Are MRI high-signal changes of alar and transverse ligaments in acute whiplash injury related to outcome?

C1 Facetectomy and Ventral Fixation of Occipitoatlantoaxial Complex for Concurrent Congenital Atlanto-Occipital Dislocation and Atlantoaxial Instability in a Toy Poodle

An 8-month-old, 3.4 kg, castrated male Toy Poodle was referred for progressive tetraparesis and respiratory disorder without a history of trauma. Repeated computed tomography (CT) and magnetic resonance imaging (MRI) with different positions of the neck revealed concurrent atlanto-occipital dislocation (AOD) and atlantoaxial instability (AAI) with spinal cord compression. This case was unique due to its congenital nature and the absence of trauma. The surgical treatment involved precise removal of the C1 vertebra's ventral articular facet, which was compressing on the spinal cord, attributed to its fixed and malaligned position within the atlantooccipital joint. Following facetectomy, the stabilization of the occipital bone to the C2 vertebra was achieved by screws, wire, and polymethyl methacrylate. Two days after surgery, the dog recovered ambulation and showed gradual improvement in gait, despite mild residual ataxia. Postoperative CT and radiographs showed successful decompression of the spinal cord. The screw loosening was confirmed at 114 days, which was managed successfully by extracting the affected screws. Through the 21-month monitoring period, the dog showed a normal gait with a wide-based stance of the pelvic limbs when standing and experienced no pain. This case represents the first report of concurrent congenital AOD and AAI treated with a ventral surgical approach, contributing new insights to the understanding and management of such complex cranio-cervical junction disorders in veterinary neurosurgery.

Post-Traumatic Atlanto-Axial Instability: A Combined Clinical and Radiological Approach for the Diagnosis of Pathological Rotational Movement in the Upper Cervical Spine

Post-traumatic rotational instability at the atlanto-axial (C1-2) joint is difficult to assess, much less quantify, due to the orientation and motion plane of the joint. Prior investigations have demonstrated that a dynamic axial CT scan, during which the patient maximally rotates the head right and left, can be used to evaluate and quantify the amount of residual overlap between the inferior articulating facet of C1 and the superior facet of C2, as an index of ligamentous laxity at the joint. We have previously demonstrated that a novel orthopedic test of rotational instability, the atlas-axis rotational test (A-ART), may have utility in identifying patients with imaging evidence of upper cervical ligament injury. In the present investigation, we assessed the correlation between a positive A-ART and a CT scan assessment of the relative quantity of residual C1-2 overlap, as a percent of the superior articulating facet surface area of C2. A retrospective review was conducted of the records of consecutive patients presenting to a physical therapy and rehabilitation clinic, over a 5-year period (2015-20) for chronic head and neck pain after whiplash trauma. The primary inclusion criteria were that the patient had undergone both a clinical evaluation with A-ART and a dynamic axial CT to evaluate for C1-2 residual facet overlap at maximum rotation. The records for a total of 57 patients (44 female/13 male) were identified who fit the selection criteria, and among these, there were 43 with a positive A-ART (i.e., "cases") and 14 with a negative A-ART (i.e., "controls). The analysis demonstrated that a positive A-ART was highly predictive of decreased residual C1-2 facet overlap: the average overlap area among the cases was approximately one-third that of the control group (on the left, 10.7% versus 29.1%, and 13.6% versus 31.0% on the right). These results suggest that a positive A-ART is a reliable indicator of underlying rotational instability at C1-2 in patients with chronic head and neck symptoms following whiplash trauma.

