eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Cervical Strain

Author: Warren Magnus, DO, Staff Physician, Fremont Medical Center, Las Vegas, NV
Coauthor(s): Paul D Moczarski, DO, Attending Physician, Emergency Resources Group and EmCare, Jacksonville, Florida
Contributor Information and Disclosures

Updated: Apr 7, 2009

Introduction

Background

Cervical strain (ICD-9 847.0) is a common injury routinely seen in the ED. Frequently the result of trauma from falls or motor vehicle accidents (MVAs), this condition causes much distress to patients but, with appropriate management, it usually has few long-term sequelae. High-speed injury mechanisms have brought the common term whiplash into use to describe these injuries as well as the more inclusive whiplash-associated disorders (WAD) that has been used in the medical literature.

Pathophysiology

A cervical strain is chiefly the result of a stretch injury to the muscular and ligamentous elements of the cervical spine, although some compressive forces can be involved as well depending on the exact mechanism of injury. Such injury can occur acutely, as in a MVA, or the injury can occur over time; repetitive stress injuries to the cervical spine are common and can be difficult to differentiate from other myofascial syndromes affecting the cervical and upper thoracic region. Additionally, a significant number of injuries to the cervical spine can result from abnormal posture. Such injuries can result from occupational situations that result in odd positioning of the neck to overnight sleep positioning related injuries.

Frequency

United States

Cervical strain is very common with as many as one million cases per year from high-velocity (whiplash type) injuries alone.

International

Throughout the developed and undeveloped world, low-speed trauma to the cervical spine is very common. High-speed trauma is, as with the United States, very high in incidence as well.

Mortality/Morbidity

Mortality is not an issue in this musculoskeletal disease. Morbidity from long-term injury can be significant such as when pain leads to disuse, resulting in loss of function. Significant impediment of occupational functioning exists as a result of cervical spine injuries.

Age

Typically, adults are more commonly affected than children.

• MVA injury mechanisms more commonly affect adults because of differences in safety requirements and in seat fit (ie, child safety seats generally provide better support of the cervical spine than typical automobile seats).
• Occupational cervical spine injuries are common and can afflict not only individuals involved in physical labor but also people in primarily desk or office positions. Modern office conditions and ergonomics can have significant impacts on susceptibility.

Clinical

History

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.

Physical

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.¹ 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.

Causes

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
  • Falls
  • Assault
  • Other trauma
• 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.

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