This week’s case focuses on a child with decreased neck movement. The initial presentation of decreased neck movement in a 12-month-old male prompted consideration of torticollis, atlantoaxial rotary subluxation (AARS), and deep neck space infections. The distinction between subluxation, which typically presents with a fixed neck position rather than pain-limited range of motion, is helpful to parse through the differential. Imaging discussions emphasized that ultrasound has lower utility in the absence of neck swelling, with CT being the preferred modality. XR may be useful as an initial step, but if unremarkable does not eliminate the need for a CT scan. Learners discussed the pros and cons of sedation for the CT.

Sedation for a CT with contrast is often considered in pediatric patients who cannot remain still for the duration of the scan, which is critical for obtaining high-quality images especially when you have one chance with the IV contrast. The decision to sedate involves balancing the need for diagnostic accuracy with the potential risks of sedation, including respiratory compromise, particularly in cases with suspected airway or neck pathology. Pre-sedation assessment includes evaluating the child’s ability to lie flat without signs of respiratory distress, stridor, or difficulty managing secretions. In cases where an unknown neck lesion is suspected, extra caution is required to avoid airway compromise during sedation.

A CT neck with contrast was performed, revealing multiple aggressive-appearing lytic lesions in the cranial and facial bones, raising suspicion for metastatic neuroblastoma. Further consultation with neuroradiology led to an abdominal ultrasound, which confirmed a heterogeneous right adrenal mass consistent with neuroblastoma, with additional hepatic involvement suggestive of metastasis.

This case highlights the importance of maintaining a broad differential, considering malignancy in atypical presentations, and carefully planning imaging to balance diagnostic yield and patient safety.