Redefining whiplash and its management
Whiplash associated disorders: redefining whiplash and its management" by the Quebec Task Force. A critical evaluation.Department of Public Health and Preventive Medicine, Oregon Health Sciences University School of Medicine, Portland, USA.
STUDY DESIGN: The two publications of the Quebec Task Force on Whiplash-Associated Disorders were evaluated by the authors of this report for methodologic error and bias. OBJECTIVES: To determine whether the conclusions and recommendations of the Quebec Task Force on Whiplash-Associated Disorders regarding the natural history and epidemiology of whiplash injuries are valid. SUMMARY OF THE BACKGROUND DATA: In 1995, the Quebec Task Force authored a text (published by the Societe de l'Assurance Automobile du Quebec) and a pullout supplement in Spine entitled "Whiplash-Associated Disorders: Redefining Whiplash and its Management." The Quebec Task Force concluded that whiplash injuries result in "temporary discomfort," are "usually self-limited," and have a "favorable prognosis," and that the "pain [resulting from whiplash injuries] is not harmful." METHODS: The authors of the current report reviewed the text and the supplement for methodologic flaws that may have threatened the validity of the conclusions and recommendations of the Quebec Task Force. RESULTS: Five distinct and significant categories of methodologic error were found. They were: selection bias, information bias, confusing and unconventional use of terminology, unsupported conclusions and recommendations, and inappropriate generalizations from the Quebec Cohort Study. CONCLUSION: The validity of the conclusions and recommendations of the Quebec Task Force regarding the natural course and epidemiology of whiplash injuries is questionable. This lack of validity stems from the presence of bias, the use of unconventional terminology, and conclusions that are not concurrent with the literature the Task Force accepted for review. Although the Task Force set out to redefine whiplash and its management, striving for the desirable goal of clarification of the numerous contentious issues surrounding the injury, its publications instead have confused the subject further.
PMID: 9589544 [PubMed - indexed for MEDLINE]
Headache & The Post-Traumatic Syndrome Following An Auto Accident--Real, Serious, And Requiring Treatment
Headache & The Post-Traumatic Syndrome Following A Traffic AccidentThe post-traumatic syndrome (PTS), previously called postconcussion syndrome, is a pattern of symptoms that can follow mild to moderate head injury (actual cranial impact). It is also seen after flexion-extension trauma (whiplash) in which no actual cranial contact has occurred.
Of the patients seeking help after whiplash, 97% report headache.
The primary symptoms of PTS, usually strikingly consistent from patient to patient, include one or more of the following: head, neck, and shoulder pain; sleep disturbance; cognitive abnormalities; mood and personality changes; and dizziness, with or without vertigo.
The prevailing view of most knowledgeable authorities is that the condition is a neurologic disorder that may arise even if frank unconsciousness has not occurred. Some patients who experience momentary loss of consciousness are not aware of it and fail to report it in emergency departments.
Headache is present in as many as 88% of patients who have mild head injury, persisting for more than 2 months in 60% of patients, even those who have apparently minor trauma. The symptoms do not correlate with the presence or duration of unconsciousness, amnesia, or any identifiable neurodiagnostic finding. Actually, an inverse relation may exist between the severity of head injury, as determined by the duration of posttraumatic amnesia, and the incidence of headache.
The prevailing view is that posttraumatic headache probably reflects a set of pathophysiologic factors that produce the wide-ranging set of symptoms and that cognitive, psychological, behavioral disturbances, and pain reflect the sequelae of brain tissue injury. Moreover, direct or indirect injury to the neck, jaw, or tissues of the scalp may similarly play a role in the development of many of the headache and other painful symptoms.
These acute changes, which may produce pain in the immediate posttraumatic period, may be followed by delayed and chronic disturbances centrally that involve pain modulation. Peripherally, painful injury can induce central pain phenomena (such as windup and sensitization) that include wide dynamic-range neurons and other recently recognized central nervous system factors involved in pain. Moreover, the kindling phenomenon, seen in experimental epilepsy, could influence the evolution from peripheral injury to chronic, centrally maintained pain, possibly producing a daily persistent headache that evolves later.
