Cervical Whiplash Research Articles

“Normal” Cervical Spine Radiographs and Computed Tomography Scans in the Emergency Department: Beware of Posttraumatic Instability of the Mobile Segment of the Lower Cervical Spine

The NEXUS criteria have been introduced in the 1990s to assist emergency department physicians to decide whether to perform radiographic work-up following cervical whiplash injury. Four criteria have been described on these profile radiographs of the cervical spine including angulation between cervical endplates, 3-mm listhesis, posterior facet joints overlap, and widened interspinous space. Although these criteria could help to detect patients suffering from unstable trauma of the mobile segment if the lower cervical spine, the radiographic signs may be so subtle that even specifically trained physicians like spine surgeons and neuroradiologists may miss them, especially during after-hour shifts. Hence, we present the striking case of a young female patient whose radiographs displayed slight but abnormal signs of lower cervical spine instability, but was nonetheless discharged home with dynamic X-rays of the cervical spine to be performed in a delayed setting. We hope that these striking features will help us remind the importance of radiologic semiology of posttraumatic unstable cervical spine.

Transient Hemiplegia in a Collegiate Ice Hockey Player.

An otherwise healthy 21-yr-old female hockey player sustained a cervical whiplash injury during competition after being checked and falling backward onto the ice. Initial assessment revealed right-sided hemiparesis and sensory abnormalities. Magnetic resonance imaging and computed tomography of the brain and spine were unremarkable. Most of her right upper limb symptoms resolved in 24 hrs, with complete resolution in 5 days. Over 6 wks, she regained right lower limb strength with mild residual sensory deficits. Repeat magnetic resonance imaging of the cervical spine was unremarkable. At 18 wks, sensory symptoms resolved, with the exception of mildly decreased lower limb proprioception. The athlete was cleared to return to noncontact drills but not competition. The differential diagnosis included transient quadriplegia and/or hemiplegia ("cervical cord neuropraxia"), which typically resolves in 48 hrs, and incomplete spinal cord injury without radiographic abnormality, which is more likely to present with persistent symptoms. This case includes features of both diagnoses, making management challenging as return to play guidelines are nonspecific. Further research is needed to develop well-defined guidelines for spinal cord injury without radiographic abnormality and cervical cord neuropraxia return-to-play decisions.

Flawed Studies of SIMS’s Diagnostic Accuracy by Teams of Puente-López and Capilla Ramírez

Background: The teams of Puente-López and Capilla Ramírez evaluated diagnostic accuracy of the Structured Inventory of Malingered Symptomatology (SIMS), a test often used to assess malingering by persons injured in motor vehicle accidents (MVAs). Yet all SIMS items represent legitimate medical symptoms, and more than 50% of them are those experienced by severely injured motorists, but they are fallaciously scored as indicative of malingering. Thus, more injured patients with more symptoms obtain higher SIMS scores for malingering. Method: The studies by Puente-López and by Capilla Ramírez were carried out on SIMS scores of injured motorists. The present article assesses the severity of their injuries, as documented by Puente-López and by Capilla Ramírez. Results and Discussion: The study by Capilla Ramírez’s team excluded patients with pathological results on physical examinations, or on X-Rays, EMG, and MRI: thus, only mildly injured motorists were included. The patients of Puente-López had signs of only a mild cervical whiplash. Almost none reported lower back pain or dizziness. Thus, both studies included patients with only mild symptoms that resulted in very low SIMS scores: they scored within the non-malingering range as defined by the SIMS manual. Their scores were below SIMS scores of healthy persons instructed to feign whiplash symptoms from an MVA. The teams of Capilla Ramírez and of Puente-López erroneously interpreted these results as demonstrating diagnostic accuracy of the SIMS for detection of malingering in injured motorists. Conclusions: The two studies of very mildly injured motorists fail to demonstrate “diagnostic accuracy of the SIMS” because the SIMS is mostly used by insurance contracted psychologists on more severely injured MVA patients (those with whiplash and post-concussion syndrome), i.e., those with more symptoms and thus, with higher SIMS scores that fallaciously classify them as “malingerers.”

