Hot Seat #23 Denouement: Persistent Neck Pain

by Priya Gopwani, Children's National
with Molly Stevens, Johns Hopkins, on the Hot Seat

The Case

This is a case of a 3 yo boy who was reportedly "walking like a robot" after a fall from a bike. He was seen multiple times in our emergency room. For a complete case presentation, please click here.

Clinical Pearls

Thank you to Joelle, Dave, and Rasha for your commentary and Molly for your thoughtful Hot Seat contributions. Click here to read them in full.

• "Your exam is really important here. You want to assess: the sternocleidomastoid muscle, eyes, retropharynx, and cervical spine in addition to routine ROM." -Dave
• "I am nervous about sending home a child with a week of concerning symptoms that have not responded to the interventions prescribed and now on the third assessment by a provider (both clinically and by radiology). How many times can we be satisfied by the abnormal radiology findings due to position?" -Joelle
• "As Molly noted, RPA is definitely higher on my differential at this third visit after that CT. You've already committed him to a CT -- would I do another one with contrast to look for an RPA?? Hmmm... would talk to Radiology and use a CBC/CRP to guide me in the direction of infectious etiology." -Joelle
• "...especially with CT scans: If you have a clinical concern, don't trust the prelim resident read. Get the attending to read it before you dispo the child." -Rasha 
• "This is not routine "my neck hurts" and i have a negative CT and i should go home in a collar and take motrin. Do that when the neck is in good alignment and there is tenderness in the neck with negative imaging. And i'd be quite reluctant do it in a 3yo. The kid would rip off the collar in 2 seconds." -Dave

Here's how you answered our questions

1. Given the concern of bony injury in the neck, do you place this child in a Miami J at this time?

Most would put this patient in a Miami J, although a large proportion also wouldn't do anything since he's been protecting it himself and it has been a while since the injury. As noted above, this child may just tear it off.

2. What is your next step?

Most people would move on to a full CT c-spine although several people would also try to admit for an MRI of the c-spine.

You decide to obtain a c-spine CT. There is no fracture. The patient continues to refuse to move his neck.

3. What is your next step now that you have no fracture on c-spine CT but your patient is no better?

Now that the CT is negative, many people are leaning towards SCIWORA while a handful of people are reassured and would send the patient home while others seem more worried and would consult the neurosurgeons.
 
His parents report they have been giving motrin around the clock and he is still in his collar, like you advised. He might be moving his neck a little more, but it is hard to tell in the collar. He has not had any fevers. 

4. You are on the phone with parents. What do you do now, if anything?

MRI is the winner again in this question. One person said that he or she would do nothing over the phone and encourage previously scheduled follow-up.

Hot Seat Response
by Molly Stevens, Johns Hopkins

My first questions for this not uncommon presentation are usually answered by HX and PE. Is there trauma or concerns of infection/inflammation, and any evidence of CNS involvement? Since we see the common things most commonly, I would expect to find knowing only the age and chief complaint that it’s due to either minor trauma (muscle strain or a fx like clavicle) vs common infections (cervical adenitis, and if sicker meningitis or peritonsillar/retropharyngeal cellulitis or abscess). More rarely are the infrequent presentations of those more scary things: c-spine fxs or subluxations, head and neck tumors, bleeds, or bony or intracranial infections/abscesses (congenital and rheumatologic rarities would come up later).

Let’s go through this visit. We have a previously normal child with 6 days of “not improving”, not wanting to move his neck, but “happy and playful” (before and currently) after initially being stiff “like a robot”. He has a hx of trauma “earlier in the day” (trauma we assume to be minor as it was not the primary initiator of the visit).

Initial VS catch my attention for a high heart rate for age, which makes me delay over his temp of 37.9, especially knowing about his ”motrin around the clock”. Is it pain or masked fever? This needs a repeat check, and maybe repeat temp check if it’s getting over 6 hours since the last ibuprofen. That keeps infection on my list with trauma for now.

He is still “happy and playful”. For hx, I would want to confirm that he’s had no fever, nor s/s of illness, particularly is eating/drinking normally without vomiting or drooling, has had no HA, and is doing his normal activities at home (ie has no hx concerning for spinal cord or intracranial ‘badness’ and no hx concerning for an infection). His exam is normal except for being unwilling to move neck and having tenderness on palpation of his c-spine. I want to confirm his normal neuro exam, no other findings of trauma, and that he has no PE evidence of infection (rash, adenopathy, drooling, normal retropharynx, etc).

We have his initial c-spine images X2; notable for being suboptimal at C1C2 (are they seeing something that draws their attention this area?).

We have a CT with next day attending read of “craniocervical malalignment, could be positional…no definitive...rotary subluxation…no fx or dislocation. Upper cervical prevertebral soft tissue thickening”.

At home he still has no fever, no new neuro findings, and is in his collar.

2 things top my differential. First: rotary atlantoaxial subluxation (more common than fractures in this age group, and can happen with relatively minor injury, manifests with torticollis and neck pain (with SCM spasm and fixed head rotation both on the same side), would have a tender C-spine on palpation, is not definitively diagnosed by CT (needs dynamic CT study for definitive dx), and can have prevertebral ST swelling. Fits pretty well.

One of the things I do on my PE when I’m thinking of AA rotary subluxation is to give motrin or diazepam, give it time to work, then examine the patient lying flat. With the head fully supported, I ask if they can “let the chin fall over to this side”, then the other. Movement past midline (I use 45 degrees past) towards each side pretty well rules out jumped C1C2 facets and makes me comfortable with not chasing a rotary subluxation.

Second on the differential is retropharyngeal cellulitis or abscess. This pt has no hx of fevers, but has been on ibuprofen RTC. Not wanting to extend or rotate the neck and the widening of the retropharyngeal ST goes with retropharyngeal cellulitis/abscess, but this child being well-appearing, drinking normally, not drooling, goes against it.

At yesterday’s visit, I may have gotten a CBC and inflammatory markers and done the ibuprofen/valium trick above. These done prior to his CT might have helped me decide if his CT should include a dynamic component after negative for fx (because I was concerned about rotary subluxation) vs with contrast (for a concern for cellulitis/abscess).

The Denouement
by Priya Gopwani, Children's National

The child was brought back to the ER for re-evaluation and labs to help determine if there was any evidence of inflammation/infection. His vitals were stable and his neck and neuro exams were unchanged. His labs showed WBC 14.7 with 46.2% pmns. ESR 111, CRP 8.18. The patient was given IV antibiotics and admitted for ENT consult and possible MRI in the AM (to eval for both abscess and SCIWORA). ENT recommended neck CT w/ IV contrast instead. The CT read was:

“Area of relative hypoattenuation in the prevertebral soft tissues at the level of the C1-C2 articulation with rim of relative increased enhancement consistent with abscess, and associated soft tissue thickening and enhancement, likely phlegmon.”

Given that the abscess is relatively small in size, the patient is currently being treated with IV antibiotics, with plan to pursue drainage only if there is no clinical improvement.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations but is on leave until September. This week's case was guest edited by Cathy Chung, faculty at Fairfax. We welcome your commentary.