eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders

Cervical Sprain and Strain: Differential Diagnoses & Workup

Author: Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Coauthor(s): Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Contributor Information and Disclosures

Updated: Jul 15, 2009

Differential Diagnoses

Cervical Radiculopathy
Factitious Disorder
Polymyalgia Rheumatica
Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology

Other Problems to Be Considered

Cervical herniated disk
Cervical myelopathy
Cervical osteoarthritis
Infection or osteomyelitis
Inflammatory rheumatologic disease
Malingering
Psychogenic pain disorder
Referred pain from cardiothoracic structures
Tumor or malignancy of cervical spine
Vascular abnormality of cervical structures

Workup

Laboratory Studies

  • Complete blood count (CBC) with differential, if infection or tumor is a concern
  • An arthritis profile, including a determination of the erythrocyte sedimentation rate (ESR), if inflammatory arthritis or polymyalgia rheumatica is suggested

Imaging Studies

  • Although not pathognomonic for sprain/strain, imaging results are important for excluding other diagnoses and more extensive injuries.
    • Motor vehicle crashes causing fatalities may also result in occult pathoanatomic lesions in the cervical intervertebral disk and zygapophysial joints. Present imaging methods do not depict these subtle lesions; hence, underreporting of pathoanatomic lesions during standard autopsy is probably common.
    • These findings may have clinical relevance in the management of road traffic trauma survivors with potentially similar pathoanatomy.44
  • Radiography is useful in the evaluation of cervical sprain and strain.
    • Only lateral views are needed for the initial screening of stability. Three views are obtained for the basic evaluation: anteroposterior (AP), lateral, and odontoid. Five views, including the 3 basic views plus bilateral oblique views, are used to evaluate the intervertebral foramen.
    • Flexion/extension views may be obtained if instability is suggested. Hypermobility in the lower cervical segments in 12 out of 34 patients with chronic whiplash-associated disorders were identified by a new measurement protocol determining rotational and translational motions of segments C34 and C56.45
    • Order radiographic studies early in any of the following cases: when significant trauma, pain, or dysfunction develops; when a chronic condition develops; or when documentation of the patient's condition is required (in instances when litigation is anticipated).
    • Radiographs of the cervical spine may show straightening or reversal of the normal lordotic curve. This finding is thought to represent spasm, guarding, or splinting of the muscles that stabilize the neck. Although these findings may be seen in as many as 20% of healthy control subjects, the rates are higher in the injured population .
  • Overall, MRI is the best noninvasive and detailed imaging study for evaluating the status of the disks and spinal cord.
    • Order MRI if detailed analysis of spinal structures (eg, spinal cord, disk) is indicated, as in, for example, an evaluation for underlying herniated nucleus pulposus (HNP).
    • A relative number of abnormal findings on cervical spine MRI scans can be found in asymptomatic individuals. According to Matsumoto and colleagues, the most common findings involve disk degeneration, but nearly 10% of patients can have asymptomatic spinal cord compression.46
    • Lateral disk protrusions are rarely found in asymptomatic patients, who usually present with concordant radiculopathy.
    • Extruded disks are not seen in asymptomatic patients. When seen in the cervical spine, they are almost invariably associated with the patient's symptoms.
    • A clearly defined extrusion, when arising from a normally hydrated disk with no osseous ridging and when compressing an appropriate nerve root concordant with the patient's symptoms, can be considered with confidence to be acute or subacute.
    • MRI is indicated in patients with persistent arm pain, neurologic deficits, or clinical signs of nerve root compression.
    • MRI is unable to reliably depict sources of cervical diskogenic pain, because significant annular tears often escape MRI detection.6
  • CT scanning may be performed if detailed bony imaging is indicated, such as when a fracture or instability is a concern. CT scanning may be used as an alternative to MRI in patients with claustrophobia, although disk imaging with CT scanning offers low resolution.
  • CT myelography is an invasive imaging study that may be useful for a detailed analysis if plain CT scanning and MRI do not provide a definitive answer regarding the suspected pathology.
    • The degree of concordance between CT myelography and MRI is only moderately good; discrepancies are noted especially in the differentiation of disk and bony pathology.
    • A disadvantage is that lumbar puncture is required.
  • Bone scanning is indicated if a spinal tumor, infection, or occult fracture is suggested.
  • Videofluoroscopy is a controversial study used to evaluate increased, decreased, or abnormal segmental movement of the cervical spine.
    • In a study by Hino and colleagues, motion patterns were different between normal spines and pathologic spines.47
    • Cineradiography allows the identification of soft-tissue injuries and early subluxations of the cervical spine that may not be identified with static radiography or physical examination.48
  • Diskography is used in the presurgical evaluation, to identify the level on which to operate. Significant tears are often missed with MRI, but diskography can reveal a diskogenic source of cervical pain. Although MRI can identify most of the painful disks, it has relatively high false-negative and false-positive rates. Diskography can direct a surgeon in making critical management decisions.49

