Abstract
Acute cervical strain is a constellation of symptoms consisting of nonradicular neck pain that radiates in a nondermatomal pattern into the shoulders and interscapular region; headache often accompanies these symptoms. The trapezius is commonly affected, with resultant spasm and limited range of motion of the cervical spine. Cervical strain is usually the result of trauma to the cervical spine and associated soft tissues, but it may occur without an obvious inciting incident. On physical examination, tenderness is elicited on palpation; spasm of the paraspinous musculature and trapezius is often present. Decreased range of motion is invariably present, and pain is increased when this maneuver is attempted. The neurologic examination of the upper extremities is within normal limits, despite the frequent complaint of upper extremity pain. Cervical strain is best treated with a multimodality approach. Physical therapy, including heat modalities and deep sedative massage, combined with nonsteroidal antiinflammatory drugs and skeletal muscle relaxants, is a reasonable starting point. For symptomatic relief, cervical epidural block, blockade of the medial branch of the dorsal ramus, or intraarticular injection of the facet joint with local anesthetic and steroid is extremely effective. Underlying sleep disturbance and depression are best treated with a tricyclic antidepressant.
Keywords
cervical strain, cervicalgia, whiplash, cervical spine, neck pain, facet syndrome, myofascial pain, fibromyalgia, antidepressants, cervical epidural nerve block, facet block, medial branch block
ICD-10 CODE S13.4xxA
The Clinical Syndrome
Acute cervical strain is a constellation of symptoms consisting of nonradicular neck pain that radiates in a nondermatomal pattern into the shoulders and interscapular region; headache often accompanies these symptoms. The trapezius is commonly affected, with resultant spasm and limited range of motion of the cervical spine. Cervical strain is usually the result of trauma to the cervical spine and associated soft tissues ( Fig. 18.1 ), but it may occur without an obvious inciting incident. Given that over 93% of the world population uses a smartphone, it is not surprising that there has been an increased incidence of cervical strain resulting from poor posture while looking down at the smartphone screen ( Fig. 18.2 ). The relationship of the angle of the cervical spine and the device screen can be quantified using a cumulative average of tilt angles of the neck over time. If the observed tilt angle is excessive, then significant strain is being placed on the cervical spine and soft tissues. The pathologic lesions responsible for this clinical syndrome may emanate from the soft tissues, facet joints, or intervertebral disks.
Signs and Symptoms
Neck pain is the hallmark of cervical strain. It may begin in the occipital region and radiate in a nondermatomal pattern into the shoulders and interscapular region. The pain of cervical strain is often exacerbated by movement of the cervical spine and shoulders. Headaches often occur and may worsen with emotional stress. Sleep disturbance is common, as is difficulty concentrating on simple tasks. Depression may occur with prolonged symptoms.
On physical examination, tenderness is elicited on palpation; spasm of the paraspinous musculature and trapezius is often present. Decreased range of motion is invariably present, and pain is increased when this maneuver is attempted. The neurologic examination of the upper extremities is within normal limits, despite the frequent complaint of upper extremity pain.
Testing
No specific test exists for cervical strain. Testing is aimed primarily at identifying an occult pathologic process or other diseases that may mimic cervical strain (see “ Differential Diagnosis ”). Plain radiographs can delineate any bony abnormality of the cervical spine, including arthritis, fracture, congenital abnormality (e.g., Arnold-Chiari malformation), and tumor ( Fig. 18.3 ). Straightening of the lordotic curve is frequently noted. All patients with the recent onset of cervical strain should undergo magnetic resonance imaging (MRI) of the cervical spine and, if significant occipital or headache symptoms are present, of the brain ( Fig. 18.4 ). Screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, antinuclear antibody testing, human leukocyte antigen (HLA)-B27 antigen screening, and automated blood chemistry should be performed to rule out occult inflammatory arthritis, infection, and tumor.
