Monograph 15
Soft-Tissue Neck Trauma By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997Copied with permission from ACAPress
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Background General Aspects of Neck Strains and Sprains Management Overview Arthrokinematics Joint Motion of the Neck Evaluating Muscle Strength of the Neck Clinical Management Electives for Neck Strains/Sprains |
Commentary Soft-Tissue Injuries of the Anterior Neck Posttraumatic Soft-Tissue Disorders of the Posterior Neck Trigger Points Cervical Contusions Torticollis, Neck Spasms, and Similar Disorders Posttraumatic Exercise for NeckSoft Tissues References and Bibliography |
The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.
BACKGROUND
The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.
Anterior injuries are more common to the head and chest as they project further forward, but a blunt blow from the front on the head or chest may cause an indirect extension or flexion injury of the cervical spine and soft tissues of the neck. In any neck injury, the injury may not be the product of a single force. For example, while extension, flexion, and lateral flexion injuries are often described separately, rotational, compressive, tensile, and shearing forces are invariably part of the picture.
The anterior and lateral aspects of the neck contain a variety of vital structures that have no bony protection. Partial protection is provided by the cervical muscles, the mandible, and the shoulder girdle.
After neck injury, a careful neurologic evaluation must be conducted, and every examination should begin with a thorough case history. See Table 1. Note any signs of impaired consciousness, inequality of pupils, or nystagmus. Do outstretched arms drift unilaterally when the eyes are closed? Standard coordination tests such as finger-to-nose, heel-to-toe, heel-to-knee, and for Romberg s sign should be conducted, along with superficial and tendon reflex tests.
Table 1 Typical Questions Asked During the Investigation of Joint Pain
What seems to be the matter?
What do you think caused it?
Where exactly does it hurt?
Does it always hurt there?
Does the pain feel sharp, dull, burning, tingling, boring, or what?
Does it feel deep inside or near the surface?
Does its quality or intensity ever change?
Is it constant or does it come and go?
Does the pain seem to start at one place and spread to another?
Do you notice other things at the time the pain is severe?
When did the pain first arise?
Did it first occur gradually or rapidly?
Was an injury or some unusual activity involved?
At what time of day is the pain worse?
At what time of day is the pain better?
How long have you suffered with this condition?
Have you ever had this condition before and it appeared to go away?
If so, what did you do for it?
Does anything seem to participate an attack?
What aggravates the pain?
What relieves the pain?
What home remedies have you tried and what were their effects?
How has this problem affected your work, activities, or sleep?
How is your health otherwise?
Are you presently being treated for any other condition?
Are you taking any drugs or medications?
What illnesses have you had in the past?
What injuries have you had in the past?
Has anybody else in your family had a condition similar to this?
Do you have any opinion on what might have caused this problem?
Is there anything else you would like to add?
Note: Many of these questions would be pertinent to a complaint other than pain.
GENERAL ASPECTS OF NECK STRAINS AND SPRAINSNeck strains (Grades 1—3) are common and most frequently involve the erectors. Flexion and extension cervical sprains are also common (Grades 1—3) and frequently involve the anterior or posterior longitudinal ligaments (making cord involvement a suspicion). The capsular ligaments and periarticular straps may be involved and always are when acute hyperkinetic subluxation has occurred. In the neck especially, strain and sprain may coexist and usually do. Severity varies considerably from mild to dangerous.
Neck sprain and disc rupture are usually associated with severe pain and muscle spasm and are more common in adults because of the reduced elasticity of supporting tissues. Pain is often referred when the brachial plexus is involved. Cervical stiffness, muscle spasm, spinous process tenderness, and restricted motion are common. When pain from either a soft-tissue or vertebral lesion occurs, it is often poorly localized and referred to the occiput, shoulder, between the scapulae, arm or forearm (lower cervical lesion), and may be accompanied by paresthesiae. Muscle clues may point to a nerve lesion. See Table 2.