Tectorial Membrane Injury, Frequently Identified in Adult Trauma Patients Who Undergo Occipital-Cervical Fusion for Craniocervical Instability

Background In the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury. Methods Adult patients requiring occipital-cervical fusion were identified retrospectively utilizing keyword searches in cervical computed tomography and magnetic resonance imaging reports between 2012 and 2020 using Nuance mPower software (Nuance, Burlington, MA). The cervical magnetic resonance imaging examinations for these patients were reviewed for craniocervical ligamentous injury by two neuroradiologists. Descriptions of craniocervical junction injuries, demographic information, clinical history, surgical management, and global outcomes were recorded. Results Nine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion. All nine patients demonstrated a ligamentous tear in at least one of the four major craniocervical junction ligaments - the occipital condylar-C1 capsular ligaments, alar ligaments, tectorial membrane, and posterior atlantooccipital membrane. The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s). There was wide variability in the number of major craniocervical junction ligaments torn, ranging from one ligament to all four ligaments. Four patients suffered persistent neurologic deficits following surgery. Conclusion Craniocervical injury is best evaluated by cervical magnetic resonance imaging. In the absence of overt craniocervical dissociation, we propose that an injury of the tectorial membrane in the adult population may indicate patients with significant craniocervical instability, possibly necessitating occipital-cervical fusion.

The nosological classification of whiplash-associated disorder: a narrative review

Whiplash-associated disorder (WAD) is the most common complaint and purported cause of chronic disability associated with motor vehicle collisions in North America. However, its construct validity remains controversial. This narrative review of the literature summarises the evidence underlying the most commonly theorised biological and psychosocial mechanisms of WAD pathogenesis. While the face validity of WAD is good, empirical evidence supporting the various constructs suggesting a causal link between a trauma mechanism and the development of symptoms is poor. Because individual expectations of recovery are outcome-predictive, future research is necessary to develop a better understanding of how to enhance expectancies in order to help affected motorists gain a greater sense of control over their health and wellbeing.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia

BACKGROUND

In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence.

METHODS

This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis.

RESULTS

Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01).

CONCLUSION

There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Do findings identified on magnetic resonance imaging predict future neck pain? A systematic review

BACKGROUND CONTEXT

Magnetic resonance imaging (MRI) has the potential to identify pathology contributing to neck pain. However, the importance of findings on MRI remains unclear.

PURPOSE

We aimed to investigate whether findings on cervical spine MRI predict future neck pain.

STUDY DESIGN

A systematic review was carried out.

PATIENT SAMPLE

People with or without neck pain comprised the study sample.

OUTCOME MEASURES

Clinically important neck pain outcomes such as pain and disability.

METHODS

The review protocol was registered on PROSPERO [CRD42016049228]. MEDLINE, CINAHL, and EMBASE databases were searched. Prospective cohort studies investigating the association between baseline MRI findings and clinical outcome were included. Cohorts with serious underlying diseases as the cause of their neck pain were excluded. Associations between MRI findings and neck pain outcomes were extracted from the included studies.

RESULTS

A total of 12 studies met all inclusion criteria. Eight studies presented data on participants with current neck pain, two studies included a mixed sample, and two studies included a sample of participants with no current neck pain. Because of the heterogeneity between the studies in terms of MRI findings, populations, and clinical outcomes investigated, it was not possible to pool the results. No consistent associations between MRI findings and future outcomes were identified. Single studies of populations with neck pain reported significant associations for neck muscle fatty infiltrate (risk ratio [RR]: 21.00, 95% confidence interval [CI]: 2.97-148.31) with persistent neck disability; disc protrusion (mean difference ranged from -1.83 to -2.88 on a 10-point pain scale), and disc degeneration (RR: 0.59; 95% CI: 0.36-0.98) with neck pain. In a population without pain, the development of foraminal stenosis over a 10-year period was associated with development of neck pain (RR: 2.99; 95% CI: 1.23-7.23).

CONCLUSION

The limited number, heterogeneity, and small sample size of the included studies do not permit definitive conclusions on the association between MRI findings of the cervical spine with future neck pain.

Diagnosis and suggested treatment against an isolated unilateral rupture of the alar ligament - Concerning one case

BACKGROUND

An isolated rupture of the alar ligament is a rare occurrence with only a few cases reported in the literature.

CASE REPORT

The objective was to report the case of a young man with a unilateral rupture of the alar ligament that we closely monitored, clinically and radiologically, in order to describe the evolution of the alar ligament lesions.

CONCLUSION

Radiological diagnosis using cervical MRI and duration of the conservative treatment remain debated and we proposed a close radiological follow-up in order to best understand the nature of these ligament lesions and their evolution following specific treatment.

