AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Cervical strain is a ubiquitous disease seen routinely in the ED. Frequently the result of trauma from falls or motor vehicle accidents (MVAs), this condition causes much distress to patients but has few long-term sequelae. The chief diagnostic challenge in the emergent or urgent setting is to differentiate cervical strain from other causes of neck pain that may result in morbidity or mortality to the patient. Over a longer term, management is focused on a patient's return to daily functioning being directed at occupational or purely lifestyle in nature.

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 MVA, 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.

Frequency

United States

Cervical strain is very common.

International

Throughout the developed and undeveloped world, low-speed trauma to the cervical spine is very common.

Mortality/Morbidity

Mortality is not an issue in this musculoskeletal disease. Morbidity from long-term injury can be significant, eg, when pain leads to disuse, resulting in loss of function. Significant impediment of occupational functioning exists as a result of cervical spine injuries.

Age

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).
• 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. Modern office conditions and ergonomics can have significant impacts on susceptibility.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The most important issues surrounding cervical spine injury involve accurate diagnosis. Emergency departments in the United States and Canada annually treat more than 13 million patients with trauma who are at risk for cervical spine injury. Although most of these cases represent soft tissue injury, the paramount concern for the emergency medicine physician is to identify the patients with fractures, dislocations, or spinal cord injury.

• Ascertainment of the mechanism of injury is essential. This postinjury analysis can give significant clues to the relative risk of strain versus a more serious cervical spine injury.
• Pain is the most common complaint reported in cervical spine injuries. Severity of discomfort with cervical strains is typically low, although some patients may report significant pain, particularly with motor vehicle injury mechanisms.
• • Soft tissue swelling is a highly variable finding but can cause significant distress to patients presenting with cervical spine strain injuries.
  • Self-reported tenderness on history.
  • Following a cervical strain injury, patients may report varying degrees of muscle spasms.
  • Reported range of motion of the cervical spine is important to diagnosis because patients who are able to voluntarily move their cervical spine can help the examining physician to clinically eliminate certain more significant cervical spine injuries and conditions. 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.
  • Radicular pain patterns can occur in cervical spine injuries of all types.

Physical

The following physical examination is focused on the evaluation of patients in whom a fracture, dislocation, or ligamentous instability has been eliminated by examination or diagnostic imaging.

• 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.
• Tissue texture changes beyond edema are also commonly present (eg, ropiness, tightness, increased muscle tension).
• Mild warmth over the involved tissues is not uncommon and is the result of inflammation of the involved tissues.
• Limited range of motion of the involved area is the result of muscle spasm and is not necessarily reflective of the severity of the injury.

Causes

The causes of cervical strain injuries can be divided into general categories based on injury speed.

• Rapid injury can occur due to traumatic mechanisms such as the following:
• • Motor vehicle accidents
  • Falls
  • Assault
  • Other trauma
• Low-velocity injuries can be more elusive in their precise mechanism and can vary from acute to chronic in their presentation.
• • Strained cervical postures (eg, painting overhead, sitting in the front row at the movies) are common.
  • Chronic strains (eg, using the neck to hold the telephone, other malposition syndromes) and repetitive motion injuries are often easier for the patient to pinpoint.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Angina
Epidural abscess

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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
• A subsequent US validation study involving 34,069 patients with trauma showed that the NLC had a sensitivity of 99.6% and a specificity of 12.9% for cervical spine injury.
• 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 time frame 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.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

All persons involved in MVAs who sustain neck injuries should, at a minimum, receive cervical collars prior to transport. Many emergency medical service (EMS) protocols require these patients to be placed on a backboard in full spinal precautions. Because MVAs often involve enough force to seriously injure the cervical spine, such precautions are essential to prevent further injury.

Emergency Department Care

• Apply ice to acute strain injuries.
• Administer analgesia and pain control.
• Administer muscle relaxants.
• Soft collars are commonly used but have not been proven effective. A single-blind study with 6-month follow-up conducted by Borchgrevink et al found that patients who received "usual care," with early mobilization and pain control, fared better than similarly treated patients placed in soft collars.

Consultations

Consultations are rarely required for strain injuries; however, follow-up with a physician familiar with rehabilitation therapies is essential for longer-term management, particularly for patients who have experienced an occupational injury.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The pharmacology of cervical strain involves pain control and palliation. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol) are mainstays of therapy. Muscle relaxants may prove valuable when treating severe strain injuries to reduce pain and muscle contracture.

Drug Category: Analgesics

For minor strain injuries, oral outpatient analgesics provide adequate pain control. OTC medications also may suffice.

Drug Category: Nonsteroidal anti-inflammatory agents

NSAIDs control mild to moderate pain and decrease inflammatory reactions. This entire family of medications may ease pain in strain injuries. Tailor dosage on an individual basis.

Drug Category: Muscle relaxants

These agents provide adjunctive therapy to allow rest, control pain, and aid physical therapy for musculoskeletal injury.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient 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.
• • Physical therapy should be encouraged early to reduce the risk of long-term loss of function due to lost range of motion.
  • Vigilance for decreased function secondary to disuse or long-standing injury should be maintained to prevent long-term sequelae from the strain injury.

In/Out Patient Meds

• Outpatient medications should include acetaminophen or an NSAID.
• Muscle relaxant medications may be considered adjunctive care.

Deterrence/Prevention

• Avoidance of unusual postures (eg, painting overhead, sitting in the front row at the movies) for extended periods can prevent acute low-speed strain injuries.
• Avoidance of chronic straining (eg, using the neck to hold the telephone, other malposition syndromes) or repetitive motion of neck muscles and/or ergonomic planning and regular breaks can assist in avoiding a significant number of cervical strain injuries.

Complications

• Long-term complications of strain injuries are typically related to decreased function secondary to disuse.

Prognosis

• Patients with cervical strain injuries who are compliant with recommended therapy, including rest, ice, and physical therapy or exercise programs, often make full, rapid recoveries.

Patient Education

• Prior to discharge from the ED, patients should be made aware of the potential for long-term injury due to noncompliance.
• Patients should be advised of the benefits of ice versus heat in acute injuries.
• Patient education in basic exercises can enhance mobility and minimize discomfort during the recovery period.
• During follow-up visits, referral to a physical therapist for patients with markedly decreased range of motion or long-standing injury prior to presentation can be significantly beneficial in regaining range of motion as well as strengthening cervical musculature.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Arthritis Center. Also, see eMedicine's patient education articles Neck Strain and Whiplash.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Medical and legal pitfalls with regard to cervical strain are generally straightforward, falling into the following general groupings:
• • Failure to diagnose more severe causes of cervical spine injury
  • Failure to prevent potential injury secondary to impairments caused by medications
  • Failure to avoid medications that alter patient's sensorium, if the patient is unlikely to comply during convalescence
  • Failure to recognize significant comorbid conditions (eg, pregnancy, other medical conditions)

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Jun 30, 2006