Etiology of child acute stiff neck
From: Spine (Phila Pa 1976). 2009 Aug 15;34(18):1906-9
Acute stiff neck in children is a common syndrome that is usually associated in medical literature with atlantoaxial subluxation. Etiology of this illness is not completely understood by modern researchers. Because of the patient’s head position during acute stiff neck, an analysis of radiograph images is difficult and diagnosis is uncertain. For this article, the authors studied and analyzed the results of 10 patients with acute stiff neck. MRI was used for the analysis.
Acute stiff neck in children is a syndrome of many diseases. A physician who is analyzing the reason of the syndrome needs to take into account a possible tumor in the posterior fossa cranium or another destructive process of tumoral or infectious nature. More often this is a syndrome of Grisel disease and atlantoaxial subluxation. Etiology and pathogenesis of these diseases have not been clarified even after introduction of highly informative scanning methods such as MRI or CT scanning. Certain researchers, using CT scanning analysis, came to a conclusion about absence of an atlantoaxial subluxation but failed to give an alternative explanation of the syndrome. Surprisingly, the authors did not manage to find publications where researches discovered an inflammation in the area of the atlantoaxial joint. We found only one article where authors used MRI scan during the first day of acute stiff neck in a child. Interestingly, the author’s results were equal to theirs.
Our MRI scan analysis corresponds with results of Maigne et al who conducted their research in the same conditions. The authors also detected a secondary blocking in the atlantoaxial joint but did not find any inflammation in this zone. They also discovered a high-intensity zone in the uncovertebral area C3-C4 that was not detected by a recurrent scanning 3 weeks later. The authors explained the syndrome with a collagen fiber break on the right edge of the disc caused by rapid movement. Mercer and Bogduk described splits and fissures in the fibers for children older than 9 years. This process develops with age and spreads to the center of the disc.
The hypothesis by Maigne et al about the collagen fibers break seems doubtful because of the following reasons:
1. Up to 30% of children with this syndrome are under 10 years of age.
2. The intervertebral disc does not have pain innervation.
3. The high intensity zone disappeared in a few days.
4. It does not explain the effectiveness of traction.
The authors propose the following explanation of the syndrome development that thry call uncovertebral wedge. The area of the uncovertebral joint is filled with vascularized tissue. The tissue is limited by the fibrous ring inside, by the ligaments in front and back, and by the discs’ bodies from top and bottom. In the authors opinion, the main reason of the acute stiff neck in children is a rapid or gradual strangulation of the vascularized tissue in the uncovertebral zones caused by head movement or prolonged incurvationed position of a neck during a profound sleep. It causes a wedge of the hydropic tissues that irritates the rear longitudinal ligaments. As a result, the head has an antalgic position and, in the most severe cases, is blocked. This gives the explanation why the extension is effective: it reduces pressure in the uncovertebral zone, improves the venous blood circulation, and therefore solves the problem. Other supporting arguments are as follows:
1. The uncovertebral zone exists only in the neck; therefore, this condition is not possible in other areas of the spine.
2. The pain starts and becomes more severe in the vertical position because in this position the pressure on intervertebral discs is increased.
3. The illness is more frequent during a fall or winter period, during which the venous flow-out decreases from the nasopharynx and nearby tissues because of seasonal diseases.
The data from Maigne et al and the authors MRI scan analysis during the first hours of the disease showed that the uncovertebral zone is involved in the process of acute stiff neck in children. We suggest the explanation of the acute stiff neck syndrome by an edema of the periosteal fascial tissues that irritate the rear longitudinal ligaments, which have a good enervation. In some cases, marked by severe pain and with particular anatomic features of C1-C2 segment, there can be a strong shift in this joint with an atlantoaxial blocking and a kyphotic scoliotic antalgic posture. Uncovertebral wedge seems to be frequent but not the only cause of acute neck pain and deformation in children. These unique results offer new approaches to the preventive and course treatment of the syndrome.
