The role of non-rigid cervical collar in pain relief and functional restoration after whiplash injury: a systematic review and a pooled analysis of randomized controlled trials

Global trends and hotspots related to whiplash injury: A visualization study

Whiplash injury, commonly occurring as a result of car accidents, represents a significant public health concern. However, to date, no comprehensive study has utilized bibliometric approaches to analyze all published research on whiplash injury. Therefore, our study aims to provide an overview of current trends and the global research landscape using bibliometrics and visualization software. We performed a bibliometric analysis of the data retrieved and extracted from the Web of Science Core Collection database in whiplash injury research up to December 31, 2022. Research articles were assessed for specific characteristics, such as year of publication, country/region, institution, author, journal, field of study, references, and keywords. We identified 1751 research articles in the analysis and observed a gradual growth in the number of publications and references. The United States (379 articles, 21.64%), Canada (309 articles, 17.65%), and Australia (280 articles, 16.00%) emerged as the top-contributing countries/regions. Among institutions, the University of Queensland (169 articles, 9.65%) and the University of Alberta (106 articles, 6.05%) demonstrated the highest productivity. "Whiplash," "Neck Pain," "Cervical Spine Disease," and "Whiplash-associated Disorders" are high-frequency keywords. Furthermore, emerging areas of research interest included traumatic brain injury and mental health issues following whiplash injury. The number of papers and citations has increased significantly over the past 2 decades. Whiplash injury research is characteristically multidisciplinary in approach, involving the fields of rehabilitation, neuroscience, and spinal disciplines. By identifying current research trends, our study offers valuable insights to guide future research endeavors in this field.

Interscapular Pain after Anterior Cervical Discectomy and Fusion: Does Zygapophyseal Joints over Distraction Play a Role?

Introduction: Anterior cervical discectomy and fusion (ACDF) for cervical disc herniation (CDH) is commonly performed. Specific post-operative complications include dysphagia, dysphonia, cervicalgia, adjacent segment disorder, cage subsidence, and infections. However, interscapular pain is commonly reported by these patients after surgery, although its mechanisms have not been clarified yet. Methods: This retrospective series of 31 patients undergoing ACDF for CDH at a single Academic Hospital. Baseline and post-operative clinical, radiological, and surgical data were analyzed. The linear regression analysis was conducted to identify any factor independently influencing the incidence rate of post-operative interscapular pain. Results: The mean age was 57.6 ± 10.8 years, and the M:F ratio was 2.1. Pre-operative mean VAS-arm was 7.15 ± 0.81 among the 20 patients reporting brachialgia, and mean VAS-neck was 4.36 ± 1.43 among those 9 patients reporting cervicalgia. At 1 month, interscapular pain was still reported by 8 out of the 17 patients who experienced it post-operatively, and it was recovered in all patients after 2 months. The regression analysis showed that interscapular pain was not directly associated with age (p = 0.74), gender (p = 0.46), smoking status (p = 0.44), diabetes (0.42), pre-operative brachialgia (p = 0.21) or cervicalgia (p = 0.48), symptoms duration (p = 0.13), baseline VAS-arm (p = 0.11), VAS-neck (p = 0.93), or mJOA (p = 0.63) scores, or disc height modification (p = 0.90). However, the post-operative increase in the mean zygapophyseal joint rim distance was identified as an independent factor in determining interscapular pain (p = 0.02). Conclusions: Our study revealed that the onset of interscapular pain following ACDF may be determined by over distraction of the zygapophyseal joint rim. Then, proper sizing of prosthetic implants could reduce this painful complication.

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing.

METHODS

The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes.

RESULTS

Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction ≥ 1° (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted.

CONCLUSIONS

Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated.

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis

INTRODUCTION

Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma.

METHOD

A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars.

RESULTS

A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion.

CONCLUSION

Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome.

LEVEL OF EVIDENCE

II, Systematic Review.

