Acute neck sprain after road traffic accident: a long-term clinical and radiological review

Pathoanatomy of the lower cervical spine facet joints in motor vehicle crash fatalities

Non-lethal injuries to the cervical spine facet joints have previously been described in decedents from motor vehicle crashes and in clinical settings these joints have been identified as potential culprits in chronic neck pain syndromes. The aim of this study was to conduct a detailed examination of the lower cervical spine facet joints in a forensic cohort of motor vehicle crash victims and controls using comparable data from medicolegal autopsy, stereomicroscopy and histological evaluations. Injuries to the cervical spine facet joints were common in the trauma cases and included facet fractures, haemarthrosis, and disruption and bleeding in the synovial folds. The injuries could not be reliably verified on stereomicroscopic evaluation, and routine autopsy procedures did not reveal any of the injuries to the facet joints. Despite the presence of these pathoanatomical lesions in road traffic crash fatalities their prevalence and potential clinical implications in survivors from motor vehicle crashes is unknown.

Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain

The authors undertook a case-control study of chronic neck pain and whiplash injuries in nine states in the United States to determine whether whiplash injuries contributed significantly to the population of individuals with chronic neck and other spine pain. Four hundred nineteen patients and 246 controls were randomly enrolled. Patients were defined as individuals with chronic neck pain, and controls as those with chronic back pain. The two groups were surveyed for cause of chronic pain as well as demographic information. The two groups were compared using an exposure-odds ratio. Forty-five per cent of the patients attributed their pain to a motor vehicle accident. An OR of 4.0 and 2.1 was calculated for men and women, respectively. Based on the results of the present study, it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.

The fluctuation in recovery following whiplash injury 7.5-year prospective review

Forty-two patients with a whiplash injury were assessed at the time of injury, after 3 months, 2 years and a mean of 7.5 years. The range of neck movement, pain, its effect on lifestyle, and psychometric testing were determined in each of the patients. Between 2 and 7.5 years, 5 (12%) described improved symptoms, 12 (29%) complained of continuing pain and 14 (33%) reported increased severity of symptoms since the accident. Neck pain was the commonest complaint in 23 (55%) and low back pain in 18 (43%). Radiation of pain was more common in the severely symptomatic patients. There was no significant difference in either the ages or sex of the patients between the symptomatic and asymptomatic groups. Anxiety and depression correlated well with symptom severity. None of the asymptomatic patients revealed any degree of psychological disturbance compared with 30 (77%) in the symptomatic groups. Symptoms largely stabilised within 3 months but there was significant fluctuation in symptom severity between 3 months and 2 years. This suggests that outcome cannot be accurately assessed during this time. In order to effectively manage those most severely affected by whiplash, patients should be identified within the first 12 weeks following injury if the outcome of their injury is to be modified.

The incidence of whiplash trauma and the effects of different factors on recovery

We performed a prospective study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery. A total of 356 patients were enrolled in the study. All the patients received a comprehensive questionnaire after the injury, and 296 cases responded to the follow-up protocol more than 1 year after the accident. Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors. The annual incidence of acute whiplash trauma in the catchment area was 4.2 per 1,000 inhabitants and 3.2 per 1,000 for whiplash-associated disorder grades 1-3. Thirty-two percent reported persisting disability at follow-up. The following factors were significantly associated with a poor prognosis: pretraumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2-3.

[Whiplash injury of the neck from concepts to facts]

OBJECTIVES

To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.

METHOD

A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.

RESULTS

From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.

CONCLUSION

In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

Injury threshold: whiplash-associated disorders

OBJECTIVES

To review current knowledge and recent concepts of the causes of injuries after minor impact automobile collisions and to acquaint those who treat these types of injuries with possible injury thresholds and mechanisms that may contribute to symptoms.

DATA SOURCES

A review of literature involving mechanisms of injury, tissue tensile threshold, and neurologic considerations was undertaken. A hand-search of relevant engineering, medical/chiropractic, and computer Index Medicus sources in disciplines that cover the variety of symptoms was gathered.

RESULTS

Soft-tissue injuries are difficult to diagnose or quantify. There is not one specific injury mechanism or threshold of injury. With physical variations of tissue tensile strength, anatomic differences, and neurophysiologic considerations, such threshold designation is not possible.

CONCLUSIONS

To make a competent assessment of injury, it is important to evaluate each patient individually. The same collision may cause injury to some individuals and leave others unaffected. With the variability of human postures, tensile strength of the ligaments between individuals, body positions in the vehicle, collagen fibers in the same specimen segment, the amount of muscle activation and inhibition of muscles, the size of the spinal canals, and the excitability of the nervous system, one specific threshold is not possible. How individuals react to a stimulus varies widely, and it is evident peripheral stimulation has effects on the central nervous system. It is also clear that the somatosensory system of the neck, in addition to signaling nociception, may influence the control of neck, eyes, limbs, respiratory muscles, and some preganglionic sympathetic nerves.

Hyperextension soft tissue injuries of the cervical spine--a review

While a full understanding of continuing symptoms following a soft tissue hyperextension injury of the cervical spine remains elusive, recent research has shown that the explanation may lie with occult lesions beyond the musculoskeletal structures of the neck. The balance of the roles of injury, psychological factors, and the effects of litigation has shifted towards the former. However this injury would be unique if the latter two played only a minor role in determining recovery. It seems likely that among the large numbers of patients presenting with symptoms after hyperextension soft tissue injuries, a proportion will have occult bone, joint, or intervertebral disc lesions. Improvements in medical imaging techniques may allow better definition of these specific injuries and the development of more appropriate treatment. The search for a central nervous system lesion in humans continues and until this is demonstrated, many will dispute the existence of an organic brain syndrome. Evidence for significant injury to the temporomandibular joints, ear, and ophthalmic system has been found and this may be amenable to specialist intervention. While there is little evidence for effective treatments of the established injury, reduction in related disability appears most likely to be achieved by prevention. Improvements in automobile design, with particular reference to head restraints, could limit the cost to society of this common and disabling injury.

The rate of recovery following whiplash injury

Fifty consecutive patients with soft-tissue neck injuries following rear end collisions were studied prospectively to assess their rate of recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into one of four groups (A, asymptomatic; B, nuisance; C, intrusive; D, disabling). Fourteen of 15 patients (93%) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86%) remained symptomatic after 2 years. After 1 year, 26 (52%) stated that they had recovered completely, but after 2 years this had fallen to 19 (38%). Nine of the 15 patients who had improved between 3 months and 1 year deteriorated to their previous status, or worse, between 1 and 2 years. In asymptomatic cases, a prognosis that is 93% accurate after 2 years can be given after 3 months, and 86% of patients who are symptomatic after 3 months will remain so after 2 years. However, the severity of their symptoms will change during this period and will be at the same degree of severity in less than 50%.