Classifying Whiplash Recovery Status Using the Neck Disability Index: Optimized Cutoff Points Derived From Receiver Operating Characteristic

OBJECTIVE

Researchers often use Neck Disability Index (NDI) scores to classify recovery status in whiplash patients. The purpose of this study was to investigate the optimal cutoff point score for the NDI as a mechanism for differentiating recovery from nonrecovery after whiplash.

METHODS

Subjects (N = 123) who had previously sustained whiplash injuries were recruited from 12 clinics. Subjects rated themselves as being recovered (36%) or nonrecovered (64%). This state variable was compared with their NDI score as test variable using the receiver operating characteristic statistic. The area under the receiver operating characteristic curve and optimized cutoff points were computed for the whole group and also dichotomized for sex and age.

RESULTS

The mean NDI score for the recovered group was 7.8. It was 27.1 for the nonrecovered group. The cutoff point that optimized sensitivity and specificity for the whole group was an NDI score of 15. For women, it was 19; for older persons, it was 21.

CONCLUSION

The optimal NDI score cutoff point for differentiating the recovery state after whiplash is 15. Misclassification errors are likely when using lower values.

Signal changes of the alar ligament in a healthy population: a dispositional or degenerative consequence?

OBJECT The alar ligaments (ALs) are vital for stabilizing the craniocervical junction. In terms of morphology, their appearance varies and is visible on MRI. Dark signal of the AL on proton-density (PD)-weighted images is generally considered the norm, but the etiology of frequently observed signal hyperintensities is poorly understood. Using spectral fat suppression, signal hyperintensities can be differentiated into fat- and nonfat-related hyperintensities (NFH). Although signal hyperintensities have no evident association with whiplash-associated disorder, age-related degeneration has often been theorized. Therefore, this study investigates the signal intensities of the ALs on 3.0-T MRI with special reference to age. Expanding thereon, the authors investigated the relationship between signal hyperintensities and patient characteristics, such as height, weight, and sex. METHODS Sixty-six healthy volunteers were scanned using 3.0-T PD-weighted MRI, including spectral fat suppression of the craniocervical junction. The study population was separated into 2 groups (old vs young) using 2 approaches: dichotomization at the median age (40.0 years) and the calculated threshold (28.5 years) using receiver operating characteristics (ROC). The AL was independently characterized with respect to continuity, course, shape, signal intensity, and graduation of homogeneity by 2 experienced neuroradiologists. Signal intensity was differentiated into fat-related hyperintensity and NFH. Univariate and multivariate logistic regression models were employed to investigate the relationship between patient characteristics and signal intensities. RESULTS Two different AL patterns were observed: inhomogeneous (33.3%) and homogeneous (66.7%). The latter pattern was mostly surrounded by a small dark rim (56.8%). Fat could be identified in 15.9% of all ALs (21 of 132 patients), and NFH was identified in 17.4% of all ALs (23 of 132 patients). Here, 28.5 years was the preferred threshold, demonstrating a relatively high sensitivity for dichotomizing the population based on the ROC of NFH. The most relevant factor for having NFH was being older than the calculated threshold (odds ratio [OR] 3.420, p = 0.051). Fat-related hyperintensities occurred significantly more frequently in men than women (OR 0.110 and p = 0.007 for women; OR 9.075 and p = 0.007 for men). Height was the second most significant factor: for every 1-cm increase, the odds of having fat lesions increased by approximately 10% (OR 1.102; p = 0.017). CONCLUSIONS This study shows that AL signal hyperintensities are substantially influenced by age, sex, and height in healthy individuals. Regarding fat-related hyperintensities, the most relevant factors proved to be sex and height. The odds of detecting NFH increased almost significantly after a relatively young age (> 28.5 years) and were remarkably more frequent in individuals older than 28.5 years. The authors caution presumptions equating signal alterations with age-related deterioration. Instead, they suggest that dispositional factors such as sex and height are more relevant in the AL constitution. Signal alterations in ALs naturally occur in healthy symptom-free individuals, underscoring the importance of cautiously interpreting such lesions on posttraumatic MRI scans.

