9.01 Cervical Strain (Whiplash)

agk’s Library of Common Simple Emergencies

Presentation

The patient may arrive directly from a car accident, arrive the following day (complaining of increased neck stiffness and pain), or long after (to have injuries documented). The injury occured when the neck was subjected to sudden extension and flexion, possibly injuring intervertebral joints, discs, and ligaments, cervical muscles, or even nerve roots. As with other strains and sprains, the stiffness and pain may tend to peak on the day following the injury.

What to do:

• Obtain a detailed history to determine the mechanism and severity of the injury. Was the patient wearing a seat belt? Was the headrest up? Were eyeglasses thrown into the rear seat? Was the seat broken? Was the car damaged? Driveable afterwards? Windshield shattered? Intrusion into the passenger compartment?
• Examine the patient for involuntary splinting, point tenderness over the spinous processes of the cervical vertebrae, cervical muscle spasm or tenderness, and for strength, sensation, and reflexes in the arms (to evaluate the cervical nerve roots).
• If there is any question at all of an unstable neck injury, start the evaluation with a cross table lateral film of the cervical spine, while maintaining cervical immobilation with a rigid collar. If necessary, the anteroposterior view and open mouth view of the odontoid can also be obtained before the patient is moved.
• To evaluate the possibility of head trauma, ask about loss of consciousness or amnesia, and check the patient’s orientation, cranial nerves, and strength and sensation in the legs as well.
• If any of the above suggest injury to the cervical spine, obtain 3 x ray views of the cervical spine: AP, lateral, and open mouth odontoid. If there is clinical nerve root impairment, or you need to see more detail of the posterior elements of the vertebrae, obliques may also be useful. Flexion and extension views may be needed to evaluate stablity of joints and ligaments, but should only be done under careful supervision, so the spinal cord is not injured in the process.
• If x rays show no fracture or dislocation, and history and physical examination are consistent with stable joint, ligament, and muscle injury, explain to the patient that the stiffness and pain are often worse after 24 hours, but usually resolve over the next 3-5 days, and are usually back to normal in a week.
• Treat with one or two days of immobilization (a soft cervical collar), topical ice for the first day, then heat for the later spasm, and anti inflammatory analgesics (aspirin, ibuprofen, naproxyn).
• Arrange followup as necessary.

What not to do:

• Do not forget to tell the patient his symptoms may well be worse a day after the injury.
• Do not skimp recording the history and physical. This sort of injury may end up in litigation, and a detailed record can obviate your being subpoenaed to testify in person.
• Do not x ray every sore neck. A thousand negative cervical spine x rays are cost effective if they prevent one paraplegic from an occult unstable fracture, but several studies have shown that patients who have no neck pain or stiffness (and are not intoxicated or distracted by other injuries) do not have to be x rayed just because they fell or hit their head.

Discussion

X ray results for whiplash neck injuries seldom add much to the clinical assessment but the sequelae of unrecognized cervical spine injuries are so severe that it is still worth while to x ray relatively mild injuries (in contrast to skull and lumbosacral spine radiographs, which are ordered far less often.) It is often useful to discuss the pros and cons of x rays with the patient, who may prefer to do without, or conversely may be in the ED purely to obtain radiological documentation of his injuries. The term “whiplash” is probably best reserved for describing the mechanism of injury, and is of little value as a diagnosis. Because of the many undesirable legal connotations which surround this term it may be advisable to substitute “flexion/extension injury.”

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