Cervical Hyperextension Injuries

BASICS

DESCRIPTION

  • Class of neck injuries typically seen in rapid, forceful extension of the cervical spine
  • Flexion–extension injuries (“whiplash”) are usually from motor vehicle accidents (MVAs), typically side-impact or rear-end collisions.
  • Diagnosed clinically after acute injury using National Emergency X-Ray Utilization Study C-Spine (NEXUS) criteria and/or Canadian C-Spine Rule (CCR) to determine if CT is required to rule out significant cervical spine injury.
  • May involve:
    • Injury to vertebral and paravertebral structures: fractures, dislocations, ligamentous tears, and disc disruption/subluxation
    • Spinal cord injury (SCI): traumatic central cord syndrome (CCS) secondary to cord compression or vascular insult, SCI without radiologic abnormality (SCIWORA)
    • Blunt cerebrovascular injury (BCVI): vertebral artery or carotid artery dissection
    • Soft tissue injury: cervical strain/sprain (i.e., whiplash), cervical stingers (See “Brachial Plexopathy.”)

EPIDEMIOLOGY

  • Predominant age: SCI average age of injury is 43 years, CCS average age 53 years.
  • High-energy trauma (e.g., road accidents) and sports injuries are more common in young adults (average age is 29 years), whereas low-energy trauma (e.g., falls) are usually implicated in the >65 years age group.
  • Most (~80%) new SCI cases are male (1).

Incidence

In the United States

  • CCS: 4/100,000 people/year
  • BCVI: estimated 1/1,000 of hospitalized trauma patients; incidence increased with cervical spine or thoracic injury.
  • Whiplash is the most common injury in MVAs and accounts for 28% of all ED visits for MVAs.
  • Incidence of whiplash is 70 to 328/100,000 with rates highest in 20- to 24-year-old women.

ETIOLOGY AND PATHOPHYSIOLOGY

Blunt trauma due to MVAs, falls, sports injuries, and violence (primarily gunshot wounds)

RISK FACTORS

  • Chronic pain and/or disability: litigation, previous neck pain or injury, female gender, report of headache/low back pain at onset, low education level
  • Fractures: osteoporosis, conditions predisposing to spinal rigidity, such as ankylosing spondylitis or other spondyloarthropathies
  • CCS: preexisting spinal stenosis present in >50%
    • Acquired: prior trauma, spondylosis
    • Congenital: Klippel-Feil syndrome (congenital fusion of any two cervical vertebrae)

GENERAL PREVENTION

Seat belts, higher neck rest, rule changes, proper technique, and proper use of protective equipment for sports activities can prevent or minimize injury.

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