Table 2 Major Muscles of the Neck
Muscle Major Function Spinal Segment Longus colli Flexion C2—C6 Longus capitis Flexion C1—C3 Rectus capitis anterior Flexion C1—C2 Rectus capitis lateral Flexion C1—C2 Scalenes Flexion, rotation C4—C8 Semispinalis capitis Extension, rotation C1—T1 Semispinalis cervicis Extension, rotation C1—T1 Splenius capitis Extension, rotation C1—C8 Splenius cervicis Extension, rotation C1—C8 Sternocleidomastoid Flexion, rotation C2, XI Trapezius, upper Extension, rotation C3—C4
Note: Spinal innervation varies somewhat in different people. The spinal nerves listed here are averages and may differ in a particular patient; thus, an allowance of a segment above and below those listed in most text tables should be considered.
Management Overview
Diagnosis and treatment are similar to that of any muscle strain-sprain, but concern must be given to induced subluxations during the initial overstress. Palpation after strain/sprain will reveal focal tenderness and spasm in affected soft tissues. In acute scalene strain, both tenderness and swelling is typical. When the longissimus capitis or the trapezius are strained, they stand out like stiff bands.
Many cervical strain/sprains heal spontaneously but may leave a degree of fibrous thickening or trigger points within the injured muscle tissue if not treated thoroughly. Residual joint restriction following acute care is more common in traditional medical care than with mobilizing chiropractic procedures.
ARTHROKINEMATICSThe head mechanically teeters on the atlanto-occipital joints, which are shaped like cupped palms tipped slightly medially. Because the line of gravity falls anterior to these articulations, a force must be constantly provided in the upright posture by the posterior neck muscles to hold the head erect. Added to this gravitational stress is the action of the anterior muscles of the neck, essentially the masticatory, suprahyoid, and infrahyoid groups, which as a chain join the anterior cranium to the shoulder girdle.
Flexion, extension, rotation, lateral flexion, and circumduction are the basic movements of the cervical region. Head motions on the neck are generally confined to the occiput-atlas-axis complex and can be described separately from movements of the neck on the trunk. Cervical motions are usually tested with normal weight bearing ) unless the patient is unable to hold the head erect. Passive motion should never be attempted if spinal fracture, dislocation, advanced arteriosclerosis, or severe instability is suspected. In any evaluation of joint motion, active motion should be observed first.
Joint Motion of the Neck
Gross joint motion is roughly screened by inspection during active motions. Mensuration is recorded by the findings of an inclinometer with the patient placed in the neutral position. The degrees of maximum active and passive flexion, extension, rotation, and lateral flexion from the neutral position are recorded. The prime movers and accessory muscles governing motion of the neck are shown in Table 3.
Table 3 Neck Motion
Joint Motion Prime Movers Accessories Flexion Sternocleidomastoid Scalenes Longus colli Hyoid muscles Longus capitis Rectus capitis anterior Rectus capitis lateralis Extension Trapezius, upper Transversospinalis group Splenius capitis Levator scapulae Splenius cervicis Semispinalis capitis Semispinalis cervicis Erector spinae capitis Erector spinae cervicis Rotation Sternocleidomastoid Scalenes Trapezius, upper Transversospinalis group Splenius capitis Splenius cervicis
Evaluating Muscle Strength of the Neck
Muscle strength is recorded as from 5 to 0 or in a percentage and compared bilaterally when possible. The myologic features of cervical root and peripheral nerve lesions are shown in Table 4.Rotation. The major muscles involved in cervical rotation are the sternocleidomastoideus, upper trapezius, and splenius group, with some assistance provided by the scalenes and intrinsics. Strength of the cervical rotators is tested by standing in front of the patient and placing the stabilizing hand on the patient s left shoulder and the resisting palm against the patient s right cheek when right rotation is being measured. The examiner s hand positions are switched for testing left rotation strength. Rotational strength is subjectively tested by having the patient attempt to slowly rotate his head against the examiner s resistance for each side.
Extension. Strength of the many extensors is subjectively tested by placing the stabilizing hand in the patient s upper dorsal area to prevent thoracic extension and the palm of the resisting hand over the occiput of the patient. Power is evaluated by having the patient slowly extend his neck against this resistance. The stabilizing hand may be placed on the superior aspect of the trapezius between the neck and the humerus to palpate muscle contraction simultaneously.
