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Cervical Hyperextension Injuries

Basics

  • Injury from rapid forceful extension of the cervical spine ("whiplash").
  • Common in MVAs (side-impact, rear-end), falls, sports injuries, violence.
  • May involve vertebral fractures, dislocations, ligament tears, disc disruption, spinal cord injury (SCI), blunt cerebrovascular injury (BCVI), and soft tissue injury.

Epidemiology

  • SCI average age: 43 years; Central Cord Syndrome (CCS) average: 53 years.
  • Young adults: high-energy trauma; elderly: low-energy trauma (falls).
  • 80% of new SCI cases are male.
  • Incidence:
  • Cervical fractures: 2-5/100 blunt trauma patients.
  • CCS: 4/100,000/year.
  • BCVI: 1/1,000 hospitalized trauma patients.
  • Cervical strain: 3-4/1,000/year.
  • Whiplash accounts for 28% of ED visits for MVAs; incidence 70-328/100,000, highest in females 20-24 years.

Etiology and Pathophysiology

  • Blunt trauma from MVAs, falls, sports, violence.
  • Injuries may cause cord compression, vascular insult, or soft tissue damage.
  • CCS due to white matter axonal disruption (corticospinal tracts).
  • BCVI involves intimal disruption leading to thrombosis and embolization.

Risk Factors

  • Whiplash: no seat belt, low neck rest, female gender, initial injury.
  • Chronic pain/disability risk: female gender, low education, prior neck injury.
  • Fractures: osteoporosis, ankylosing spondylitis, spondyloarthropathies.
  • CCS: preexisting spinal stenosis (>50%).
  • Congenital: Klippel-Feil syndrome.

Prevention

  • Seat belts, rule changes, proper sports protective equipment.

Commonly Associated Conditions

  • Closed head injury, whiplash-associated disorders (WAD), SCI, soft tissue trauma.

Diagnosis

History

  • Acute neck pain, stiffness, headaches ± neurological symptoms following hyperextension trauma.

Physical Exam

  • External trauma signs: abrasions, lacerations, contusions.
  • Neck tenderness:
  • Posterior midline: fracture concern.
  • Paraspinal/lateral soft tissue: muscle/ligament injury.
  • Anterior: vascular injury concern.
  • Carotid bruit: suspect carotid dissection.
  • Neurologic exam for weakness, paresthesias, incontinence.
  • CCS: distal > proximal weakness, UE > LE involvement, sensory changes.

Differential Diagnosis

  • Disc pathology, osteoarthritis, cervical radiculopathy.
  • CCS mimics: Bell cruciate palsy, brachial plexus injury, artery dissection.

Diagnostic Tests

  • Use Canadian C-Spine Rule (CCR) or NEXUS to clear low-risk patients clinically.
  • Imaging for high-risk:
  • CT cervical spine (occiput to T1) with sagittal/coronal reconstructions preferred.
  • MRI for spinal cord injury, ligamentous injury, soft tissue.
  • CT angiography or MR angiography for BCVI.
  • Flexion-extension x-rays only if no neurologic deficits and asymptomatic.

Treatment

General Measures

  • Whiplash/WAD: limited or no benefit from cervical collar (<72 hours if used).
  • Fractures:
  • Stability guides treatment.
  • Hangman fracture: halo immobilization for 12 weeks.
  • Odontoid fractures:
    • Type I: usually stable, collar.
    • Type II: unstable, high nonunion risk, may require surgery.
    • Type III: usually stable, halo/collar immobilization.
  • Hyperextension teardrop fractures:
    • Stable: rigid collar/brace 8-14 weeks.
    • Unstable: halo brace up to 3 months.
  • CCS: immobilization, PT/OT.
  • Cervical strain: NSAIDs/acetaminophen; possible soft collar short-term.

Medication

  • Fracture pain control: analgesics.
  • CCS: Methylprednisolone within 8 hours (bolus + infusion) may improve motor recovery.
  • BCVI: anticoagulation (heparin → warfarin) or antiplatelet if contraindicated.
  • Cervical strain: NSAIDs, acetaminophen, limited benefit from muscle relaxants.

Surgery

  • Fractures: fixation if unstable or nonunion.
  • Odontoid type II: surgical stabilization if displaced or older patient.
  • CCS: decompression/fixation if unstable or worsening neuro.
  • BCVI: surgery or angiographic interventions for pseudoaneurysm, occlusion.

Admission & Nursing

  • Trauma protocol with backboard and collar.
  • Admission depends on injury severity, imaging, comorbidities.

Ongoing Care

  • Specialist follow-up with serial imaging.

Patient Education

  • Injury prevention resources (ThinkFirst Foundation).

Prognosis

  • Neurologic status at presentation critical.
  • Fracture healing varies by type.
  • BCVI benefits from early diagnosis and treatment.
  • CCS: >50% spontaneous motor recovery over weeks.
  • WAD risk factors for chronic symptoms: initial pain intensity, disability, cold hyperalgesia.

Complications

  • Fractures: instability, malunion, infection.
  • BCVI: ischemic stroke, pseudoaneurysm.

Clinical Pearls

  • Use CCR or NEXUS to decide imaging need.
  • Always suspect SCI until ruled out.
  • Consider BCVI if neuro symptoms don't match imaging or with high-risk mechanism.
  • Elderly and preexisting conditions increase injury risk and complicate imaging interpretation.