Factors related to non-recovery from whiplash. The Nord-Trøndelag Health Study (HUNT)

BACKGROUND

Whiplash injuries show a variable prognosis which is difficult to predict. Most individuals experiencing whiplash injuries rapidly recover but a significant proportion develop chronic symptoms and ongoing disability.

PURPOSE

By employing longitudinal data, we investigated how psychological and physical symptoms, self-rated health, use of health services and medications, health behavior and demographic factors predict recovery from whiplash.

METHOD

Data from two waves of a large, Norwegian, population-based study (The Nord-Trøndelag Health Study: HUNT2 and HUNT3) were used. Individuals reporting whiplash in HUNT2 (baseline) were identified in HUNT3 11 years later. The characteristics of individuals still suffering from whiplash in HUNT3 were compared with the characteristics of individuals who had recovered using Pearson's chi-squared test, independent sample t-tests and logistic regression.

RESULTS

At follow-up, 31.6 % of those reporting whiplash at baseline had not recovered. These individuals (n = 199) reported worse health at baseline than recovered individuals (n = 431); they reported poorer self-rated health (odds ratio [OR] = 3.12; 95 % confidence interval [CI], 2.20-4.43), more symptoms of anxiety (OR = 1.70; 95 % CI, 1.15-2.50), more diffuse somatic symptoms (OR = 2.38; 95 % CI, 1.61-3.51) and more musculoskeletal symptoms (OR = 1.21; 95 % CI, 1.13-1.29). Individuals still suffering from whiplash also visited more health practitioners at baseline (OR = 1.18; 95 % CI, 1.06-1.32) and used more medications (OR = 1.24; 95 % CI, 1.09-1.40).

CONCLUSION

Poor self-rated health seems to be a strong risk factor for whiplash injuries becoming chronic. Diffuse somatic symptoms, musculoskeletal symptoms and symptoms of anxiety at baseline are important prognostic risk factors. Knowledge of these maintaining risk factors enables identification of individuals at risk of non-recovery, facilitating adequate treatment for this vulnerable group.

Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: a case report

Cranio-vertebral instability (CVI) due to loss of bony or ligamentous integrity is one of the sequelae that may result after a whiplash mechanism injury. Due to the lack of specificity of diagnostic tests, this condition is often missed and the default classification of whiplash associated disorder (WAD) is assigned. This case report describes a 14-year-old boy who was initially classified with WAD II after a rugby injury. He was initially advised to return to usual activity, a treatment recommended in clinical guidelines for WAD. Due to an adverse response to this course of action, his primary carer, a musculoskeletal physiotherapist, continued with facilitating secondary referrals that ultimately led to a specialist physiotherapist. The patient was subsequently found to have CVI arising from a loss of bony integrity due to spina bifida atlanto, a congenital defect in the atlas. Treatment thus was immobilization and stabilization, a treatment usually recommended against in WAD guidelines. The patient recovered and within 8 weeks had returned to school and non-contact sports. This case study, therefore, presents a scenario where current clinical guidelines for whiplash could not be followed, and where pursuing clinical reasoning led to accurate diagnosis as well as safe and tailored management. The case also highlights the integrated roles that primary and specialist health professionals should play in the clinical pathway of care after WAD. As a result, an expanded diagnostic algorithm and pathway of care for WAD are proposed.

Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To update a previous review and meta-analysis on risk factors for persistent problems following whiplash secondary to a motor vehicle accident.

BACKGROUND

Prognosis in whiplash-associated disorder (WAD) has become an active area of research, perhaps owing to the difficulty of treating chronic problems. A previously published review and meta-analysis of prognostic factors included primary sources up to May 2007. Since that time, more research has become available, and an update to that original review is warranted.

METHODS

A systematic search of international databases was conducted, with rigorous inclusion criteria focusing on studies published between May 2007 and May 2012. Articles were scored, and data were extracted and pooled to estimate the odds ratio for any factor that had at least 3 independent data points in the literature.

