Cervical Strain Workup

  • Author: Warren Magnus, DO; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 19, 2011
 

Imaging Studies

Radiologic studies are often not indicated acutely in the management of cervical strain. However, given the catastrophic sequelae of cervical spinal cord injury, many emergency physicians have a low threshold for ordering cervical spine radiographs in patients with blunt trauma. However, the literature supports that very few of these patients actually have a cervical spine fracture and the past pattern of use of radiography has not been efficient. While cervical spine radiography is a low-cost procedure, it adds substantially to overall healthcare costs given the high volume of its use, in addition to leading to considerable discomfort for patients immobilized by a backboard and hard collar while awaiting radiography.

Clinical evaluation and history have been proven effective in guiding the need for radiography to further evaluate patients with possible clinically significant cervical spine injury. The National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) were first described in 1992 and state that cervical-spine radiography is indicated for patients with trauma unless they meet all of the following 5 criteria:

  • No posterior midline cervical-spine tenderness
  • No evidence of intoxication
  • A normal level of alertness
  • No focal neurologic deficit
  • No painful distracting injuries

High-speed helical CT technology has made it possible to rapidly perform cervical spine CT with reconstruction and is an efficient and cost-effective method of screening for cervical injury in high-risk trauma patients. For high-risk patients, severe head injury, high-energy injury mechanism of motor vehicle collision, victims of motorcycle collision, and pedestrians struck by automobiles, CT has higher sensitivity than plain films in the detection of fractures, with less chance of a missed fracture leading to severe neurologic injury, such as paralysis. Furthermore, CT is a cost-effective initial screening strategy in patients with high risk of injury, neurologic deficits, or severe head injury when long-term timeframe costs are considered.

MRI is generally more effective in evaluating spinal cord and ligamentous injury. Recent reviews suggest that, in the setting of multiple injury, negative findings on CT scans and lateral plain film still warrant an MRI to eliminate instability. In patients who are obtunded or difficult to examine or in patients with persistent focal neurologic deficits or radicular pain, MRI may be necessary to rule out cord injury. MRI is also indicated in patients if new neurologic symptoms develop after the patient's initial presentation to the emergency department.

Even with a normal static radiologic evaluation, a second assessment must be made in high-risk patients to ensure no ligamentous instability is present and to assess the risk of myelopathy developing from a destabilizing cervical injury. Muscle spasm and limited range of motion secondary to pain after an injury of significant mechanism can hide an anterior subluxation and unstable ligamentous injury. Further radiographic evaluation with dynamic flexion/extension radiography should be arranged on an outpatient basis within 1 week of injury in patients with continued pain or tenderness.

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Contributor Information and Disclosures
Author

Warren Magnus, DO  Staff Physician, Fremont Medical Center, Las Vegas, NV

Warren Magnus, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Paul D Moczarski†, DO  Former Attending Physician, Emergency Resources Group and EmCare, Jacksonville, Florida

Paul D Moczarski†, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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External craniocervical ligaments.
Internal craniocervical ligaments.
Lateral view of the muscles of the neck.
Anterior view of the muscles of the neck.
Radiograph of the cervical spine shows a normal lordotic curve.
Radiograph of the cervical spine shows straightening of the lordotic curve.
 
 
 
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