The pain and headache symptoms may arise from both central or peripheral factors. Persistent pain, particularly neck ache, may arise from traumatic injury to cervical facet joints or the third cervical nerve, estimated to be involved in 58% of patients whose major complaint after whiplash is headache. Moreover, entrapment or trauma to the third occipital nerves by osteophytes of C2-3 or traumatic arthritis of C2-3 is relevant and often overlooked, as are instances of occipital neuralgia and facet joint disturbances. Jaw injury, styloid process trauma, and other peripheral causes of pain are likewise frequently overlooked.
The neurocognitive impairment results in reduced concentration, an inability to process information at a normal pace, and memory impairment. These have been well delineated in the literature.
Neuropsychiatric and behavioral phenomena are likewise noted. Recently, in a well-controlled study, noted amelioration of psychological disturbances in patients who had head and neck pain when pain control was established.
A variety of spells or seizure-like events is also reported in patients who have PTS. Although true epilepsy or syncope rarely occurs, a variety of nonspecific, periodic, paroxysmal events is noted, including narcolepsy or cataplexylike phenomena. These events should not be discounted simply because of the absence of true epilepsy features or because they represent variations from classical presentations.
Diagnostically, no diagnostic study can confirm the diagnosis; conversely, neither do they refute it. Neurocognitive tests are the most sensitive practical studies to assess cerebral dysfunction. MRI or CT imaging rules in or rules out serious alterations in brain, which are either related or unrelated to the trauma.
The neurologist must rule out organic disturbances that might mimic PTS or cause persistent head or neck ache. Some of these may be the direct result of the trauma itself. These include subdural or epidural hematomas, CSF hypotension (from traumatic leak), cerebral vein thrombosis, cerebral hemorrhage, true seizures, posttraumatic hydrocephalus, vertebral (facet joint)/cervical root/cervical nerve/suboccipital injury, temporomandibular disorders, or styloid ligament or process damage.
In a review of the available literature after 1 month 31% to 90% of patients still had headache. At 2 to 3 months postinjury, 32% to 78% of patients still had headache. One year after injury, 8% to 35% of patients still had headache. Between 2 and 4 years after injury, as many as 20% to 24% of patients have persistent headache. Neurocognitive, dizziness, and mood symptoms may persist for years.
The legitimacy of this condition and the believability of patients reporting largely subjective complaints have been challenged because of long-standing assumptions regarding the influence of litigational dynamics on the presence and persistence of symptoms. However, the premise that protracted cases result primarily from litigation-related motives or other nonphysiologic circumstances is not currently supported by the data.
On balance, the prevailing studies fail to support either that the presence of symptoms or their termination is linked to litigational factors.
It is acknowledged that pretraumatic or posttraumatic psychological factors may influence and confound the clinical circumstances. These do not give license, however, to a generalization that most cases of protracted symptomatology are rooted in litigational dynamics.
It is more likely that protracted cases result from a failure to alleviate valid symptomatology effectively. It has been demonstrated in a well-controlled study that posttraumatic psychological disturbances after whiplash were alleviated when pain control was established, which required invasive deep upper cervical neuroblockade.
Accumulating data on brain changes after trauma and a variety of other factors compel the neurologist to approach posttraumatic symptoms in a cautious and prudent way.
Although by no means certain, it is likely that most patients fulfilling the criteria and demonstrating the features of this syndrome suffer legitimate symptomatology. Overlooked or misdiagnosed neurocognitive, cervical, or peripheral pathology may better explain persistent symptoms than assumptions regarding litigational motivation.
PTS can no longer be arbitrarily denied its physiologic legitimacy, particularly with such compelling clinical support and growing physiologic data.
There is yet much more to learn than is currently known. The absence of objective markers does not prove the absence of legitimacy.
The history of medicine is replete with examples of illnesses suffered long before they were formally discovered. Generalized prejudice and cynicism must give way to at least reasoned neutrality in the face of strong, albeit subjective, and circumstantial clinical evidence and growing, yet preliminary, objectifying data.
Whiplash-shake injury syndrome due to nonaccidental trauma
The infant whiplash-shake injury syndrome
The infant whiplash-shake injury syndrome: a clinical and pathological study.
Hadley MN, Sonntag VK, Rekate HL, Murphy A.
Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.