Other Tests

  • Electrodiagnostic studies
    • These physiologic studies may show nerve injury (as opposed to imaging studies, which may show only structural injury).
    • These studies should be performed and interpreted by an appropriately trained and board certified electromyographer. The American Association of Neuromuscular and Electrodiagnostic Medicine (formerly the American Association of Electrodiagnostic Medicine) is the certifying board.
  • Electromyography (EMG)
    • Electromyographic studies can be used to determine if radiculopathy is a factor in the patient's symptoms.
    • EMG is usually performed after 1-2 weeks (or longer), when the physiologic changes are first found.
    • In patients with acute radiculopathy, electromyographic findings include increased insertional activity, fibrillation potentials, positive sharp waves, and complex repetitive discharges.
    • Chronic radiculopathy findings are noted after a few months of nerve root involvement; they include polyphasic or broad-duration/large-amplitude motor units, drop out of motor units, decreased recruitment, and an incomplete interference pattern.
    • Findings in the posterior primary division of the nerve root are noted in the cervical paraspinous muscles.
    • The anterior primary division of the nerve root findings is noted in the specific root-innervated muscles of the upper extremity.
    • The accessory spinal nerve innervates the trapezius muscle, which is often a source of chronic neck pain due to spasm. Contribution from the C2-C4 motor roots is minimal and inconsistent. Electromyographic recordings from the trapezius muscle can show dysfunction of the spinal motor nerve root.50
    • When electromyographic findings of radiculopathy are interpreted, the duration of the symptoms should not influence the diagnosis.51
  • Nerve conduction studies
    • In some cases, a nerve conduction study (NCS) may be performed by an appropriately trained and supervised technician.
    • These tests should be interpreted by a board certified electrodiagnostic medicine specialist only with the entire clinical picture in mind.
    • An NCS is indicated if a concomitant peripheral nerve involvement is suspected and needs to be evaluated. The study would be performed, for example, when numbness of the radial aspect of the upper extremity is a symptom or when carpal tunnel syndrome versus C6 radiculopathy needs to be identified.

More on Cervical Sprain and Strain

Overview: Cervical Sprain and Strain
Differential Diagnoses & Workup: Cervical Sprain and Strain
Treatment & Medication: Cervical Sprain and Strain
Follow-up: Cervical Sprain and Strain
Multimedia: Cervical Sprain and Strain
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

C-spine sprain, C-spine strain, acceleration/deceleration injury, acceleration-deceleration injury, cervical myofascial pain, cervical soft-tissue pain syndrome, cervical sprain, cervicobrachial strain, chronic cervical sprain, chronic cervical strain, chronic neck sprain, chronic neck strain, extension-flexion injury, extension/flexion injury, flexion-extension injury, flexion/extension injury, hyperflexion-hyperextension injury, hyperflexion/hyperextension injury, neck/shoulder girdle soft-tissue injury, neck sprain, neck strain, regional soft-tissue pain syndrome, WAD, whiplash-associated disorders, whiplash syndrome

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Contributor Information and Disclosures

Author

Oregon K Hunter Jr, MD, Physiatrist, Southeastern Rehabilitation Medicine, SIMED
Oregon K Hunter Jr, MD is a member of the following medical societies: American Academy of Pain Management, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Legal Medicine, American College of Occupational and Environmental Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Florida Medical Association, Florida Society of Physical Medicine and Rehabilitation, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, National Association of Disability Evaluating Professionals, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael D Freeman, PhD, MPH, DC, Clinical Associate Professor of Epidemiology, Department of Public Health and Preventive Medicine, Oregon Health Sciences University; Adjunct Associate Professor of Forensic Medicine and Epidemiology, Institute of Forensic Medicine, Faculty of Health Sciences at Aarhus University, Denmark
Michael D Freeman, PhD, MPH, DC is a member of the following medical societies: American Academy of Forensic Sciences, American Academy of Pain Management, American College of Epidemiology, Association for the Advancement of Automotive Medicine, North American Spine Society, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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