Novel treatment with percutaneus electrolysis in cervical whiplash syndrome

Introduction and Aims Cervical whiplash syndrome (CWS) commonly occurs because of the rear impact of motor vehicle collisions, producing a forced passive extension of the neck, followed by a rapid flexion in the form of a whip. This violent flexion can lead to an enthesopathy of the levator scapulae muscle (LS). The aim of this study was to evaluate the effectiveness of the percutaneous needle electrolysis (PNE) technique on the enthesopathy of the LS after a CWS and to compare this with a conventional physical therapy protocol. Material and Methods In a physical therapy center specialized in traffic accidents, we arranged to interview a sample of 100 voluntary patients, providing subjects with the inclusion-exclusion criteria and an informed consent form. Participants recruited to the study had their pain quantified using the visual analog scale (VAS) for pain, the validated neck pain questionnaire (NPQ), and an algometer. Two groups were created. One received the PNE technique and the other received the conventional physiotherapy protocol. Once treatments were completed, pain was quantified once again and the results were obtained. Results The most important findings are highlighted, regarding the comparison of variables of pain quantification in both groups and regarding the cost per treatment session. Conclusions 1. The conventional physiotherapy protocol used is effective for the reduction of pain in the SLC in the enthesopathy of the LS.2. Treatment with the PNE technique is effective for the reduction of pain in the CWS for LS enthesopathy.3. Physiotherapy treatment which includes the PNE technique is more effective in the algometry variable than treatment performed with conventional physiotherapy techniques by 16.8%.3. The PNE technique is superior to the protocol of conventional physiotherapy in the cost/effectiveness relationship by 85%.4. The PNE technique, without combining the same with any other physiotherapy technique, is effective for the reduction of pain in cases of enthesopathy.

The neck-tongue syndrome following cervical whiplash injury

Abstract Background Neck-tongue syndrome is a disorder causing unilateral neck pain, accompanied by simultaneous ipsilateral numbness of the tongue. It is explicable by compression of the second cervical root in the atlantoaxial space on sharp rotation of the neck. It may be secondary, idiopathic, familial, more frequent in females, in young people and the pain lasts from a few seconds to a few minutes. Treatment is symptomatic but also prophylactic, benefit is made by physiotherapy treatment. International Headache Society (IHS) places it between “Painful lesions of the cranial nerves and other facial pain”, describing as sudden onset of pain in the occiput or upper neck associated with abnormal sensation in the same side of the tongue. Methods A 42-year-old female, who a month after reported a whiplash injury, following a car accident, manifested the symptoms of neck-tongue syndrome. The rotational movements of the head to the right side provoked intense pain in the neck and along the right half of the tongue. The pain also appeared spontaneously, duration varied from a few seconds to few minutes, associated with burning, frequency of about two episodes per day. Radiography and cervical spine MRI showed signs of spondylosis. Results Topiramate combined with non-steroidal anti-inflammatory drugs, improved pain both in the neck and the tongue, reducing the episodes in frequency and intensity. Conclusions Neck-tongue syndrome is a rare disorder, which manifests with pain in the neck and pain associated with burning of half of the tongue, by unknown etiology. Secondary forms following whiplash injury have not been described, Treatment of these secondary forms concerns use of symptomatic drugs for pain, buth also anticonvulsants as prophylaxis.

Endurance test of extensor muscles of the neck: Improve usability with a modification of applied load