Phillips points out the necessity of normally lax ligaments at the atlanto-axial joints to allow for normal articular gliding, thus making tonic muscle action the only means by which head stability is maintained. Goodheart reports that the splenius muscles are responsible for maintaining head level more than any other muscles. "Occipital sideslip and jamming frequently are associated here."
Flexion. The action of flexion of the neck as a whole is done primarily by the sternocleidomastoideus, the longus group, and the rectus capitis anterior and lateralis, with secondary assistance from the scalenes and hyoid muscles. Extension is controlled by the upper trapezius, splenius group, the semispinalis group, and the erector spinae, which form the paravertebral extensor mass. Secondary assistance is provided by several small intrinsic neck muscles and the levator scapulae.
The position to test strength of the cervical flexors is taken by stabilizing the patient s sternum with one hand to prevent thoracic flexion and placing the palm of the other hand against the patient s forehead. Strength is subjectively evaluated by having the patient slowly attempt to flex his neck against this resistance.
Lateral Flexion. Lateral flexion is accomplished by the scalenus anticus, medius, posticus, and the levator scapulae. Secondary assistance is provided by the small lateral intrinsic muscles of the neck. Strength of the lateral flexors is tested by standing at the side of the patient and placing the stabilizing hand on the patient s shoulder to prevent thoracic movement and the resisting palm on the patient s skull above the ear. Strength is evaluated by having the patient slowly flex his neck laterally against the resistance.
Table 4 Muscle Features of Cervical Root & Peripheral Nerve Lesions
Site Muscle Signs C6 root Shoulders are held abducted Forearm pronators weak Elbow flexors weak Forearm supinators weak Elbow extensors weak Wrist extensors weak C7 root Elbow extensors weak Wrist extensors weak Forearm pronators weak Grip weak Wrist flexors weak Wrist extensors weak
Grip weakThumb little finger apposition poor
Finger extensors weakThumb flexion weak Finger spread poor Radial nerve Elbow extensors weak Wrist extensors weak Forearm supinators weak Finger extensors weak Median nerve Forearm pronators weak Grip weak Wrist flexors weak Thumb pressure weak Ulnar nerve Grip weak Finger spread poor Thumb pressure weak
After attending to life-threatening potentialities, a more thorough examination may proceed. Seek gross abnormalities, then check for details. Required transportation, however, should never be delayed for diagnostic purposes.
If examination may proceed, note the action of the cricoid cartilage area when the patient swallows. Check the trachea for midline alignment. Evaluate abnormal contours, curvatures, and restricted movements. Venous thrombosis, masses, and exudates may produce visible and palpable edema in the neck. Palpate the neck with the patient supine so that the muscles are relaxed and the head may be passively controlled.
Tracheal Injury
Fortunately, trauma to the trachea is rare. It commonly results from a clothesline-type injury or a "chop" to the base of the neck just below the "Adam s apple." Possible airway obstruction requires quick and careful evaluation. After any neck or thorax injury, the trachea should be checked for its midline position.
Tracheal rupture causes air to leak into neck tissues (balloon neck) and connective tissues of the shoulder girdle. Fracture also features emphysema and breathing difficulties. A similar blow above the sternum may cause a thyroid hematoma, characterized by severe hoarseness. Indirect whiplash injury to the cervical spine is also a possibility with any blow to the anterior neck.Emergency Care. The priority is to assure an adequate airway. The problem becomes complex when endotracheal intubation is necessary (requiring extension of the neck) and possible cervical spine and/or cord damage occurs, making cervical extension contraindicated. This emergency requires "blind" endotracheal intubation, cricothyrotomy, or tracheotomy by an experienced person. Also, if the larynx has split from the trachea or separated between two tracheal rings, attempts at endotracheal intubation may be fatal. This situation requires inserting the tube below the separation if possible.