The cases of 13 infants (median age, 3 months) who sustained nonaccidental trauma were reviewed. All presented with profound neurological impairment, seizures, retinal hemorrhages, and intracranial subarachnoid and/or subdural hemorrhages. Of 8 infants who died, autopsy was performed on 6. No patient had a skull fracture, and only one had an extracalvarial contusion. Five of the 6 patients on whom autopsy was performed had injuries at the cervicomedullary junction consisting of sub- or epidural hematomas of the cervical spinal cord with proximal spinal cord contusions. The authors conclude that direct cranial trauma is not an essential element of the injury mechanism in young patients who sustain severe whiplash-shake injuries. In addition to the classic injuries reported to occur with the shaken-baby syndrome, hemorrhages and contusions of the high cervical spinal cord may contribute to morbidity and mortality.
Motor vehicle accidents with a whiplash mechanism of injury
Whiplash injuries usually result in neck pain owing to myofascial trauma: "States. Proper adjustment of head restraints can reduce the incidence of neck pain in rear-end collisions by 24%. Persistent neck pain is more common in women by a ratio of 70:30. Whiplash injuries usually result in neck pain owing to myofascial trauma, which has been documented "
Some observations on whiplash injuries.
Evans RW.
Neurology Section, AMI Park Plaza Hospital, Houston, Texas.
Motor vehicle accidents with a whiplash mechanism of injury are one of the most common causes of neck injuries, with an incidence of perhaps 1 million per year in the United States. Proper adjustment of head restraints can reduce the incidence of neck pain in rear-end collisions by 24%. Persistent neck pain is more common in women by a ratio of 70:30. Whiplash injuries usually result in neck pain owing to myofascial trauma, which has been documented in both animal and human studies. Headaches, reported in 82% of patients acutely, are usually of the muscle contraction type, often associated with greater occipital neuralgia and less often temporomandibular joint syndrome. Occasionally migraine headaches can be precipitated. Dizziness often occurs and can result from vestibular, central, and cervical injury. More than one third of patients acutely complain of paresthesias, which frequently are caused by trigger points and thoracic outlet syndrome and less commonly by cervical radiculopathy. Some studies have indicated that a postconcussion syndrome can develop from a whiplash injury. Interscapular and low back pain are other frequent complaints. Although most patients recover within 3 months after the accident, persistent neck pain and headaches after 2 years are reported by more than 30% and 10% of patients. Risk factors for a less favorable recovery include older age, the presence of interscapular or upper back pain, occipital headache, multiple symptoms or paresthesias at presentation, reduced range of movement of the cervical spine, the presence of an objective neurologic deficit, preexisting degenerative osteoarthritic changes; and the upper middle occupational category. There is only a minimal association of a poor prognosis with the speed or severity of the collision and the extent of vehicle damage. Whiplash injuries result in long-term disability with upward of 6% of patients not returning to work after 1 year. Although litigation is very common and always raises questions of secondary gain in patients with persistent symptoms, most patients are not cured by a verdict. Acute treatment of neck pain consists of ice for 24 hours followed by heat applications, pain pills, NSAIDs, and muscle relaxants. Trigger point injections can be beneficial in both the acute and the persistent phases. Use of cervical collars should probably be kept to a minimum during the first 2 to 3 weeks after the injury and then avoided. Early passive mobilization and range of motion exercises may accelerate recovery. Physical therapy and transcutaneous nerve stimulators may be helpful in reducing pain and improving movement.(ABSTRACT TRUNCATED AT 400 WORDS)
Pediatric neck injuries
Pediatric neck injuries. A clinical study.
Pediatric neck injuries. A clinical study.
Hill SA, Miller CA, Kosnik EJ, Hunt WE.
This review of pediatric neck injuries includes patients admitted to Children's Hospital of Columbus, Ohio, during the period 1969 to 1979. The 122 patients with neck injuries constituted 1.4% of the total neurosurgical admissions during this time. Forty-eight patients had cervical strains; 74 had involvement of the spinal column; and 27 had neurological deficits. The injuries reached their peak incidence during the summer months, with motor-vehicle accidents accounting for 31%, diving injuries and falls from a height 20% each, football injuries 8%, other sports 11%, and miscellaneous 10%. There is a clear division of patients into a group aged 8 years or less with exclusively upper cervical injuries, and an older group with pancervical injuries. In the younger children, the injuries involved soft tissue (subluxation was seen more frequently than fracture), and tended to occur through subchondral growth plates, with a more reliable union than similar bone injuries. In the older children, the pattern and etiology of injury are the same as in adults. The entire cervical axis is at risk, and there is a tendency to fracture bone rather than cartilaginous structures.