The endurance of extensor muscles of the neck has an important impact on functional status. Neck pain, cervical whiplash and few rheumatisms cause alteration of neck muscle performance. Harms-Ringdahl has designed a clinical test to assess endurance capability. If this test has good metrologic characteristics, unfortunately this method needs long time (6 min) to check if the patient reaches normal performance threshold. Because of this, physiotherapists don’t use this test in current practice. The aim of this study was to determine, by using various weights, which is the best one to estimate the cervical extensor endurance with short time cost. The second goal was to evaluate the link between endurance performances of extensor muscles and anthropometric characteristics. Twenty-five healthy volunteers were recruited. We successively measured the holding time to the endurance test of cervical extensors (ETCE). Three different loads were used in randomized order: 2 kg (original method of Harms-Ringdahl), 4 kg and 6 kg. The tests were interrupted after 900 sec. Age and anthropometric data (height, weight, neck length and cervical circumference) were noted. Non-parametric statistical tests were used. Finally, 15 women and 10 men participated. They were 21.7 ± 2.0 years old (m ± SD). Height, weight, neck length and cervical circumference were respectively: 170 ± 9 cm; 63 ± 10 kg; 12.8 ± 1.6 cm and 34.0 ± 2.7 cm. We found significantly different medians for the holding time ( P = 0.001): 900 sec [191–900] (median [min–max]); 350 s [121–900] and 209 sec [65–467], respectively for 2, 4 and 6 kg. Moreover, we found out that the holding times were correlated between them (0.67). Increase load in used of ETCE seems to be a relevant parameter to make this test less time-consuming. According to our results on healthy and young subjects, the 6 kg load is the most appropriate option for having an adequate holding time for clinical practice. However this weight remains to be tested on people experiencing non-specific neck pain and varied age groups.

No immediate changes on neural and muscular mechanosensitivity after first rib manipulation in subjects with cervical whiplash: A randomized controlled trial.

Upper rib manipulative therapy appears to be effective on primary complaint of shoulder pain, but its efficacy has not been evaluated in subjects with whiplash-associated disorders. To assess the immediate changes on neural and muscular mechanosensitivity after first-rib manipulation in patients with neck or cervicobrachial pain secondary to cervical whiplash (CW). A single-blind (evaluators were blinded to subject allocation) randomized trial was conducted. Fifty-three (N = 53) subjects, 34.7 (SD 10.8 years; 56.6% females), with cervical or cervicobrachial pain following CW, were distributed into two groups. The experimental group (n = 27) underwent a single first-rib high-velocity low-amplitude manipulation technique, while the control group (n = 26) received a sham placebo intervention. Outcome measures were taken at baseline and immediately after intervention, of the pressure pain threshold over the trigeminal, median and ulnar nerves, and over the area described for the location of tense bands in the upper trapezius, masseter, biceps brachii and triceps brachii muscles. No significant differences in mechanosensitivity values were observed after intervention in the between-groups comparison (p > 0.05). The use of a sole first-rib thrust technique has no immediate effect on neural or muscular mechanosensitivity, when compared to placebo, in subjects with cervical or cervicobrachial pain after CW.

Comparison of the Effectiveness of Sling Exercise and McKenzie Exercise in Patients with Acute Cervical Whiplash Associated Disorder Following Rear-end Collision

Comparison of the Effectiveness of Sling Exercise and McKenzie Exercise in Patients with Acute Cervical Whiplash Associated Disorder Following Rear-end Collision

Sensibilización central al dolor en pacientes con síndrome del latigazo cervical: una revisión

The cervical whiplash syndrome is a disorder that affects a many people following road traffic accidents and which has a high economic cost. The disorders associated with whiplash syndrome are numerous, and include neck pain and muscle stiffness, headache, and dizziness. In approximately 50% of people who suffer from whiplash, the initial pain develops and is maintained into the chronic phase. Mechanisms of central sensitization to pain has been recognized as an important pathophysiological mechanism which may mediate various types of pain and which may be responsible for its chronification in these patients, as they show signs of hypersensitivity to pain, including decreased pain pressure thresholds and altered temporal summation to noxious stimuli. With regards to treatment, although there is a wide range of physical therapies available to treat whiplash disorders, currently there is no consensus on which therapy is most effective. Understanding the mechanisms by which pain becomes chronic following whiplash will help to develop an effective therapy that could directly treat the disorders associated with this pathology in many people with chronic pain symptomatology based on the evidence-based diagnosis of pathophysiological mechanisms.

Usefulness of K-Point Injection for the Nonspecific Neck Pain in So-Called K-Point Syndrome.