Cricothyroid and Hyoid Injuries
The cricoid and thyroid cartilages are quite vulnerable to direct trauma of the neck. Injury can be a medical emergency. Displaced fractures of the cricoid, especially, must be quickly reduced surgically as the cricoid encircles the airway. Subglottic stenosis is a common posttraumatic result of associated lacerations and mucosal tears not being carefully reapproximated. Hyoid injuries are rare, extremely painful, and rarely affect the integrity of the airway.
Laryngeal Injury
Obstruction within the upper airway is the second most common cause of death resulting from head and neck trauma. Thus, the priority concern in any anterior neck injury is airway impairment. Any injured person tends to hyperventilate. Thus, ventilation is not difficult to assess. A minor airway obstruction may soon become suddenly life threatening or be delayed for several hours after injury.
The larynx may be crushed between a blunt object and the anterior cervical spine, leading to cartilaginous fractures, subluxation, and/or dislocation. The most common fracture of the thyroid cartilage is that of a vertical anterior split between the thyroid notch and the cricothyroid membrane producing avulsion of the anterior vocal cord attachments and hematoma.
Laryngeal injury usually produces a louder stridor than tracheal injury, but stridor may be absent if the obstruction is severe enough to completely obstruct the airway. Besides stridor, other signs and symptoms of laryngeal fracture are loss of cartilaginous landmarks from edema, dyspnea, dysphonia from paresis or hematoma, pain increased by neck motion, dysphagia, subcutaneous emphysema (sometimes from scalp to clavicle), and local tenderness. Otolaryngeal consultation should be quickly sought.
Less severe bruises are the result of a pole, rod, fist, elbow, baseball, racket, or stick. Hoarseness and point tenderness are exhibited, but edema and airway obstruction are absent. An overnight ice collar is usually sufficient.
Thyroid Cartilage Fixation
A chronic pain or an ache may occasionally arise from a fixated thyroid cartilage. This is usually the result of previous trauma resulting in restricted mobility. This annoying condition is far removed from the more serious acute disorders that may occur in the area of the anterior neck such as cartilage fractures of the larynx or trachea that can obstruct the airway and jeopardize life.Mobilization Technique. For correction, the patient is placed on a table in the supine position without a pillow. The doctor stands to the side of the patient and grasps the upper and lower margins of the patient s thyroid cartilage with the fingers of his caudad hand while his cephalad hand supports the patient s chin. Gently manipulation is then made in a clockwise and counterclockwise motion with the fingers, using the thumb as a pivot. The action should come from the doctor s elbow rather than his wrist or fingers. Several movements should show increased cartilaginous mobility after 1 3 sessions, with a reduction in symptoms following.
Hypopharyngeal and Esophageal Injuries
The esophagus is normally collapsed and shielded by surrounding structures, but because it has extremely delicate walls, it can be easily injured by internal (eg, foreign body ingestion, exploration) or external penetrating wounds. Simple tears of the oropharynx or nasopharynx respond well to saline irrigation, restricting solid food, and taking precautions against infection. More severe injuries require surgical repair and antibiotics.
Direct Vascular Injuries
Excepting spinal cord damage, injuries of the major blood vessels comprise the highest mortality and morbidity of all neck trauma. The most serious consequences are those of airway obstruction from blood, air embolism, spurting hemorrhage, cerebral infarct, and neurologic deficits consequent to cerebral hypoxia. Seek signs of bleeding, discoloration, swelling, lack of superficial pulses, or auscultated bruits. Pressure will control most hemorrhages.
POSTTRAUMATIC SOFT-TISSUE DISORDERS OF THE POSTERIOR NECKTrigger Points
The cervical and suprascapular areas of the trapezius frequently refer pain and deep tenderness to the lateral neck (especially the submastoid area), temple area, and angle of the jaw. The sternal division of the sternocleidomastoideus refers pain chiefly to the eyebrow, cheek, tongue, chin, pharynx, throat, and sternum. The clavicular division refers pain mainly to the forehead (bilaterally), back of and/or deep within the ear, and rarely to the teeth. Vapocoolant sprays to isolated sites often produce rapid spasm reduction of affected areas.