Citation analysis of the most influential publications on whiplash injury: A STROBE-compliant study

Whiplash injury is a common diagnosis and causes substantial economic burden. Numerous papers have been published to provide new insights into whiplash injury. However, so far there has not been a comprehensive analysis of the most influential publications on whiplash injury. This study aimed to determine the 100 most cited publications on whiplash injury and analyze their characteristics. A keyword search was conducted using the Web of Science database. The top 100 cited publications relevant to whiplash injury were gathered. The main characteristics including title, year of publication, citation, authorship, journal, country, institution, and topic were generated. The number of citations of the top 100 cited publications ranged from 82 to 777. Fifteen countries contributed the top 100 publications. Australia had the largest number of publications (26), followed by the United States (21), and Canada (12). The majority of the publications were from Europe (40) and North America (33). A total of 19 institutions and 17 authors published more than one publication. The University of Queensland (16) and the author Sterling M (7) had the leading publication record. This is the first citation analysis to identify and characterize the highest impact researches on whiplash injury. The present analysis provides the most influential studies on whiplash injury, and reveals the leading journals, counties, institutions, and authors with special contributions in this filed. The list may serve as an archive of historical development of whiplash injury and a basis for further research.

Differences between spinal cord injury and cervical compressive myelopathy in intramedullary high-intensity lesions on T2-weighted magnetic resonance imaging: A retrospective study

Increases in aging populations have raised the number of patients with cervical spinal cord injury (SCI) without fractures due to compression of the cervical spinal cord. In such patients, it is necessary to clarify whether SCI or cervical compressive myelopathy (CCM) is the cause of disability after trauma. This study aimed to clarify the differences in magnetic resonance imaging (MRI) features between SCI and CCM. Overall, 60 SCI patients and 60 CCM patients with intramedullary high-intensity lesions on T2-weighted MRI were included in this study. The longitudinal lengths of the intramedullary T2 high-intensity lesions were measured using sagittal MRI sections. Snake-eye appearance on axial sections was assessed as a characteristic finding of CCM. The T2 values of the high-intensity lesions and normal spinal cords at the first thoracic vertebra level were measured, and the contrast ratio was calculated using these values. The longitudinal length of T2 high-intensity lesions was significantly longer in SCI patients than in CCM patients. Snake-eye appearance was found in 26 of the 60 CCM patients, but not in SCI patients. On both the sagittal and axial images, the contrast ratio was significantly higher in the SCI group than in the CCM group. Based on these results, a diagnostic scale was created. This scale made it possible to distinguish between SCI and CCM with approximately 90% accuracy.

Use of Soft Cervical Collar among Whiplash Patients in Two Italian Emergency Departments Is Associated with Persistence of Symptoms: A Propensity Score Matching Analysis

Purpose: Although the use of soft cervical collars in the emergency department (ED), for whiplash-associated disorders (WAD), is controversial, it is still widely adopted. The purpose of our study was to investigate the impact of the early use of soft cervical collars on the return to the ED, within three months of a road traffic collision. Methods: We conducted a retrospective observational study on WAD patients from two EDs in Verona (Italy). Patients in the earlier acute phase of WAD (within 48 h from the trauma) were included; those with serious conditions (WAD IV) were excluded. As an end point, we considered patients who returned to the ED complaining of WAD symptoms within three months as positive outcome for WAD persistence. Results: 2162 patients were included; of those, 85.4% (n = 1847/2162) received a soft cervical collar prescription. Further, 8.4% (n = 156/1847) of those with a soft cervical collar prescription, and 2.5% (n = 8/315) of those without a soft cervical collar (p < 0.001) returned to the ED within three months. The use of the soft cervical collar was an independent risk factor for ED return within three months, with an OR, adjusted for possible clinical confounders, equal to 3.418 (95% CI 1.653–7.069; p < 0.001). After the propensity score matching, 25.5% of the patients (n = 25/98) using the soft cervical collar returned to the ED at three months, compared to the 6.1% (n = 6/98) that did not adopt the soft cervical collar. The use of a soft cervical collar was associated with ED return with an OR = 4.314 (95% CI 2.066–11.668; p = 0.001). Conclusions: Our study shows that the positioning of the soft collar in a cohort of patients with acute WAD, following a rear-end car collision, is an independent potential risk factor to the return to the ED. Clinically, the use of the collar is a non-recommended practice and seems to be related to an increased risk of delayed recovery. There is a need to inform healthcare providers involved in the ED of the aim to limit the use of the soft cervical collar. A closer collaboration between clinicians (e.g., physicians, physical therapists, nurses) is suggested in the ED. Future primary studies should determine differences between having used or not having used the collar, and compare early physical therapy in the ED compared with the utilization of the collar.