Neck injuries resulting from rear-end vehicle collisions
The prognosis of neck injuries resulting from rear-end vehicle collisionsThe prognosis of neck injuries resulting from rear-end vehicle collisions.
Norris SH, Watt I.
Injury of the neck may result when a motor vehicle is run into from behind; such injury is frequently the cause of prolonged disability and litigation. We report a series of 61 patients with these injuries. A classification, based upon the presenting symptoms and physical signs has been evolved. This classification is shown to be a reliable basis for formulating a prognosis. Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, muscle spasm, and pre-existing degenerative spondylosis.
Whiplash injuries in low-speed rear impacts
Do whiplash injuries occur in low-speed rear impactsAcademy of Manual Medicine, Westfalische Wilhelms-Universitat Munster, Germany.
A study was conducted to find out whether in a rear-impact motor vehicle accident, velocity changes in the impact vehicle of between 10 and 15 km/h can cause so-called
whiplash injuries. An assessment of the actual injury mechanism of such whiplash injuries and comparison of vehicle rear-end collisions with amusement park bumper car collisions was also carried out. The study was based on experimental biochemical, kinematic, and clinical analysis with volunteers. In Europe between DM 10 and 20 billion each year is paid out by insurance companies alone for whiplash injuries, although various studies show that the biodynamic stresses arising in the case of slight to moderate vehicle damage may not be high enough to cause such injuries. Most of these experimental studies with cadavers, dummies, and some with volunteers were performed with velocity changes below 10 km/h. About 65% of the insurance claims, however, take place in cases with velocity changes of up to 15 km/h. Fourteen made volunteers (aged 28-47 years; average 33.2 years) and five female volunteers (aged 26-37 years; average 32.8 years) participated in 17 vehicle rear-end collisions and 3 bumper car collisions. All cars were fitted with normal European bumper systems. Before, 1 day after and 4-5 weeks after each vehicle crash test and in two of the three bumper car crash tests a clinical examination, a computerized motion analysis, and an MRI examination with Gd-DTPA of the cervical spine of the test persons were performed. During each crash test, in which the test persons were completely screened-off visually and acoustically, the muscle tension of various neck muscles was recorded by surface electromyography (EMG). The kinematic responses of the test persons and the forces occurring were measured by accelerometers. The kinematic analyses were performed with movement markers and a screening frequency of 700 Hz. To record the acceleration effects of the target vehicle and the bullet vehicle, vehicle accident data recorders were installed in both. The contact phase of the vehicle structures and the kinematics of the test persons were also recorded using high-speed cameras. The results showed that the range of velocity change (vehicle collisions) was 8.7-14.2 km/h (average 11.4 km/h) and the range of mean acceleration of the target vehicle was 2.1-3.6 g (average 2.7 g). The range of velocity change (bumper car collisions) was 8.3- 10.6 km/h (average 9.9 km/h) and the range of mean acceleration of the target bumper car was 1.8-2.6 g (average 2.2 g). No injury signs were found at the physical examinations, computerized motion analyses, or at the MRI examinations. Only one of the male volunteers suffered a reduction of rotation of the cervical spine to the left of 10 degrees for 10 weeks. The kinematic analysis very clearly showed that the whiplash mechanism consists of translation/extension (high energy) of the cervical spine with consecutive flexion (low energy) of the cervical spine: hyperextension of the cervical spine during the vehicle crashes was not observed. All the tests showed that the EMG signal of the neck muscles starts before the head movement takes place. The stresses recorded in the vehicle collisions were in the same range as those recorded in the bumper car crashes. From the extent of the damage to the vehicles after a collision it is possible to determine the level of the velocity change. The study concluded that, the "limit of harmlessness" for stresses arising from rear-end impacts with regard to the velocity changes lies between 10 and 15 km/h. For everyday practice, photographs of the damage to cars involved in a rear-end impact are essential to determine this velocity change. The stress occurring in vehicle rear-end collisions can be compared to the stress in bumper car collisions.
Spine - Abstract: Volume 23(12) June 15, 1998 p 1314-1323 Morphometry of Human Neck Muscles.
Morphometry of Human Neck Muscles
Objective. To describe systematically the musculotendinous lengths, fascicle lengths, pennation angles, and physiologic cross-sectional areas of neck and shoulder muscles implicated in head movement.
