What is the appropriate evaluation and treatment for a patient with neck pain presenting two weeks after a motor vehicle accident (MVA)?

Neck Pain Two Weeks After Motor Vehicle Accident

For a patient presenting with neck pain two weeks after an MVA, begin exercise and mobilization of the cervical spine immediately, as this has been proven effective in reducing symptoms of whiplash-associated disorder (WAD), while using imaging selectively only to exclude delayed cervical spine instability that would prevent safe mobilization. 1

Clinical Assessment Priority

The diagnosis and prognosis of WAD is based almost exclusively on clinical and psychosocial data, not imaging. 1 At two weeks post-MVA, focus your evaluation on:

• Psychological distress level - This is the strongest predictor of persistent neck pain, more important than collision characteristics 2
• Pre-collision history of widespread body pain - Increases risk of persistent symptoms more than fivefold 2
• Initial neck disability and whiplash-associated symptoms - These predict chronicity better than vehicle damage or collision speed 2
• Presence of interscapular or upper back pain - Associated with less favorable recovery 3
• Occipital headache and multiple symptoms - Risk factors for poor prognosis 3

Imaging Strategy

Imaging has been found to be of little usefulness in diagnosing and predicting prognosis of WAD. 1 However, imaging serves one critical purpose at this stage:

When to Image:

• Consider flexion-extension radiographs if you need to exclude delayed cervical spine instability before initiating mobilization exercises 1
• In the outpatient setting at two weeks, patients can tolerate upright imaging better than acutely, making flexion-extension views more adequate 1
• Ensure at least 30° of excursion for both flexion and extension, as instability may only appear near terminal range 1

When NOT to Image:

• Do not obtain MRI routinely - While MRI is most sensitive for ligament injury, it has poor specificity (64-77%) and false-positive rates of 25-40%, leading to overestimation of injury severity 1
• No role for MRA, CTA, or arteriography unless clinical suspicion for vascular injury exists 1

Treatment Algorithm

Immediate Management (Week 2):

Discontinue cervical collar use - Collar use should be kept to a minimum during the first 2-3 weeks, then avoided entirely 3

Initiate active mobilization immediately:

• Early passive mobilization and range of motion exercises accelerate recovery 3
• Exercise and mobilization have been shown effective in reducing symptoms of both acute and chronic WAD 1

Pharmacologic management:

• NSAIDs for pain control 3
• Muscle relaxants if muscle spasm is prominent 3
• Consider trigger point injections for persistent myofascial pain 3

Physical therapy:

• Heat applications (after initial 24-hour ice period has passed) 3
• Transcutaneous nerve stimulators may help reduce pain and improve movement 3

Prognosis Counseling

Set realistic expectations: More than 30% of patients report persistent neck pain at 2 years, and more than 10% report persistent headaches 3. However, most patients (approximately 73%) do recover within 3 months 3.

High-risk features for chronicity (more than fivefold increased risk):

• High psychological distress 2
• Pre-collision widespread body pain 2
• Multiple whiplash-associated symptoms 2
• Significant initial neck disability 2

Common Pitfalls to Avoid

• Do not over-rely on imaging - There are no radiographic findings that confidently differentiate WAD from nontraumatic neck pain 1
• Do not delay mobilization - Prolonged immobilization worsens outcomes 3
• Do not assume litigation explains symptoms - Most patients are not cured by a verdict; persistent symptoms are real 3
• Do not ignore psychological factors - These predict outcome better than collision severity 2
• Do not expect MRI to guide treatment - MRI findings correlate poorly with symptoms and prognosis 1