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Cervical Whiplash

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Other Names

  • Whiplash Syndrome
  • Whiplash
  • Whiplash-associated Disorders (WAD)
  • Whiplash injury
  • Cervical Sprain
  • Cervical Strain

Background

  • This page describes 'whiplash' and whiplash-associated disorders (WAD) as well as cervical sprains and strains
    • Primarily a clinical diagnosis as there are no diagnostic radiological, electrophysiological or neuropchological studies[1]
    • Because of the diagnostic challenges, the diagnosis is considered controversial

Epidemiology

  • Incidence between 4 and 325 per 100,000 person years depending on cited study[2][3]
  • Affects up to 83% of patients involved in motor vehicle accidents[4]
  • Economic burden estimated at $3.9 billion annually in the United States, which balloons to $29 when including litigation.[5]

Pathophysiology

  • Caused by rapid acceleration and/or deceleration injuries with energy transfer to the neck
    • Theorized to be hyperextension of lower cervical vertebrae with flexion of the upper cervical vertabrae producing an S-shape cervical spine at the time of impact[6]
    • Subsequent cervical sprain or strain
  • Pathophysiology is generally poorly understood
    • Believed to be complex injury pattern to ligaments, tendons, nerves, muscles, discs, and bones of the neck

Etiology

  • Most commonly due to motor vehicle crashes
  • Other etiologies
    • Sports accident
    • Domestic violence
    • Amusement park rides
    • ATV

Risk Factors

  • Hyperextension
  • Hyperflexion
  • Lateral Flexion/ Sidebending

Differential Diagnosis


Clinical Features

  • General: Physical Exam Neck
  • History
    • Patients will endorse a history of trauma, typically MVC
    • They often report some combination of neck pain and stiffness that may or may not radiate down the arm(s)
    • They also have headaches, visual disturbances, memory and concentration problems and psychological distress
    • Tempormandibular joint dysfunction is also common
    • Psychosocial symptoms include g depression, anger, fear, anxiety, and hypochondriasis[7]
  • Physical Exam
    • Physical exam often reveals myofascial pain and tenderness along the cervical spine and paracervical musculature
    • Range of motion may be diminished and/or a painful arc of motion

Evaluation

  • There are no reliable radiographic findings for whiplash[8]
  • The role of imaging is in excluding other diagnoses

Radiographs

CT

  • Typically normal
  • Used to exclude fractures associated with trauma

MRI

  • Most valuable for evaluating soft tissue pathology of the neck and cervical spine
  • Potential findings[9]
    • Loss of lordosis
    • Prevertebral edema
    • Ligamentous injury (often the alar and the transverse ligaments)
    • Fractures of the articulating facet
  • Not indicated immediately following trauma due to high false positive rate
  • In a study of 100 patients following normal radiographs, only 1 had abnormal MRI of the cervical spine (prevertebral edema)[10]

Classification

Quebec Classification Of Whiplash-associated Disorders[11]

  • Grade 0: no neck complaints and no physical signs
  • Grade I: neck pain, stiffness or tenderness, and no physical signs
  • Grade II: neck complaints accompanied by musculoskeletal signs, with decreased range of motion and point tenderness
  • Grade III: neck complaints accompanied by musculoskeletal and neurologic signs, with muscle weakness and sensory deficits
  • Grade IV: neck complaints accompanied by fracture or dislocation

Management

Prognosis

  • Most patients will recover within a few weeks
  • Approximately 50% of patients will still have pain or discomfort at one year post injury[12]
    • Subsequently, they can develop chronic pain
    • Implications for morbidity, economic burden
  • Studies have suggested between 25-40% of patients have persistent symptoms at 1 year and up to 40% at 7 years[13]
  • Factors associated with delayed recovery[14]
    • Female gender
    • Older age
    • Initial intensity of neck pain
    • Neurologic deficit
    • Preexisting neck pain

Acute

  • By definition, nonsurgical clinnical entity
  • Ice
  • Cervical Collar, typically soft
  • Analgesia including NSAIDS
  • Physical Therapy
    • Active (as opposed to passive) intervention had reduced pain intensity and sick leave at 6 months and 3 years[15]
  • Exercise
    • Range of motion exercises result in reduced pain, improved function[16]
  • Oral Corticosteroids
    • High dose steroids given within 8 hours of injury reduces number of sick days and disabling symptoms compared to controls[17]

