Cervical Strain Workup
- Author: Warren Magnus, DO; Chief Editor: Trevor John Mills, MD, MPH more...
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) 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.
Computed tomography has been found to be effective in the detection of clinically significant cervical spine injuries in adults with a neurologic deficit or cervical spine pain. In one study, the sensitivity and specificity of CT for detecting cervical spine injury was 90.9% and 100%, respectively. For clinically significant cervical spine injuries, the sensitivity was 100% and specificity was 100%.[3, 4, 5, 6]
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. Although CT with reconstruction is highly sensitive for clinically significant cervical injury, subsequent magnetic resonance imaging can confirm significant ligamentous injury.[5, 6]
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.
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].