Summary of Background Data. In previous studies of neck-muscle anatomy, researchers described only a subset of muscle features, often using crude or indirect methods. None used microdissected muscles to correct measured parameters for the presence of multiple fiber compartments, internal aponeuroses, or variations in fiber or sarcomere length required for quantitative models of force-generating capabilities.
Methods. Muscle mass, pennation angle, fascicle length, and sarcomere length were measured in 14 neck muscles from 10 human cadavers. Architecturally complex muscles with multiple attachments were divided into subvolumes, and each subvolume was examined from both the superficial and deep surfaces. Internal aponeuroses were microdissected within muscles to characterize architectural specializations. Physiologic cross-sectional areas were calculated from the morphometric data.
Results. The neck musculature was architecturally complex. Many muscles crossed two or more joints and had multiple attachments to different bones. In some, the presence of tendons and aponeuroses was associated with specializations in fascicle organization. Considerable interindividual variation was found in the number and location of tendinous insertions of the scalenes and longissimus capitis muscles. In addition, rhomboideus showed significant variations in its size and shape. The cross-sectional areas of neck muscles from large and small subjects did not scale proportionately with body height and weight, nor did individual muscles with widely varying cross-sectional areas (0.3-15.3cm2) scale from one subject to another.
Conclusions. The accuracy of morphometry can be improved by incorporating measurements made by microdissecting neck muscles. The presence of aponeurotic attachments can greatly shorten fascicle length; failure to identify such attachments can lead to underestimates of cross-sectional areas. Accuracy of a generalized model of the neck is also improved by normalizing sarcomere lengths in all muscles.
The National Football Head and Neck Injury Registry: 14-year report on cervical quadriplegia
The National Football Head and Neck Injury Registry:
"The specter of catastrophic cervical neurotrauma resulting from athletic participation, although infrequent, has been consistently associated with football, water sports, gymnastics, rugby, and ice hockey. Injury involving intracranial hemorrhage can result in death or permanent neurologic impairment, whereas certain fractures and dislocations of the cervical spine are associated with quadriplegia. Athletic injuries to both the central nervous system and spinal cord demand our attention as an active area of clinical and basic injury. A review of the available literature reveals changing injury patterns as well as current concepts regarding the mechanism responsible for most athletic injuries to these structures. Accurate descriptions of the mechanism(s) responsible for a particular injury transcend simple academic interest. In order that preventive measures be implemented, the manner in which injury occurs must be accurately defined. The purpose of this article is to describe how the application of this principle resulted in the significant reduction of cervical spine injuries associated with quadriplegia that have occurred in tackle football since 1976."
Neck Injury in Sports
Neck Injury in Sports:
"Neck injuries in sports are common, typically debilitating, and quite predictable in retrospect by mechanism of injury as to one of four natures--sprains/strains, fractures, brachial plexus pinches/stretches, and spinal cord injury. Of these, the spinal cord injury, whether a concussion or contusion or physical disruption, is obviously the most severe and also, ironically, the best tracked because of its definition and notoriety when it is experienced. This article discusses the essence of what has been learned epidemiologically over recent decades since the advent of organized attention to spinal cord injuries among athletes."
SpringerLink - Article
Neck sprain in patients injured in car accidents: a retrospective study covering the period 1970-1994
Abstract:
Abstract During the 25-year period 1970-1994 694 patients were diagnosed with neck sprain resulting from a car accident at the Emergency Room of the University Hospital Groningen. The purpose of the present study was to analyse the prevalence, groups at risk and trends in these patients, taking into account changes in the number of cars per inhabitant and the average number of kilometres driven. We defined the population as car accident victims diagnosed with neck sprain. Binominal tests were used to obtain measures of statistical significance. Over the 25-year period a steady increase in the number of these patients was observed, from 10 in 1970 to 122 in 1994. The highest prevalence was found for the age group 25- to 29-year olds (28.3 per 100,000), followed by 40- to 44-year-olds (27.9 per 100,000). Across the life span, the male: female ratio was 1 : 0.98. Eight percent of the victims were treated as inpatients. The increase in the number of car accident victims with neck sprain appears not to be an isolated phenomenon, because a parallel rise in the number of cars per inhabitant and in the average number of kilometres driven was found. No direct relation was observed between seat belt legislation and the increase in neck sprain injuries. The effect of the media on awareness of the consequences of car accidents is discussed.
