9.01 Cervical Strain (Whiplash)
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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 splint- 
    ing, 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 super- 
    vision, 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:
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- Do not forget to tell the patient his sym- 
    ptoms 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
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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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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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