Common trigger points involved in "stiff neck" are in the trapezius (usually a few inches lateral to C7) or the levator scapulae and splenius cervicis lateral to C4 C6 cervical processes. These points are often not found unless the muscle is relaxed during palpation.
Cervical Contusions
Contusions in the neck are similar to those of other areas. They often occur in the neck muscles or cervical spinous processes. Painful bruising and tender swelling will be found without difficulty, especially if the neck is flexed. They present little biomechanical significance unless severe scarring occurs.
Torticollis, Neck Spasms, and Similar DisordersInflammation. "Wry neck" spasm (tonic, rarely clonic) of the sternocleidomastoideus and trapezius may be due to irritation of the spinal accessory nerve or other cervical nerves by swollen glands, abscess, acute upper respiratory infections, scar, or tumor. A spontaneous subluxation of the atlas may follow severe throat infection (eg, pharyngitis). Neck rigidity may also be the result of a sterile meningitis from blood in the cerebrospinal fluid. Thus, if a patient has slight fever, rapid pulse, and rigid neck muscles, subarachnoid hemorrhage should be suspected. Lateralizing signs are often indefinite.
Congenital, Neuropathic, and Idiopathic Forms. The congenital form of torticollis is commonly associated with Klippel-Feil syndrome, atlanto-occipital fusion, and pterygium colli. Focal neuropathic causes include ocular dysfunctions, syringomyelia, and tumors of the spinal cord or brain. Idiopathic forms are seen in acute calcification of a cervical disc, rheumatic arthritis, tuberculosis, or "nervous" individuals. Nelson feels that wry neck may also be the result of subdiaphragmatic or subclinical visceral irritation being mediated reflexly into the trapezius and cervical muscles.
Subluxation-Induced Torticollis. This common syndrome will be described in a subsequent paper.
General Management. The muscles are rigid and tender, the head tilts toward the spastic sternocleidomastoideus, and the chin is rotated to the contralateral side. The priority is to locate and relieve causative or contributing subluxation complexes or other points of focal irritation. After the acute stage, isotonic exercises are useful in improving circulation and inducing the stretch reflex, especially in the cervical extensors. These exercises should be done supine to reduce exteroceptive influences on the central nervous system.
Peripheral inhibitory afferent impulses can be generated to partially close the presynaptic gate by acupressure, acu-aids, acupuncture, or transcutaneous nerve stimulation. Most authorities feel deep sustained manual pressure on trigger points is the best method, but a few others prefer severe short-duration pressure (1 2 sec). Deep pressure is contraindicated in any patient receiving anti-inflammatory drugs (eg, cortisone) as subcutaneous hemorrhage may result. The effects of cervical traction are often dramatic but sometimes short lived if a herniated disc is involved. In chronic cases, relaxation training with biofeedback is helpful.
It should not be overlooked that a metabolic disturbance may be the cause. For example, an acid-base imbalance from muscle hypoxia and acidosis is frequently a etiologic factor. It may be prevented by Lindahl s alkalization mixture (potassium citrate, 33.5%; calcium lactate, 41%; sodium citrate, 12%; magnesium glyconate, 12%; lithium citrate, 1.5%).
Posttraumatic Exercise for Neck Soft Tissues
Allman recommends a two-phase approach: the first limited to active exercise; the second, to resisted exercise. He advises that the exercise of Phase 1 should not begin until pain fades and that progress to more strenuous exercise should not be allowed during Phase 1. Phase 2 exercises should only begin when pain and stiffness have disappeared, and this phase includes Phase 1 exercises with resistance progressively added.Phase 1 Mode includes (1) active head rotation to the right and left, (2) active lateral flexion toward the shoulder bilaterally with the shoulders held erect, (3) active forward thrust of the neck with the chin forward and downward in an attempt to touch the lower thorax, and (4) active backward motion but not past the neutral position. Allman believes that hyperextension will aggravate most neck problems.
Phase 2 Mode includes (1) partner resisting motion (with hands) in all planes of movement, (2) self-applied resistance with a towel or the patient s hands, and (3) movement against a spring-loaded or weight-loaded head strap.
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