BackgroundShoichi Kokubun introduced his successful experience with local anesthetic injection at the occipital insertion of the sternocleidomastoid muscle in K-point syndrome. The purpose of this study was to evaluate the short-term and long-term effectiveness of K-point injection and investigate factors affecting treatment results.MethodsK-point injection was performed in 58 patients with K-point syndrome at Yeungnam University Medical Center. The syndrome was associated with cervical whiplash injury in 10 patients and was of nonspecific origin in the rest. One milliliter of 2% lidocaine mixed with 1 milliliter of dexamethasone was injected in 50 patients and 2 milliliters of 1% lidocaine alone in the rest. Initially, the severity of local tenderness at the K-point and other tender points was examined and the degree of immediate pain relief effect was assessed within 1 hour after injection. Early effect within 1 month after the injection and current effect were evaluated in 27 patients using a modified Kim's questionnaire with regard to the duration of improvement, degree of improvement in pain and daily living activities, and satisfaction.ResultsOf the total 58 patients, 44 (75.8%) apparently had immediate pain relief after K-point injection. The only factor associated with successful immediate pain relief was the whiplash injury associated with traffic accident (TA). The early pain control effect was associated with the immediate effect. The current effect was associated with the early effect alone. Satisfaction with the K-point injection was related to early successful pain relief.ConclusionsK-point injection would be useful for early pain relief in nonspecific neck pain syndrome so called K-point syndrome, but not for current pain relief. Especially, it was very effective for early pain control in the whiplash injury associated with TA.

Diagnostic Value of Clinical Cervical Spine Tests in Patients With Cervicogenic Somatic Tinnitus.

Tinnitus can be related to many different etiologies, such as hearing loss or a noise trauma, but it also can be related to the somatosensory system of the cervical spine. The diagnosis of cervicogenic somatic tinnitus (CST) is made when the predominant feature is the temporal coincidence of appearance or increase of both neck pain and tinnitus. The aim of this study was to assess the diagnostic value of clinical cervical spine tests in people with CST. A cross-sectional study was conducted. The study was conducted at a tertiary referral center. Consecutive adult patients with chronic subjective nonpulsatile tinnitus were included. Exclusion criteria were vertigo, Ménière disease, middle ear pathology, intracranial pathology, cervical spine surgery, whiplash trauma, and temporomandibular dysfunction. A full ear, nose, and throat examination was conducted to classify patients into CST and non-CST groups. The physical therapist examination included completion of the Neck Bournemouth Questionnaire (NBQ) and the following clinical cervical spine tests: manual rotation test, adapted Spurling test (AST), trigger point tests, and tests for strength and endurance of the deep neck flexors. Eighty-seven patients with tinnitus were included, of whom 37 (43%) were diagnosed with CST. The diagnosis of CST becomes less likely with NBQ scores of <14 points (sensitivity of 80%, likelihood ratio [LR] of 0.3, and posttest probability of 19%). Absence of trigger points corresponded to an LR of 0.3, a sensitivity of 82%, and a posttest probability of 22%. A positive manual rotation test and AST indicate a higher probability of CST (LR of 5, specificity of 90%, and posttest probability of 78%). A limited number of clinical cervical spine tests were used in this study. Although tests with good validity and reliability were included, additional tests could provide more information on cervical spine dysfunction in patients with CST. Clinical cervical spine tests can support the diagnostic process for CST. An NBQ score of <14 points and the absence of trigger points can help to exclude CST. In contrast, a positive manual rotation test and AST can help to include CST. In future studies, these tests should be included in a multidisciplinary assessment of patients with suspected CST.

WITHDRAWN: Botulinum toxin for subacute/chronic neck pain.

Background Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. Objectives To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. Search methods We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. Selection criteria We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. Data collection and analysis A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. Main results We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies. High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). Authors' conclusions Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.

Neck range of motion measurements using a new three-dimensional motion analysis system: validity and repeatability.