Soft-collar use in rehabilitation of whiplash-associated disorders - A systematic review and meta-analysis

BACKGROUND

Active rehabilitation of Whiplash Associated Disorders (WAD) is favoured over passive modalities such as soft-collars. However, the effectiveness of soft-collar use remains unclear.

OBJECTIVE

To investigate the effectiveness of soft-collar use on pain and disability in WAD.

DESIGN

Systematic review.

METHOD

Databases (AMED, CINAHL Complete, Cochrane Library, Embase, Medline, PEDro, PsycINFO, PubMed, SPORTDiscus) were searched for guidelines, reviews and RCTs on soft-collar use as part of WAD treatment. Reference lists of reviews and guidelines were screened for additional RCTs. Study quality was rated using the PEDro-scale and overall quality of evidence with GRADE.

RESULTS

Four RCTs (n = 409) of fair-good quality (PEDro-scores) were included with three using a soft collar in addition to other conservative treatment while one study compared soft-collar use to act-as-usual. All studies found that an active or act-as-usual approach was more effective in reducing pain intensity compared to soft-collar use, confirmed by meta-analysis (two RCTs with data: SMD of -0.80 (-1.20, -0.41)). No studies reported disability outcomes while contrasting results were found between groups regarding total cervical range of motion (two RCTs with data: SMD of 0.16 (-0.21, 0.54)) or rotation (two RCTs with data: SMD of 0.54 (-0.19, 1.27)). Overall quality of the evidence was low to very low.

CONCLUSION

All four RCTs favoured an active approach/act-as-usual over soft-collar treatment. However, due to methodological concerns and low certainty of evidence, future studies investigating soft collar use in combination with an active rehabilitation strategy for acute/subacute WAD are needed.

Long-term Radiologic and Clinical Outcomes after Three-level Contiguous Anterior Cervical Diskectomy and Fusion without Plating: A Multicentric Retrospective Study

BACKGROUND

 Anterior cervical diskectomy and fusion (ACDF) has been providing good surgical, clinical, and radiologic outcomes in patients suffering from cervical degenerative disk disease (DDD). However, the role of anterior plating is still debated, especially in three-level procedures. This study aimed to investigate long-term clinical and radiologic outcomes and complications after three-level contiguous ACDF without plating for cervical DDD.

METHODS

 Two institutional databases were retrieved (January 2009-December 2014) for patients treated with three-level contiguous ACDF without plating. Minimum follow-up (FU) was 5 years. Demographical data, smoking status, implant types, Neck Disability Index (NDI), visual analog scale (VAS) for neck pain, complications, fusion rate, adjacent segment degeneration (ASD), cervical lordosis (CL), and residual segmental mobility were evaluated.

RESULTS

 We enrolled 21 patients. Tantalum and carbon fiber cages were implanted, respectively, in 13 and 8 patients. The mean FU length was 5.76 ± 0.87 years. Mean NDI score was 78.29 ± 9.98% preoperatively and 8.29 ± 1.67% at last FU (p < 0.01), whereas mean VAS score decreased from 7.43 ± 1.14 preoperatively to 0.95 ± 0.95 at last FU (p < 0.01). Complications were one postoperative hematoma, one superficial wound infection, and five cases of postoperative dysphagia (recovered within 3 days). The fusion rate was 90% and ASD was reported in three (14%) cases. The mean CL was 6.33 ± 2.70 degrees preoperatively, 8.19 ± 1.97 degrees 3 months after surgery (p = 0.02), and 7.62 ± 1.96 degrees at latest FU. There was no residual mobility on every operated segment at last FU. The smoking status was an independent risk factor for nonfusion in this case series (p = 0.02).

CONCLUSIONS

 Three-level contiguous ACDF without plating seems to be an effective treatment for cervical DDD. Properly designed comparative clinical trials are needed to further investigate this topic.

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study

OBJECTIVE

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS

The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS

Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS

Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.