Neck sprain

Neck sprains and whiplash injuries are commonly caused by direct impact or abnormal neck movement. Neck sprains occur due to overstretching, while whiplash injuries result from abrupt flexion/extension of the neck. Both conditions are diagnosed clinically. After acute injury, cervical spine precautions are maintained until the clinical assessment is complete. Clinical decision rules (e.g., NEXUS C-spine criteria, Canadian C-spine rule) are used to determine whether imaging is required to rule out significant cervical spine injury. Treatment of uncomplicated neck sprains and whiplash injuries involves pain management with nonopiate analgesics, early mobilization, and physiotherapy. Clinically significant cervical spine injuries require urgent specialist consultation.

• Neck sprain: neck ligament injury and/or muscle strain due to overstretching ^[1]
• Whiplash injury: injury pattern caused by abrupt flexion/extension movement of the neck ^[2][3]

Whiplash injuries are a common cause of cervical strain and sprain.

• Motor vehicle crashes ^[2][5]
• Falls
• Sports injuries
• Work-related injuries
• Physical assault

Common features ^[1][2]

Any of the following may occur immediately or appear hours to days following injury:

• Neck pain, stiffness, and tenderness
• Reduced neck range of motion
• Palpable shoulder and neck muscle tension
• Occipital headaches
• Upper back, shoulder, and upper limb pain and/or paresthesia
• Dizziness, fatigue, insomnia, visual disturbances, tinnitus, difficulty concentrating

Whiplash injury and mTBI can occur simultaneously and have overlapping symptoms such as headaches, dizziness, and visual disturbances. ^[6]

Red flags ^[4][6]

The following red flags in post-trauma patients are concerning for C-spine fracture or neurovascular injury and should prompt further investigation:

• Neck pain after major trauma
• Signs of vertebral fractures, e.g., paravertebral hematoma
• Features of vascular injury, e.g., arterial bruit or symptoms of cerebral ischemia
• Neurological features, e.g., hypesthesia or Horner syndrome

The absence of neurologic deficits does not rule out clinically significant cervical spine injury.

Approach ^[2][6]

• Neck sprain and whiplash injury are clinical diagnoses.
• Determine the need for CT to rule out significant C-spine injury using a validated clinical decision rule, e.g.:
  • NEXUS C-spine criteria
  • Canadian C-spine rule
• Consider additional imaging to assess for fractures, dislocation, ligament damage, and/or neurovascular injury.
• Consult spine surgery urgently for any evidence of vertebral fractures or cervical facet dislocation.
• See “Diagnosis of C-spine injury” for details.

Following acute trauma, maintain C-spine precautions until the initial assessment is complete.

Obtain imaging of the cervical spine in any patient with polytrauma or altered mental status after acute trauma.

Imaging ^[6][7]

Imaging may be used to rule out fractures, dislocations, ligament damage, and neurovascular injury (see “Diagnostics for C-spine injury”).

• CT cervical spine without IV contrast
  • Initial test of choice in most patients with acute nonpenetrating trauma to the neck
  • Also indicated to evaluate any abnormal x-ray findings
• MRI C-spine without IV contrast
  • Alternative to CT for initial testing
  • Also used to evaluate persistent clinical suspicion of ligamentous or neurologic injury despite normal CT
• X-ray cervical spine
  • Rarely indicated ^[7]
  • Views: lateral, anteroposterior, and open-mouth view of the odontoid
• Vascular studies (e.g., CTA neck, MRA neck): if clinical or imaging findings suggest arterial injury

After vertebral fractures and cervical facet dislocations have been excluded, the treatment of neck sprain and whiplash injury is mainly supportive. ^[4][6]

• Offer reassurance.
• Provide adequate non-opioid pain control. ^[8]
• Encourage early mobilization and refer to physiotherapy. ^[6][9]
• Arrange follow-up with a primary care provider.