Cervical Sprain

The mechanism of injury is essential in the diagnosis of a whiplash-associated disorder. Typically the patient will report a history of an injury that shows rapid acceleration and deceleration forces such as an MVC, or a sports injury with a collision similarly affecting the neck.[8] The patient may present immobilized with a hard-cervical collar by EMS rescue personnel or the triage provider to prevent further injury until seen and cleared by the appropriate healthcare provider. Patients can present with varied symptoms, including but not limited to, neck pain and stiffness, interscapular pain, upper limb pain and paresthesias, temporomandibular dysfunction, occipital headache, visual disturbances, psychological distress. Also, memory and concentration could be affected.[13] A myriad of psychosocial symptoms has been reported with whiplash injuries, including anxiety, depression, and hypochondriasis.[14]

A comprehensive examination and trauma evaluation are necessary with the cervical spine in a neutral position and while the provider palpates the spine and the paraspinal muscles.  Any midline tenderness or step off dictates further imaging and that the collar remains in place. Distracting injuries or intoxication are prohibiting factors that serve as absolute contraindications to c-spine clearance in the acute traumatic setting. Serial and follow-up examinations are warranted once the patient is appropriately alert and oriented to participate in a comprehensive physical examination.

In otherwise normal patients presenting with a low clinical suspicion of injury with no midline tenderness and unremarkable physical examination allows for clearance of the c-spine precautions without additional imaging. A neurological exam of the upper extremities including strength and sensation is necessary to rule out any deficits. NEXUS [Neuro Emergency X-ray Utilization Study], validated cervical spine criteria or Canadian Cervical Spine Rule are used to help rule in and rule out the need for additional imaging.[7]

The Canadian cervical spine rules or NEXUS criteria are useful for the evaluation of cervical spine injuries in the emergency department.[15]  These criteria determine the need for imaging based on the mechanism of injury, physical presentation at the time of the accident, symptomatic presentation in the emergency department, as well as the physical exam.[16]  The NEXUS c-spine criteria recommend imaging if there is posterior midline cervical-spine tenderness,  focal deficits,  altered mental status,  intoxication or distracting injuries. The Canadian c-spine rules define the need for imaging with patients greater than 65 years of age, dangerous mechanism of injury, paresthesia, midline tenderness, immediate onset of neck pain and impaired range of motion.[17]  Additional imaging such as MRI may be necessary for abnormal findings on CT to evaluate for cord injury.  Flexion and extension films can help rule out ligamentous injury.[18]

Immobilization with a soft cervical collar, resumption of normal activity, and mobilization exercises are generally the treatment of choice.  Immobilization has shown the least improvement[12][19] Ultrasound has also been shown to relieve muscle pain for whiplash-associated disorders.[20]  First-line treatments include analgesics, nonsteroidal anti-inflammatories, ice, and heat.[21]  Other controversial analgesic measures include muscle relaxants, which have been shown to have some therapeutic effect in limited studies.[22]  Biofeedback has also demonstrated effectiveness when used in conjunction with other modalities in acute WAD.[23]  Injection of lidocaine intramuscularly was also found to relieve pain symptoms.[24]  Most treatments alone appeared to have moderate effectiveness with combinations of treatment measures improving efficacy and early mobilization consistently most effective.[22]

The differential diagnosis for cervical spine injuries includes cervical spine fracture, carotid artery dissection, herniated disc, spinal cord injury, subluxation of the cervical spine, muscle strain, facet injury, ligamentous injury.  Whiplash is an injury associated with trauma; remote trauma should dictate evaluation for other causes, such as mass, tumor, infection, etc.  

Prognosis varies secondary to comorbidities prior to the injury, severity of WAD, age and socioeconomic environment.  Full recovery has been shown to occur in a few days to several weeks.[11]  However, disability can be permanent and range from chronic pain to impaired physical function.[11]  There have been inadequate studies that incorporate mitigating factors, such as socioeconomic and legal, which can impact an accurate assessment of recovery.  In regions where there is little or no litigation, the prognosis is more favorable lending that economic gain for disability may play a role in determining the patient's reports of full recovery.[11]

Though cervical pain is the most common symptom, dizziness and/or headaches can be chronic, persistently reported symptoms.[8]  Chronic pain, subsequent interference with work, and physical function can cause loss of income and lifestyle.[25]

In a retrospective analysis, seatbelt restraints have been shown to reduce the incidence of WAD.[4] Low-velocity MVAs remain one of the leading causes of cervical strain or WAD.[4]  Safe, alert driving practices, as well as the avoidance of distraction activities (such as text messaging),  can help reduce the incidence of MVAs and WADs occurring due to reckless driving practices.  Early mobilization is most effective when other more serious clinical pathologies noted on examination and imaging diagnostics have been ruled out.[22]

Diagnosis and treatment of WAD are complex and associated with many complex issues.  Legal environment, prior injury, comorbidity, age, and defensive medicine all play roles in the management and outcomes.[11]  There is a large variation in diagnosis and persistence of symptoms depends largely on legal culture or the ability to seek compensation for WAD. The nexus c-spine criteria, as well as the Canadian C-spine rules, are widely accepted as guidelines for imaging in the evaluation of cervical spine injury associated with acceleration/deceleration injury.[15][17]  A recent study by Parikh et al. showed that more guidelines aim at treatment recommendations as opposed to diagnosis, prognosis, and outcomes.[17] Additional studies are needed to fully understand the etiology, pathophysiology, and prognosis of patients with WAD, taking into accounts, pre-existing conditions, age-related degeneration of the spine can influence of compensation laws on outcomes.[11] Primary care providers and nurse practitioners should educate the public on the use of seatbelts and avoiding distractions during driving to help lower the frequency of WAD. Many of these patients need long term followup with enrollment in a physical therapy program.