RESULTS

Four new cohorts (n = 1121) were identified. In combination with findings of a previous review, 12 variables were found to be significant predictors of poor outcome following whiplash, 9 of which were new (n = 2) or revised (n = 7) as a result of additional data. The significant variables included high baseline pain intensity (greater than 5.5/10), report of headache at inception, less than postsecondary education, no seatbelt in use during the accident, report of low back pain at inception, high Neck Disability Index score (greater than 14.5/50), preinjury neck pain, report of neck pain at inception (regardless of intensity), high catastrophizing, female sex, WAD grade 2 or 3, and WAD grade 3 alone. Those variables robust to publication bias included high pain intensity, female sex, report of headache at inception, less than postsecondary education, high Neck Disability Index score, and WAD grade 2 or 3. Three existing variables (preaccident history of headache, rear-end collision, older age) and 1 additional novel variable (collision severity) were refined or added in this updated review but showed no significant predictive value.

CONCLUSION

This review identified 2 additional prognostic factors and refined the estimates of 7 previously identified factors, bringing the total number of significant predictors across the 2 reviews to 12. These factors can be easily identified in a clinical setting to provide estimates of prognosis following whiplash.

Are two readers more reliable than one? A study of upper neck ligament scoring on magnetic resonance images

Background

Magnetic resonance imaging (MRI) studies typically employ either a single expert or multiple readers in collaboration to evaluate (read) the image results. However, no study has examined whether evaluations from multiple readers provide more reliable results than a single reader. We examined whether consistency in image interpretation by a single expert might be equal to the consistency of combined readings, defined as independent interpretations by two readers, where cases of disagreement were reconciled by consensus.

Methods

One expert neuroradiologist and one trained radiology resident independently evaluated 102 MRIs of the upper neck. The signal intensities of the alar and transverse ligaments were scored 0, 1, 2, or 3. Disagreements were resolved by consensus. They repeated the grading process after 3–8 months (second evaluation). We used kappa statistics and intraclass correlation coefficients (ICCs) to assess agreement between the initial and second evaluations for each radiologist and for combined determinations. Disagreements on score prevalence were evaluated with McNemar’s test.

Results

Higher consistency between the initial and second evaluations was obtained with the combined readings than with individual readings for signal intensity scores of ligaments on both the right and left sides of the spine. The weighted kappa ranges were 0.65-0.71 vs. 0.48-0.62 for combined vs. individual scoring, respectively. The combined scores also showed better agreement between evaluations than individual scores for the presence of grade 2–3 signal intensities on any side in a given subject (unweighted kappa 0.69-0.74 vs. 0.52-0.63, respectively). Disagreement between the initial and second evaluations on the prevalence of grades 2–3 was less marked for combined scores than for individual scores (P ≥ 0.039 vs. P ≤ 0.004, respectively). ICCs indicated a more reliable sum score per patient for combined scores (0.74) and both readers’ average scores (0.78) than for individual scores (0.55-0.69).

Conclusions

This study was the first to provide empirical support for the principle that an additional reader can improve the reproducibility of MRI interpretations compared to one expert alone. Furthermore, even a moderately experienced second reader improved the reliability compared to a single expert reader. The implications of this for clinical work require further study.

Magnetic resonance imaging signal changes of alar and transverse ligaments not correlated with whiplash-associated disorders: a meta-analysis of case-control studies

PURPOSE

Hypothesis that loss of integrity of the membranes in the craniocervical junction might be the cause of neck pain in patients with whiplash-associated disorders (WADs) has been proposed. In recent years, with development of more detailed magnetic resonance imaging (MRI) techniques, morphologic changes of the ligaments and membranes in the craniocervical junction, especially alar and transverse ligaments have been discussed. A meta-analysis was performed to evaluate the relationship of MRI signal changes of alar and transverse ligaments and WADs.

METHODS

A systematic search of EMBASE, PUBMED, and Cochrane Library and references from eligible articles were conducted. Comparative studies reporting on evaluating the relationship between MRI high-signal changes of alar and transverse ligaments and WADs were regarded eligible. A pooled estimate of effect size was produced.