Chronic

  • Overall dearth of research on chronic management of whiplash
  • Physical Therapy
  • Vendrig et al: following 6 months of exercise, group therapy, and occupational therapy[18]
    • 65% of patients had complete return to work
    • 92% reporting complete or partial return to work
    • 81% reported no medical or paramedical treatments
  • Cervical radiofrequency neurotomy (CRFN)
    • Prushansky et al: 70% patients reported improvement in symptoms on neck disability index, range of motion[19]
  • Other proposed but unstudied treatments
    • Temperomandibular joint treatment
    • Cervical traction
    • Intraarticular corticosteroids
    • Botulinim toxin

Rehab and Return to Play

Rehabilitation

  • Emphasis on cervical range of motion
  • Strengthening peri-scapular and scapular muscles
  • Neck stabilization exercises

Return to Play

  • Needs to be updated

Complications

  • Chronic neck pain
  • Inability to return to work

See Also


References


  1. Sanjay Yadla, John K. Ratliff, James S. Harrop. Whiplash: diagnosis, treatment, and associated injuries. (2008) Current Reviews in Musculoskeletal Medicine. 1 (1): 65.
  2. Khushnum Pastakia, Saravana Kumar. Acute whiplash associated disorders (WAD). (2011) Open Access Emergency Medicine. 3: 29
  3. Barnsley L, Lord SM, Bogduk N. Whiplash injury. Pain 1994;58: 283–307
  4. Cote PDC, Hogg-Johnson S, et al. Initial patterns of clinical care and recovery from whiplash injuries. Arch Intern Med 2005; 165:2257–63.
  5. Freeman MD. A review and methodologic critique of the literature refuting whiplash syndrome. Spine 1999;24:86–98.
  6. Grauer JN, Panjabi MM, et al. Whiplash produces an S-shaped curvature of the neck with hyperextension at lower levels. Spine 1997;22:2489–94.
  7. Van Geothem JW, et al. Whiplash injuries: is there a role for imaging? Eur J Radiol 1996;22:30–37.
  8. James M. Elliott, Sudarshan Dayanidhi, Charles Hazle, Mark A. Hoggarth, Jacob McPherson, Cheryl L. Sparks, Kenneth A. Weber II. Advancements in Imaging Technology: Do They (or Will They) Equate to Advancements in Our Knowledge of Recovery in Whiplash?. (2016) Journal of Orthopaedic & Sports Physical Therapy. 46 (10): 862-873.
  9. Erika Jasmin Ulbrich, Sandra Eigenheer, Chris Boesch, Juerg Hodler, André Busato, Christian Schraner, Suzanne E. Anderson, Harald Bonel, Heinz Zimmermann, Matthias Sturzenegger. Alterations of the Transverse Ligament: An MRI Study Comparing Patients With Acute Whiplash and Matched Control Subjects. (2012) American Journal of Roentgenology. 197 (4)
  10. . Ronnen HR, de Korte PJ, et al. Acute whiplash injury: is there a role for mr imaging?—a prospective study of 100 patients. Radiology 1996;201 1:93–6
  11. TRACsa: Trauma and Injury Recovery . Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders. Adelaide, Australia: South Australian Centre for Trauma and Injury Recovery (TRACsa); 2008.
  12. ourse and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD): Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. (2008) Spine. 33 (4S): S83-92
  13. Rodriquez AA, Barr KP, Burns SP. Whiplash: pathophysiology, diagnosis, treatment, and prognosis. Muscle Nerve 2004;29:768– 81.
  14. Dufton JA, et al. Prognostic factors associated with minimal improvement following acute whiplash-associated disorders. Spine 2006;20:E759–65
  15. Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R. Active intervention in patient with whiplash-associated disorder improves long-term prognosis. Spine 2003;28:2491–8.
  16. Motor Accidents Authority . Your guide to whiplash recovery in the first 12 weeks after the accident. Sydney, Australia: Motor Accidents Authority; 2007
  17. Petterson K, Toolanen G. High-dose methylprednisolone prevents extensive sick leave after whiplash injury. a prospective, randomised, double-blind study. Spine 1998;23:984–9.
  18. Vendrig AA, van Akkerveeken PF, McWhorter KR. Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine 2000;25:238–44
  19. Prushansky T, Pevzner E, Gordon C, Dvir Z. Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures. J Neurosurg 2006;4:365–73
Created by:
John Kiel on 17 June 2019 14:30:14
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Last edited:
17 November 2020 16:34:22
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