Neck movement is important for many activities of daily living (ADL). Neck disorders, such as cervical spondylosis and whiplash can limit neck movement and ADL. The cervical range of motion (CROM) device has been recently used to measure neck range of motion (ROM); however, this measurement includes trunk motion, and therefore does not represent a pure neck ROM measurement. The authors aimed to develop a new method to establish pure neck ROM measurements during flexion, extension, lateral bending, and rotation using a three-dimensional motion analysis system, VICON. Twelve healthy participants were recruited and neck ROMs during flexion, extension, lateral bending, and rotation were measured using VICON and the CROM device. Test-retest repeatability was assessed using interclass correlation coefficients (ICCs), standard error of measurement (SEM), and minimal detectable change (MDC). Validity between two measurements was evaluated using a determination coefficient and Pearson's correlation coefficient. ICCs of neck ROM measured using VICON and the CROM device were all at substantial or almost perfect levels [VICON: ICC(1,2) = 0.786-0.962, the CROM device: ICC(1,2) = 0.736-0.950]. Both SEMs and MDCs were low in all measurement directions (VICON: SEM = 1.3°-4.5°, MDC = 3.6°-12.5°; the CROM device: SEM = 2.2°-3.9°, MDC = 6.1°-10.7°). Determination coefficients (R(2)s) and Pearson's correlation coefficients (rs) between the two measurement methods were high (R(2) = 0.607-0.745, r = 0.779-0.863). VICON is a useful system to measure neck ROMs and evaluate the efficacy of interventions, such as surgery or physiotherapeutic exercise.

Double-door laminoplasty for treatment of cervical whiplash injury

Objective To analyze efficacy of double door laminoplasty for treatment of whiplash injury of the cervical spine.Methods Forty-one cases of cervical whiplash injury treated surgically from January 2001 to October 2011 and available to follow up were analyzed retrospectively.There were 32 males and 9 females with mean age of (51.0 ± 12.0) years (range,28 to 74 years).Causes of injury included traffic accidents in 30 cases,fall on the ground in 8,and high fall in 3.All cases were combined with developmental cervical stenosis and six with ossification of the posterior longitudinal ligament.Posterior double-door laminoplasty was operated in 36 cases and one-stage surgery via anterior-posterior approach in 5 cases.Cases were grouped according to their ages,preoperative cervical Japanese Orthopedic Association (JOA) score,and operation time.Results were compared among groups.Results Operation lasted for 70-180 minutes (mean,121.9 minutes) and showed blood loss of 30-500 ml (mean,177.8 ml).All cases were followed up for 12 to 110 months (mean,59.4 months).Overall JOA score averaging 14.7 points improved significantly after operation with mean improvement rate of 77.8％ (P ＜0.01).Whereas between non-elderly and elderly groups,postoperative JOA improvement rate [(79.6 ± 18.8)％ vs (73.5 ±22.8)％] and excellent rate (90％ vs 83％) were similar.For cases grouped according to their preoperative JOA score,the results were satisfactory for all groups,but the differences were insignificant.Besides,JOA score at the last follow-up differed significantly among groups (P ＜ 0.0l).Improvement rate of JOA score was better in early surgery group than in late surgery group [(84.6±13.3)％ vs (75.4±24.0)％,P＜0.05].Conclusions Double door laminoplasty is reliable in treatment of cervical whiplash injury on condition that surgical indications are grasped strictly.Elderly or gravely injured patients can also have considerable recovery of neurological function,but patients with severe injury or late surgery are associated with poor prognosis. Key words: Spinal cord injuries; Cervical vertebrae; Whiplash injury

The Comparitive Study on the Effect of &amp;lt;i&amp;gt;Shinbaro&amp;lt;/i&amp;gt; Pharmacopuncture and Bee Venom Pharmacopuncture Treatment of Patient Diagnosed as Cervical Disc Hermiation Based on the MRI after Traffic Accident: A Retrospective, Case Series Observational Study

Objectives : The purpose of this study is to compare the effect of Shinbaro pharmacopuncture treatment and bee venom pharmacopuncture treatment on cervical disc herniation and whiplash injury induced by traffic accident. Methods : This study was carried out on the 59 patients with whiplash injury by traffic accident and diagnosed as cervical disc herniation. The patients were divided into 2 groups ; Shinbaro pharmacopuncture group was treated with Shinbaro pharmacopuncture along with herbal medicine and general acupuncture. Bee venom pharmacopuncture group was treated with bee venom pharmacopuncture along with herbal medicine and general acupuncture. We measured verbal numerical rating scale(VNRS) and neck disability index(NDI) before the treatment and 1, 2, 3 weeks afterwards. Results : Shinbaro pharmacopuncture group and Bee venom pharmacopuncture both showed significant decrease in VNRS and NDI. Shinbaro pharmacopuncture group showed significant decrease over Bee venom pharmacopuncture group in VNRS decrement in the first week, while Bee venom pharmacopuncture group showed significant decrease over Shinbaro pharmacopuncture group in the secone week of treatment. Conclusion : According to the result of this study, it is suggested that Shinbaro pharmacopuncture group is more effective in reducing pain in the earlier period of treatment. Also suggests that further study on the effect of Shinbaro pharmacopuncture on patients diagnosed as cervical disc herniation after traffic accident for longer period of treatment.

