Abstract
Cervical sprain or strain, also known as whiplash injury, is most common in traumatic injury, specifically in motor vehicle collision. The purpose of this review is to define cervical sprain or strain, provide criteria of diagnosis (including primary findings during physical examinations and neurologic findings), and discuss possible evidence-based treatment and rehabilitation of the injury.
Keywords
Cervical myalgia, cervical sprain, cervical strain, neck sprain, neck strain, whiplash injury
| Synonyms | |
| |
| ICD-10 Codes | |
| M54.2 | Cervicalgia |
| M60.9 | Myositis, unspecified |
| M79.1 | Myalgia |
| S13.4 | Whiplash injury (cervical spine) |
| S13.9 | Neck sprain, unspecified parts of the neck |
| S16.1 | Neck strain |
| S23.3 | Thoracic sprain |
| S39.012 | Back strain |
Definition
Cervical sprain or strain typically refers to acute pain arising from injured soft tissues of the neck, including muscles, tendons, and ligaments. The most common event leading to such injuries is motor vehicle collision. The mechanism of injury is complex. During a rear-end motor vehicle collision, the initial head and neck acceleration lags behind vehicular acceleration. Eventually, head and neck acceleration reaches up to 2½ times the maximum car acceleration, which subsequently results in dramatic deceleration at end range of motion of the neck. Although such injury can also result in fracture, disc, or neurologic injury, cervical strain or sprain, by definition, excludes these entities.
Although these other entities need to be excluded from the differential diagnosis, recent evidence implicates the zygapophyseal joints as a source of neck pain after whiplash injury. Specifically, in a randomized controlled trial in which the medial branches of the cervical dorsal rami were blocked with local anesthetics or treated with saline, it was shown that 60% of patients with whiplash injury had complete neck pain relief after injection of local anesthetic compared with no relief by injection of placebo.
Many factors have been associated with worse outcome in acceleration-deceleration injuries involving motor vehicles. Older women tend to have a worse prognosis than that of younger women and men in general. In addition, poor education and a history of prior neck pain are prognostic factors for worse pain in women. Low family income, a history of prior neck pain, and lack of awareness of head position in the crash are associated with a poor prognosis in men. Additional crash-related factors associated with a worse outcome include occupancy in a truck, being a passenger, colliding with a moving object, and getting hit head-on or perpendicularly. A high intensity of neck pain, a decreased onset of latency of the initial pain, and radicular symptoms are also prognostic of worse outcomes. Because many of these injuries result in initiation of litigation by patients, this too is a poor prognostic indicator.
Other causes include sleeping in awkward positions, lifting or pulling heavy objects, and repetitive motions involving the head and neck.
Estimates exist that 1 million whiplash injuries each year are due to motor vehicle collisions.
Symptoms
The most common presentation of patients with cervical strain or sprain is nonradiating neck pain ( Fig. 6.1 ). Patients will also complain of neck stiffness, fatigue, and worsening of symptoms with cervical range of motion. The pain often extends into the trapezius region or interscapular region. Headache, probably the most common associated symptom, originates in the occiput region and radiates frontally. Increased irritability and sleep disturbances are common. Paresthesias, radiating arm pain, dysphagia, visual symptoms, auditory symptoms, and dizziness may be reported. Although an isolated cervical sprain or strain injury should be without these symptoms, there is the possibility of concomitant neurologic or bone injury. If these symptoms are present, alternative diagnoses should be suspected. Myelopathic symptoms, which suggest a different diagnosis that is more serious, such as bowel and bladder dysfunction, must be investigated.
Physical Examination
The primary finding in a cervical sprain or strain injury is decreased or painful cervical range of motion. This may be accompanied by tenderness of the cervical paraspinal, trapezius, occiput, or anterior cervical (i.e., sternocleidomastoid) muscles ( Fig. 6.2 ).
A thorough neurologic examination should be performed to rule out myelopathic or radicular processes. In an isolated cervical sprain injury, the neurologic examination findings should be normal.
The result of the neurocompression test, in which the patient is asked to rotate and extend the head, thereby reducing the neuroforaminal space, should be negative with cases of cervical sprain or strain.
Functional Limitations
Restricted range of motion of the cervical spine may contribute to difficulty with daily activities such as driving. Patients often complain of neck fatigue, heaviness, and pain with static cervical positions such as reading and working at the computer. Sleep may also be affected.
Diagnostic Studies
It is generally accepted that radiographs to exclude fracture should be obtained in patients involved in a traumatic event and who have altered consciousness, are intoxicated, or exhibit cervical tenderness and focal neurologic signs with decreased range of motion on physical examination. Although the clinician may commonly see straightening of the cervical lordosis on the lateral cervical radiograph, this is thought to be related to spasm of the paracervical musculature and bears no other significance ( Fig. 6.3 ).
