From the Guidelines
Red flags for a patient with whiplash injury include trauma, malignancy, prior neck surgery, spinal cord injury, systemic diseases, history of intravenous drug use, intractable pain despite therapy, or tenderness to palpation over a vertebral body, as these symptoms may indicate more serious underlying conditions that require immediate medical attention. According to the study by 1, these red flags are recommended by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders for cervical and neck pain. Other concerning signs include severe neck pain that worsens rather than improves over time, pain that radiates down one or both arms, numbness or tingling in the arms or hands, weakness in the arms or legs, difficulty with coordination or walking, loss of bladder or bowel control, and severe headaches that worsen over time.
Some key points to consider when evaluating a patient with whiplash injury include:
- Screening patients to identify those with a higher likelihood of serious pathology/red flag conditions, as recommended by 1
- Considering the patient's medical history, including pre-existing conditions such as osteoporosis or rheumatoid arthritis, and medications such as blood thinners
- Evaluating the mechanism of injury, including high-energy mechanisms such as high-speed motor vehicle accidents
- Assessing the patient's symptoms, including severe neck pain, radiating pain, numbness or tingling, weakness, and difficulty with coordination or walking
- Performing a thorough physical examination, including palpation of the vertebral bodies and assessment of neck instability
It is essential to prioritize the patient's morbidity, mortality, and quality of life when evaluating and managing whiplash injuries, and to promptly evaluate patients with red flags using appropriate imaging studies such as CT or MRI to rule out serious pathology. As noted by 1, most cases of acute cervical neck pain with radicular symptoms resolve spontaneously or with conservative treatment measures, but patients with red flags require more urgent attention.
From the Research
Red Flags for Whiplash Injury
The following are potential red flags for a patient with whiplash injury:
- Severe neck pain and stiffness
- Interscapular pain
- Arm pain and/or occipital headache
- Neurologic deficits, such as numbness, tingling, or weakness in the arms or legs
- Suspected disc or spinal cord damage
- Fracture or ligamentous damage
- Preexisting degenerative changes in the cervical spine
- Abnormal motion pattern in the cervical spine, such as an S shape curvature 2
- Rotated or inclined head position at the moment of impact, which can lead to more severe symptoms and signs of musculoligamental cervical strain and neural damage 3
- Unprepared occupants, who may have a higher frequency of multiple symptoms and more severe headache 3
- Rear-end collision, which can be associated with a higher frequency of multiple symptoms, especially cranial nerve or brainstem dysfunction 3
Diagnostic Considerations
Diagnostic testing, such as cervical roentgenography, conventional or computed tomography (CT), and magnetic resonance imaging (MRI), may be necessary to rule out more serious causes of neck pain and to assess the extent of the injury 4, 2, 5
- MRI can be particularly useful in assessing soft-tissue lesions and dynamic imaging may show functional disturbances 4
- Advanced MRI sequences can also be used to quantify neuromuscular degeneration in chronic whiplash 6
Treatment Considerations
Treatment regimens should be evidence-based and focus on treatments that have proven to be effective in treating acute and chronic whiplash injuries 5