Short-term changes in median nerve neural tension after a suboccipital muscle inhibition technique in subjects with cervical whiplash: a randomised controlled trial

ObjectivesTo assess the immediate effect of a suboccipital muscle inhibition (SMI) technique on: (a) neck pain, (b) elbow extension range of motion during the upper limb neurodynamic test of the median nerve (ULNT-1), and (c) grip strength in subjects with cervical whiplash; and determine the relationships between key variables. DesignRandomised, single-blind, controlled clinical trial. SettingFaculty of Nursing, Physiotherapy and Podiatry, University of Seville, Spain. ParticipantsForty subjects {mean age 34 years [standard deviation (SD) 3.6]} with Grade I or II cervical whiplash and a positive response to the ULNT-1 were recruited and distributed into two study groups: intervention group (IG) (n=20) and control group (CG) (n=20). InterventionsThe IG underwent the SMI technique for 4minutes and the CG received a sham (placebo) intervention. Measures were collected immediately after the intervention. Main outcome measuresThe primary outcome was elbow range of motion during the ULNT-1, measured with a goniometer. The secondary outcomes were self-perceived neck pain (visual analogue scale) and free-pain grip strength, measured with a digital dynamometer. ResultsThe mean baseline elbow range of motion was 116.0° (SD 10.2) for the CG and 130.1° (SD 7.8) for the IG. The within-group comparison found a significant difference in elbow range of motion for the IG [mean difference −15.4°, 95% confidence interval (CI) −20.1 to −10.6; P=0.01], but not for the CG (mean difference −4.9°, 95% CI −11.8 to 2.0; P=0.15). In the between-group comparison, the difference in elbow range of motion was significant (mean difference −10.5°, 95% CI −18.6 to −2.3; P=0.013), but the differences in grip strength (P=0.06) and neck pain (P=0.38) were not significant. ConclusionThe SMI technique has an immediate positive effect on elbow extension in the ULNT-1. No immediate effects on self-perceived cervical pain or grip strength were observed.

WHIPLASH INJURIES IN SPORTS ACTIVITIES. CLINICAL OUTCOME AND BIOMECHANICS

BackgroundCervical whiplash syndrome, or hyperextension-hyperflexion injury, is a common traumatic injury in sports activities. The mechanisms of injury that cause cervical whiplash syndrome vary, but they may be sufficient enough...

Vertebral artery injury and third-party liability: the wrongful attack to whiplash injury, L.27/12 (G.U.n.71 del 24.03.12)

