Cervical Spine Injuries

4.1 Cervical Strain/Sprain

Ligamentous Sprain, Neck Strain, Whiplash, Myofascial Neck Pain

Prim Care 2004;31:19; Phy Sportsmed 1997;25:60; Current Diagnosis and Treatment in Family Medicine. McGraw-Hill, New York 2004:297

Cause: Strain is injury to muscle-tendon unit. Sprain is ligamentous or capsular injury.

Epidem: Often due to rapid and excessive range of motion in one or more planes; falls, motor vehicle accidents.

Pathophys:

The anterior longitudinal ligament prevents hyperextension. Injury to this ligament results in a “whiplash.”
The posterior longitudinal ligament prevents hyperflexion.
Additional support is provided by the ligamentum flavum, interspinous ligaments, ligamentum nuchae.
Soft-tissue injury involving these supportive muscles and ligaments of the neck.
Normal ROM:
- Flexion 60°, extension 70°, lateral flexion 45°, rotation 80°.

Sx:

Nonradicular neck and shoulder pain worsened by motion of neck.
Decreased cervical range of motion.

Si: Decreased range of motion in multiple directions. Spasm of local musculature may be present. No neurologic dysfunction or bony tenderness.

Crs: Self-limited. Most symptoms resolve completely within 4-6 wk.

Cmplc: Chronic pain and disability; cervical spine instability; HNP; spondylosis or acquired cervical spinal stenosis with or without myelopathy.

Diff Dx: Cervical spondylosis (see 4.2); cervical fracture; cervical radiculopathy (see 4.3); meningitis; myofascial pain.

X-ray: Basic assessment with a 3-view series (AP, lateral, odontoid); consider lateral flexion/extension views to r/o instability for severe, persistent pain or a severe mechanism (abn include >3.5-mm horizontal displacement with adjacent vertebrae or 11° rotational difference).

Rx:

Rest, anti-inflammatory medications.
Ice massage.
Consider short-term rest neck in a soft collar.
Muscle relaxants may be indicated.
Range-of-motion rehabilitation when tolerated and a strengthening program starting with isometrics then isotonic exercises.
Focus on posture during activity and esp at work and while driving.

Return to Activity: Only when asymptomatic, normal muscle strength, and pain-free full cervical range of motion is present. There should be no neck pain with and without axial compression or Spurling’s.

4.2 Cervical Spondylosis/ Spinal Stenosis

Cervical Spine Degenerative Disc Disease, Cervical Spine Degenerative Joint Disease, Osteoarthritis

Ortho Clin North Am 2002;33:329; Am Fam Phys 2000;62:1064; Clin Sports Med 1990;9:279; Clin Sports Med 1998;17:121

Cause: Ingrowth of bony spurs or herniation of disc material.

Epidem: Cervical spine stenosis increases the risk of permanent neurologic injury. Highest risk of injury in athletes participating in contact and collision sports.

Pathophys:

Spondylosis is degeneration of intervertebral discs and facet joints with subsequent osteophytic encroachment.
Cervical spinal stenosis is developmental narrowing of the AP diameter of the cervical canal or secondary to spondylosis and degenerative disease.
Narrowing (stenosis) of the spinal canal or neural foramen with restriction/ compression of the spinal cord or nerve roots.
Loss of normal cerebral spinal fluid cushion around the cord or deformation of the cord.
These changes can result in nerve root symptoms or cord encroachment.
Cord changes from pressure result in myelopathy, with upper motor neuron symptoms in the lower extremity.

Sx:

Chronic neck pain, stiffness, and crepitus with normal motion.
Reduce cervical ROM.
Radicular upper extremity symptoms.
Myelopathy with upper motor neuron symptoms of spasticity, gait disturbance, hyperreflexia or in advanced cases, bladder symptoms.

Si:

Tenderness to palpation along lateral neck or along the spinous processes.
Limitations of neck motion.
Positive Spurling’s (see 4.3).
Evaluate the motor and sensory function of the upper extremity and DTRs in the LE (see 4.3).

Crs: Usually a progressive process, although it is difficult to predict who will progress.

Cmplc:

May develop quadriparesis due to central cord syndrome (contusion of central portion of spinal cord).
Transient quadriplegia/cervical cord neuropraxia is an acute transient neurologic episode of cervical cord origin. Findings include both arms, legs, all four extremities, or an ipsilateral arm and leg. Sensory changes are present with or without motor findings.
Probability or recurrence depends on spinal canal/vertebral body ratio.

Diff Dx: Burner/stinger (see 4.5), herniated cervical disc (see 4.4), cervical fracture.

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