Differential Diagnosis of Neck Stiffness

Distinguish between limited range of neck movement and neck

stiffness throughout range of movement.

Limited Neck Range of Movement

1. Chronic cervical spondylitis with osteophytes:

Suggested by:
No fever or associated symptoms
Confirmed by:
Limitation in range of neck movement but no stiffness within free
range of movement.
Normal WBC, no fever, no neurological signs, X-ray appearance
of neck

Neck Stiffness Throughout Range of Movement

1. Bacterial Meningitis

Suggested by:
Gradual headache over days
Photophobia
Vomiting
Fever
High neutrophil count
Petechial rash in meningococcal meningitis

Confirmed by:
Lumbar puncture: Turbid cerebrospinal fluid (CSF). Increased
CSF neutrophil count with decreased glucose. Bacteria on
microscopy. Growth of bacteria on culture of CSF.
2. Viral Meningitis

Suggested by:
Gradual headache over days
Fever
High lymphocyte count
Normal neutrophil count

Confirmed by:
Lumbar puncture: clear CSF. Increased CSF lymphocyte count
with normal glucose. No bacteria on microscopy. No growth of
bacteria on CSF culture.
3. Meningismus due to Viral Infection

Suggested by:
Gradual headache over days
Fever
High lymphocyte count
Normal neutrophil count

Confirmed by:
Lumbar puncture: clear CSF. Normal CSF white cell count. No
bacteria on microscopy. No growth of bacteria on CSF culture
4. Subarachnoid Hemorrhage

Suggested by:
Sudden onset of headache over seconds
Variable degree of consciousness
No fever
Normal white cell count

Confirmed by:
CT or magnetic resonance imaging (MRI) brain scan.
Lumbar puncture: blood-stained CSF that does not clear in
successive bottle collection, or presence of xanthochromia in CSF
(12 hours to 2 weeks after hemorrhage).

5. Acute Cervical Spondylitis

Suggested by:
Gradual neck pain (occasionally a headache) over hours or days
Immobile neck
Usually past history of similar episodes
No fever

Confirmed by:
Above history
6. Posterior fossa tumor
Suggested by:
Headache
Papilledema
Confirmed by:
CT or MRI scan appearances
7. Anxiety with Semi-Voluntary Resistance
Suggested by:
Improvement with reassurance or temporary distraction
Confirmed by:
Resolution after rest and observation