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."
