contrast for suspected deep-space abscess (retropharyngeal, parapharyngeal)
- Open-mouth odontoid + flexion/extension views if rotatory subluxation suspected (only if patient cooperative and no acute injury)
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| C-spine fracture / ligamentous injury | Trauma + midline tenderness or neuro deficit | Maintain immobilization, CT c-spine, neurosurgery / ortho spine |
| SCIWORA (spinal cord injury without radiographic abnormality) | Transient or persistent neuro deficit, normal CT/XR (more common < 8 y) | MRI c-spine, neurosurgery, immobilize |
| Atlantoaxial rotatory subluxation (Grisel syndrome) | Fixed 'cock-robin' torticollis post-URI or ENT surgery | Soft collar, NSAIDs, ENT/ortho; dynamic CT if persistent |
| Retropharyngeal abscess | Fever, drooling, neck extension, trismus, age 2–4 y | Lateral neck XR, CT neck with IV contrast, ENT, IV abx (ampicillin-sulbactam or clindamycin) |
| Peritonsillar abscess | Adolescent, trismus, muffled 'hot potato' voice, uvular deviation | Bedside US or CT, ENT drainage, IV abx |
| Meningitis | Fever, photophobia, AMS, nuchal rigidity, petechiae | Empiric abx (ceftriaxone + vancomycin ± ampicillin if < 1 mo), LP, dexamethasone if Hib suspected |
| Cervical lymphadenitis | Tender unilateral node, overlying erythema, fever | PO clinda or cephalexin; US if fluctuant; I&D if abscess |
| Muscular torticollis (congenital or acquired) | Infant: SCM mass; older child: post-sleep, viral, trauma | PT, NSAIDs, soft collar; image if not resolving in 1 wk |
| Discitis / vertebral osteomyelitis | Insidious neck/back pain, refusal to move, low-grade fever, ↑ ESR/CRP | MRI with & without contrast, blood cx, IV abx |
| JIA (cervical involvement) | Morning stiffness, multiple joints, > 6 wk | Rheumatology, ANA, RF, slit-lamp |
| Atlantoaxial instability (Down syndrome, Klippel-Feil, JIA) | Predisposing syndrome + neck pain or new neuro signs | Flexion/extension views or MRI; neurosurgery |
| Bone tumor / leukemia / lymphoma | Night pain, mass, lymphadenopathy, systemic symptoms | XR, MRI, CBC w/ diff, hem/onc |
| Referred pain (otitis, dental, thyroiditis) | Localized source on exam | Treat underlying cause |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg/dose) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g/dose) | |
| Ceftriaxone (meningitis / deep space) | 100 mg/kg IV (max 4 g) for meningitis; 50 mg/kg q12h otherwise | |
| Vancomycin (empiric meningitis cover) | 15 mg/kg IV q6h | |
| Ampicillin-sulbactam (retropharyngeal) | 50 mg/kg IV q6h (ampicillin component) | |
| Clindamycin (PCN allergy / MRSA) | 10 mg/kg IV q6–8h |
Management / next steps
- Trauma → maintain c-spine precautions until cleared clinically (PECARN) or by imaging
- Febrile with neck stiffness → empiric meningitis coverage immediately; do not wait for imaging
- Drooling / extension posture → upright, NPO, prepare airway, ENT
- Atypical or persistent torticollis → image to exclude rotatory subluxation or mass
- Down syndrome / JIA — counsel families about atlantoaxial instability before sports clearance
Pearls
- Children < 8 y injure C1–C3 (high fulcrum); ≥ 8 y injure C5–C7 like adults.
- Pseudosubluxation of C2 on C3 (up to 3 mm) is normal in children — assess Swischuk's line.
- Retropharyngeal soft tissue widening on lateral neck film is invalid if not in true inspiration with neck extended.
- Meningitis in infants may present only as irritability, poor feeding, or bulging fontanelle — no meningismus.