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Cervical Sprain and Strain Workup

  • Author: Oregon K Hunter, Jr, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Dec 28, 2015
 

Laboratory Studies

See the list below:

  • 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
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Imaging Studies

See the list below:

  • 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 disc 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.[47]
  • 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 C3-4 and C5-6.[48]
    • 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 lateral cervical spine may show straightening or reversal of the normal lordotic curve (see images below). 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 .
      Radiograph of the lateral cervical spine shows a nRadiograph of the lateral cervical spine shows a normal lordotic curve.
      Radiograph of the lateral cervical spine shows strRadiograph of the lateral cervical spine shows straightening of the lordotic curve.
  • Overall, MRI is the best noninvasive and detailed imaging study for evaluating the status of the discs and spinal cord.
    • Order MRI if detailed analysis of spinal structures (eg, spinal cord, disc) 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 disc degeneration, but nearly 10% of patients can have asymptomatic spinal cord compression.[49]
    • Lateral disc protrusions (see image below) are rarely found in asymptomatic patients, who usually present with concordant radiculopathy.
      MRI of the cervical spine shows disc protrusion. MRI of the cervical spine shows disc protrusion.
    • Extruded discs 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 disc 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 discogenic pain, because significant annular tears often escape MRI detection.[8]
  • 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 disc 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 disc 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.[50]
    • 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.[51]
  • Discography is used in the presurgical evaluation, to identify the level on which to operate. Significant tears are often missed with MRI, but provocative discography can reveal a discogenic source of cervical pain. Although MRI can identify most of the painful discs, it has relatively high false-negative and false-positive rates. Discography can direct a surgeon in making critical management decisions.[52]
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Other Tests

See the list below:

  • 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 approximately 3 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 (myotome) 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.[53]
    • When electromyographic findings of radiculopathy are interpreted, the duration of the symptoms should not influence the diagnosis.[54]
  • 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.
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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 Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners Institute, American College of Legal 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 Examiners, North American Spine Society, American College of Occupational and Environmental Medicine, American Academy of Pain Management, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Coauthor(s)

Michael D Freeman, MedDr, PhD, MPH Associate Professor of Forensic Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Center

Michael D Freeman, MedDr, PhD, MPH 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, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

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

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Radiograph of the lateral cervical spine shows a normal lordotic curve.
Radiograph of the lateral cervical spine shows straightening of the lordotic curve.
MRI of the cervical spine shows disc protrusion.
 
 
 
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