Cervical Strain Clinical Presentation
- Author: Warren Magnus, DO; Chief Editor: Trevor John Mills, MD, MPH more...
The most important issues surrounding cervical spine injury involve accurate diagnosis. Emergency departments in the United States and Canada annually treat more than 13 million patients with trauma who are at risk for cervical spine injury. Although most of these cases represent soft tissue injury, the paramount concern for the emergency medicine physician is to identify the patients with fractures, dislocations, or spinal cord injury.
Ascertainment of the mechanism of injury is essential. This postinjury analysis can give significant clues to the relative risk of strain versus a more serious cervical spine injury. The greater the amount of force experienced by the cervical spine, the greater the risk of destabilizing injury and the need to rapidly eliminate more severe diagnoses.
Pain is the most common complaint reported in cervical spine injuries. Severity of discomfort with cervical strains is typically low, although some patients may report significant pain, particularly with motor vehicle injury mechanisms.
Soft tissue swelling is a highly variable finding but can cause significant distress to patients presenting with cervical spine strain injuries. Self-reported tenderness may be noted on the patient’s history. Following a cervical strain injury, patients may report varying degrees of muscle spasms.
Reported range of motion of the cervical spine is important to diagnosis because patients who are able to voluntarily move their cervical spine can help the examining physician to clinically eliminate certain more significant cervical spine injuries and conditions. All posttrauma patients with cervical pain should be "clinically cleared" using National Emergency X-Radiography Utilization Study (NEXUS) or the Canadian C-Spine Rule as decision rules to guide the use of cervical spine radiography to rule out cervical fractures, dislocations, or spinal cord injury.
Radicular pain patterns can occur in cervical spine injuries of all types and do not necessarily eliminate strain injuries from the differential.
The following physical examination is focused on the evaluation of patients in whom a fracture, dislocation, or ligamentous instability has been eliminated by examination or diagnostic imaging.
Edema of cervical tissues, although not to the point of pitting, is a common finding in patients with cervical strain. The most common presentation is a palpable bogginess of the cervical posterior musculature.
Tissue texture changes beyond edema are also commonly present (eg, ropiness, tightness, increased muscle tension).
Mild warmth over the involved tissues is not uncommon and is the result of inflammation of the involved tissues.
Limited range of motion of the involved area is often the result of muscle spasm and is not necessarily reflective of the severity of the injury. However, all patients with a significant reduction of range of motion should be considered for cervical spine radiographs.
Where radicular symptoms are present, the Spurling Maneuver (compression of the cervical spine by downward pressure) can be useful. Reproduction of the radicular symptom with compression suggests encroachment on the nerve by arthritic change or disk herniation rather than a muscular or ligamentous strain.
In 1995, the Quebec Task Force on Whiplash-Associated Disorders, as part of their consensus document, proposed the following grading system. This system has become more widely referenced in recent years as literature reviews have begun to examine the effectiveness of various therapeutic modalities for treatment of whiplash-associated disorders (ie, cervical strain).
Grade I - Complaint of neck stiffness only with no associated findings
Grade II - Complaint of neck pain with physical findings such as palpable tenderness or reduced range of motion
Grade III - Complaint of neck pain with physical findings and objective neurologic findings such as reduced muscle strength or deep tendon reflexes
Grade IV - Adds radiologic changes such as fracture or dislocation and no longer falls within the realm of cervical strain
With certainty, the majority of cervical strain injuries fall within Quebec Task Force grades I and II.
The causes of cervical strain injuries can be divided into general categories based on injury speed.
Rapid injury can occur due to traumatic mechanisms that result in rapid whipping of the head on the neck, hence the common term "whiplash," such as the following:
Motor vehicle accidents
Low-velocity injuries can be more elusive in their precise mechanism and can vary from acute to chronic in their presentation. Strained cervical postures (eg, painting overhead, sitting in the front row at the movies) are common. Chronic strains (eg, using the neck to hold the telephone, other malposition syndromes) and repetitive motion injuries are often easier for the patient to pinpoint.
Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine. 1995 Apr 15. 20(8 Suppl):1S-73S. [Medline].
Conforti M, Fachinetti GP. High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1° and 2° grade of the Quebec Task Force classification) involving muscles and ligaments. Muscles Ligaments Tendons J. 2013 Apr. 3(2):106-11. [Medline]. [Full Text].
Blackmore CC, Mann FA, Wilson AJ. Helical CT in the primary trauma evaluation of the cervical spine: an evidence-based approach. Skeletal Radiol. 2000 Nov. 29(11):632-9. [Medline].
Grogan EL, Morris JA Jr, Dittus RS, et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg. 2005 Feb. 200(2):160-5. [Medline].
Resnick S, Inaba K, Karamanos E, Pham M, Byerly S, Talving P, et al. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study. JAMA Surg. 2014 Sep. 149 (9):934-9. [Medline].
Grunau BE, Dibski D, Hall J. The daunting task of "clearing" the cervical spine. CJEM. 2012 May. 14 (3):187-92. [Medline].
Khwaja SM, Minnerop M, Singer AJ. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: a randomized controlled trial. CJEM. 2010 Jan. 12(1):39-44. [Medline].
Frohna WJ. Emergency department evaluation and treatment of the neck and cervical spine injuries. Emerg Med Clin North Am. 1999 Nov. 17(4):739-91, v. [Medline].
Wiangkham T, Duda J, Haque S, Madi M, Rushton A. The Effectiveness of Conservative Management for Acute Whiplash Associated Disorder (WAD) II: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. PLoS One. 2015. 10 (7):e0133415. [Medline].
Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute treatment of whiplash neck sprain injuries. A randomized trial of treatment during the first 14 days after a car accident. Spine. 1998 Jan 1. 23(1):25-31. [Medline].
Kongsted A, Qerama E, Kasch H, et al. Neck collar, "act-as-usual" or active mobilization for whiplash injury? A randomized parallel-group trial. Spine. 2007 Mar 15. 32(6):618-26. [Medline].
Pape E, Hagen KB, Brox JI, Natvig B, Schirmer H. Early multidisciplinary evaluation and advice was ineffective for whiplash-associated disorders. Eur J Pain. 2009 Jan 30. [Medline].
Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, et al. Massage for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD004871. [Medline].
Brose SW, Jennings DC, Kwok J, Stuart CL, O'Connell SM, Pauli HA, et al. Sham manual medicine protocol for cervical strain-counterstrain research. PM R. 2013 May. 5(5):400-7. [Medline].
Klein R, Bareis A, Schneider A, Linde K. Strain-counterstrain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomized trial. Complement Ther Med. 2013 Feb. 21(1):1-7. [Medline].
Myrtveit SM, Skogen JC, Petrie KJ, Wilhelmsen I, Wenzel HG, Sivertsen B. Factors Related to Non-recovery from Whiplash. The Nord-Trøndelag Health Study (HUNT). Int J Behav Med. 2013 Sep 19. [Medline].
Nieto R, Miró J, Huguet A. Pain-Related Fear of Movement and Catastrophizing in Whiplash-Associated Disorders. Rehabil Psychol. 2013 Sep 16. [Medline].
Beazell JR, Magrum EM. Rehabilitation of head and neck injuries in the athlete. Clin Sports Med. 2003 Jul. 22(3):523-57. [Medline].
Bourbeau R, Desjardins D, Maag U, Laberge-Nadeau C. Neck injuries among belted and unbelted occupants of the front seat of cars. J Trauma. 1993 Nov. 35(5):794-9. [Medline].
Bylund PO, Bjornstig U. Sick leave and disability pension among passenger car occupants injured in urban traffic. Spine. 1998 May 1. 23(9):1023-8. [Medline].
Calliet R. Neck and Arm Pain. 2nd ed. FA Davis Co; 1981.
Daffner RH. Controversies in cervical spine imaging in trauma patients. Emerg Radiol. 2004 Aug. 11(1):2-8. [Medline].
Davis CG. Injury threshold: whiplash-associated disorders. J Manipulative Physiol Ther. 2000 Jul-Aug. 23(6):420-7. [Medline].
Dickinson G, Stiell IG, Schull M, et al. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med. 2004 Apr. 43(4):507-14. [Medline].
Dreyer SJ, Boden SD. Laboratory evaluation in neck pain. Phys Med Rehabil Clin N Am. 2003 Aug. 14(3):589-604. [Medline].
Galasko CSB, Murray P, Stephenson W. Incidence of whiplash-associated disorder. BCMJ. Jun 2002. 44(5):237-240. [Full Text].
Griffiths HJ, Olson PN, Everson LI, Winemiller M. Hyperextension strain or "whiplash" injuries to the cervical spine. Skeletal Radiol. 1995 May. 24(4):263-6. [Medline].
Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992 Dec. 21(12):1454-60. [Medline].
Kappler RE. Cervical Spine. Ward RC, et al, eds. Foundations for Osteopathic Medicine. Lippincott, Williams & Wilkins; 1997. 541-546.
Ladig D, DeBell LS, Hubert MK. Mosby's Complete Drug Reference 1997. Physicians GenRx. Mosby-Year Book, Inc; 1997.
Martinez JA, Timberlake GA, Jones JC, et al. Factors affecting the cervical prevertebral space in the trauma patient. Am J Emerg Med. 1988 May. 6(3):268-72. [Medline].
McMorland G, Suter E. Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis. J Manipulative Physiol Ther. 2000 Jun. 23(5):307-11. [Medline].
McSwain NE, Martinez JA, Timberlake GA. Cervical Spine Trauma: Evaluation and Acute Management. 1989.
Patel RV, DeLong W Jr, Vresilovic EJ. Evaluation and treatment of spinal injuries in the patient with polytrauma. Clin Orthop Relat Res. 2004 May. 43-54. [Medline].
Richards PJ. Cervical spine clearance: a review. Injury. 2005 Feb. 36(2):248-69; discussion 270. [Medline].
Shaffer MA, Doris PE. Limitation of the cross table lateral view in detecting cervical spine injuries: a retrospective analysis. Ann Emerg Med. 1981 Oct. 10(10):508-13. [Medline].
Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25. 349(26):2510-8. [Medline].
Sturzenegger M, DiStefano G, Radanov BP, Schnidrig A. Presenting symptoms and signs after whiplash injury: the influence of accident mechanisms. Neurology. 1994 Apr. 44(4):688-93. [Medline].
Van Goethem JW, Maes M, Ozsarlak O, van den Hauwe L, Parizel PM. Imaging in spinal trauma. Eur Radiol. 2005 Mar. 15(3):582-90. [Medline].
Wang JC, Hatch JD, Sandhu HS, Delamarter RB. Cervical flexion and extension radiographs in acutely injured patients. Clin Orthop Relat Res. 1999 Aug. 111-6. [Medline].
Zmurko MG, Tannoury TY, Tannoury CA, Anderson DG. Cervical sprains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clin Sports Med. 2003 Jul. 22(3):513-21. [Medline].