Practice Essentials

Cervical strain (sprain of the ligaments of the cervical spine) is a common injury routinely seen in the emergency department (ED). A cervical strain is chiefly the result of a stretch injury to the muscular and ligamentous elements of the cervical spine. 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).^{[1, 2, 3, 4, 5]}

(See the images below.)

Radiograph of the cervical spine shows a normal lordotic curve.

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Radiograph of the cervical spine shows straightening of the lordotic curve.

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Cervical strain is very common, with as many as one million cases per year from high-velocity (whiplash-type) injuries alone. The incidence of whiplash injury ranges from 16 to 200 per 100,000 population. 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).^[6]

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, with modern office conditions and ergonomics having significant impact on susceptibility.

Diagnosis

The chief diagnostic challenge in the emergent or urgent setting is to differentiate cervical strain from other causes of neck pain. 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.^{[7, 4, 5, 8]}

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.

Where radicular symptoms are present, the Spurling Maneuver (compression of the cervical spine by downward pressure) can be useful. In a systematic review, the Spurling maneuver showed high specificity ranging from 0.89 to 1.00 (95% confidence interval [CI]: 0.59-1.00) and sensitivity ranging from 0.38 to 0.97 (95% CI: 0.21-0.99) for the diagnosis of cervical radiculopathy.^[9]

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.

Treatment

In the ED, apply ice to acute strain injuries, and administer analgesia and pain control, as well as muscle relaxants. Outpatient medications should include acetaminophen or an NSAID. Muscle relaxant medications may be considered adjunctive care.

Follow-up with a primary care physician is strongly recommended in cervical strain injuries to facilitate further care. For patients involved in occupational injuries, appropriate referral for follow-up is particularly important.

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 motor vehicle accident, 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.

Lateral view of the muscles of the neck.

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External craniocervical ligaments.

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Clinical Presentation

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