Lesions after blunt cervical trauma could be, infrequently, associated with complications that require a discussion under clinical and legal medical point of view. Vertebral artery dissection as a serious consequence of a cervical trauma is a rare complication of patients with blunt injury mechanisms. Artery lesions could be frequently initially unrecognized or they may present a variety of symptoms ranging from a simple pain involving neck to ischemic lesions and cerebral ictus. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe vascular stenosis or occlusion. Vertebral artery injury and third-party liability: the wrongful attack to whiplash injury, L. 27/12 (G.U. n.71 del 24.03.12) www.preventionandresearch.com 311 Oct-Dec 2012|P&R Scientific|Volume 2|N°4 In medical literature several injury hypotheses which may cause a dissection of the arterial walls of vertebral arteries have been analyzed. Among them, repeated micro-traumatism which, acting on already altered wall, cause the dissection. Some jobs or sports are characterized by this risk because they imply frequent and repeated flexoextension movements or head rotations. Also a single minor trauma, such as a blunt cervical trauma following car accident, could cause the dissection of the vertebral arterial wall. The case reported concerns a 43 year-old man who suffered a bruising trauma following a car accident (a bumper-tobumper crash with an articulated lorry). The reported symptomatology consisted of pain along the rachis and on the back on the neck and a diagnosis of cervical whiplash was made. After the worsening of the symptomatology, neurological tests revealed right hemiataxia and dysarthria. Succeeding MRI scanning with angiographic sequences revealed a dissection of the left vertebral artery with a hyperdense lesion of the right cerebellar hemisphere, as an outcome of an infarct in the area of a postero-inferior cerebellar artery. Vertebral artery stretch during trauma is a possible pathogenic mechanism that could explain some aspects of the whiplash symptom complex and serious consequences. At the present this issue shows many controversial points from a pathogenetic point of view. The described uncertainties and the rareness of this kind of injury may explain the “superficiality” of a doctor giving first-aid to a patient with cervical whiplash and “generic” symptoms and it could be related to possible economical benefits consequent from insurance indemnity. However the persistence of symptoms or the negative evolution of the same suggests that it wasn’t the “usual whiplash invented for compensation purposes” and that late complications of an injury of the walls of encephalic arteries must be taken into serious consideration specially under clinical point of view.

Posttraumatic Dystonia and Hemiplegic Migraine

The development of focal hand dystonia after a traumatic injury of the central or the peripheral nervous system is a rare condition with multifactorial predisposing factors. We report on a patient who developed focal dystonia of the left hand after a cervical whiplash injury. Magnetic resonance imaging did not show cerebral or spinal lesions, whereas a brain F-FDG PET scan revealed hypometabolism of the right primary sensory-motor cortex extending to the inferior and superior parietal lobule. The patient had a history of recurrent migraine attacks. Four months before the whiplash injury, she had transient dystonic posture of the left hand during a hemiplegic migraine attack. Brain magnetic resonance imaging scan and neurovascular investigations were negative. Among the predisposing factors to the development of trauma-induced dystonia, a putative role of neuronal hyperexcitability, shared by migraine and dystonia, is discussed.

Shaken Baby Syndrome: fact or fiction in Portugal?

Shaken Baby Syndrome (SBS) is an unquestionable and current worldwide problem, as it is considered one of the most severe forms of child abuse, with significant morbidity and mortality among children under one year of age. In Portugal the actual incidence of SBS is still unknown and probably undervalued and underdiagnosed, but international literature reports incidences between 14 and 40.5 per 100.000 children a year in several different countries. It is classically considered SBS to consist of shaking a child repeatedly and violently, inducing a cervical whiplash like movement. Due to the child's development stage, this external force of acceleration/deceleration acting on the head and cervical musculature may cause several lesions, specially subdural, subarachnoid and retinal hemorrhage, and sometimes even bone fractures. However, there is no unanimity concerning this trauma mechanism, especially on the requirement of direct trauma to the head leading to intracranial lesions, since a satisfactory biomechanical model to test it is still lacking. Its diagnosis is controversial, difficult and has important legal and family implications, always adding an emotional element to it, susceptible of withholding the necessary objectivity. In order to substantiate a strong suspicion it is thus mandatory to correlate the clinical history, the physical examination and all the diagnostic auxiliary exams. Consequences may range from mild to fatal, encompassing the child's psychological, cognitive, physical and sensory-motor development, on a short or long term basis. Nevertheless, from a global perspective, its prognosis is almost always poor. So, education and prevention assume primary importance in order to reduce incidence, morbidity and mortality of the SBS. Countries like the U.S.A, Scotland, France, Germany, Switzerland, Canada, Estonia and Japan have long been interested in studying this syndrome's trauma mechanism and incidence, as well as in the development of prevention campaigns and other forms of intervention, particularly through education. However, SBS is still greatly undisclosed in Portugal, since there are neither epidemiological studies nor educational campaigns (or other forms of intervention) on this subject. Thus, the aim of this study is to promote reflection and debate on the issue, displaying the relevance of studying it and investing in information and training in Portugal, in order to prevent and properly diagnose such cases in a timely fashion.