RESULTS

Alar ligaments: Six studies (total n = 622) were included. MRI signal changes of alar ligaments did not appear to be related with WADs (P = 0.20, OR = 1.54, 95 % CI = 0.80-2.94). Heterogeneity was present (I (2) = 46 %, P = 0.10), which was eliminated upon sensitivity analysis bringing the OR to 1.27 (95 % CI = 0.87-1.86, I (2) = 0 %). Transverse ligaments: Four studies (total n = 489) were included. MRI signal changes of transverse ligament did not appear to be related with WADs (P = 0.51, OR = 1.44, 95 % CI = 0.49-4.21). Heterogeneity was present (I (2) = 77 %, P = 0.005), which was eliminated upon sensitivity analysis bringing the OR to 0.79 (95 % CI = 0.49-1.28, I (2) = 0 %).

CONCLUSION

MRI signal changes of alar and transverse ligaments are not supposed to be caused by whiplash injury, and MRI examination of alar and transverse ligaments should not be used as the routine workup of patients with WADs.

The pearls and pitfalls of magnetic resonance imaging for the spine

Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

Follow-up MR imaging of the alar and transverse ligaments after whiplash injury: a prospective controlled study

BACKGROUND AND PURPOSE

The cause and clinical relevance of upper neck ligament high signal intensity on MR imaging in WAD are controversial. The purpose of this study was to explore changes in the signal intensity of the alar and transverse ligaments during the first year after a whiplash injury.

MATERIALS AND METHODS

Dedicated high-resolution upper neck proton attenuation-weighted MR imaging was performed on 91 patients from an inception WAD1-2 cohort, both in the acute phase and 12 months after whiplash injury, and on 52 controls (noninjured patients with chronic neck pain). Two blinded radiologists independently graded alar and transverse ligament high signal intensity 0-3, compared initial and follow-up images to assess alterations in grading, and solved any disagreement in consensus. The Fisher exact test was used to compare proportions.

RESULTS

Alar and transverse ligament grading was unchanged from the initial to the follow-up images. The only exceptions were 1 alar ligament changing from 0 to 1 and 1 ligament from 1 to 0. The prevalence of grades 2-3 high signal intensity in WAD was thus identical in the acute phase and after 12 months, and it did not differ from the prevalence in noninjured neck pain controls (alar ligaments 33.0% versus 46.2%, P = .151; transverse ligament 24.2% versus 23.1%, P = 1.000).

CONCLUSIONS

Alar and transverse ligament high signal intensity in patients with WAD1-2 observed within the first year after injury cannot be explained by the trauma. Dedicated upper neck MR imaging cannot be recommended as a routine examination in these patients.

Occult hypermobility of the craniocervical junction: a case report and review

STUDY DESIGN

Resident's case problem.

BACKGROUND

Patients often present to physical therapists with chief complaints of neck pain, occipital headache, and dizziness associated with a past history of cervical spine injury. These symptoms may be associated with various cervical spine conditions, including craniocervical junction (CCJ) hypermobility.

DIAGNOSIS

This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral shear test, which is intended to stress the alar ligaments. The lateral shear test was perceived as demonstrating excessive mobility and a soft end feel, with a "shift" of C1 on C2. Stress cervical radiographs, obtained using open-mouth projections in neutral, left, and right cervical lateral flexion, revealed a 3-mm lateral offset of the right lateral mass of C1 on C2. MRI evaluation of the lower cervical spine did not reveal any significant disc derangement; however, images of the soft tissues of the craniocervical junction were not obtained. Based on the examination and imaging studies, the patient was determined to have a previously undiagnosed hypermobility of the atlantoaxial joint.

DISCUSSION

The patient was advised to avoid rotational manipulation and end range lateral flexion stretching exercises. Axial traction manipulation techniques, midrange stabilization exercises, and postural advice appeared to provide good relief of symptoms. Physical therapists should consider the possibility of CCJ hypermobility in the frontal plane when examining the cervical spine in patients with chronic neck pain, headache, and a past history of trauma. The lateral shear test and stress radiography may provide simple screening tests for occult CCJ hypermobility; however, the reliability and validity of these tests is lacking. Further research on diagnosis and management of CCJ hypermobility is warranted.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

Does cervical kyphosis relate to symptoms following whiplash injury?

The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.