Definition of whiplash injury
• it’s seen in about 25 percent of rear-end collision of RTAs.
• Seventy percent of those affected are women.
• it’s common within the 3rd or 4th decades.
• Pain on the upper neck that becomes worse with movement.
• Occipital headache.
• Neck stiffness.
• Rarely vertigo, auditory or visual disturbances, etc.
• Decreased range of neck movements.
• Neck muscle spasm is seen.
Note: Symptoms will appear within 48 hours of the injury and 57 percent recover within three months.
X-rays are usually normal. MRI helps to make a diagnosis.
It is mainly conservative and consists of the following:
• Drugs: NSAIDs, muscle relaxants, etc. are given.
• Collars: These are recommended for the primary three days.
• Short arc active movements are slowly begun.
• Active ROM exercises are slowly commenced.
• After pain subsides, isometric strengthening exercises are slowly work.
• Other modalities like ultrasound, traction, manipulation, massage, etc. also helps in the treatment.
Allen’s Classification of Cervical Spine Fractures
Compressive flexion (5 stages): Ranges from blunting of anterosuperior vertebral margin to posterior displacement into the vertebral canal . It is usually a stable fracture but may become unstable if compression is quite 50 percent.
Vertical compression (3 stages): Ranges from fracture of superior or inferior endplate with centrum fracture of the vertebral body. Stable fracture if compression is a smaller amount than 50 percent of the vertebral body.
Distractive flexion (4 stages): This is an unstable fracture. Failure of posterior ligamentous ranges from complex to full-width vertebral body displacement.
|Cervical Spine Injury|
Compression extension (5 stages): Ranges from unilateral neural arch fracture to bilateral neural arch fracture with full-vertebral body displacement anteriorly. It is unstable.
Distractive extension: This is an unstable frscture. Ranges from failure of anterior ligament complex to posterior ligament complex.
Lateral flexion: Ranges from asymmetric compression and ipsilateral neural arch to fracture without displacement and with displacement. May become unstable.
The patient usually gives history of trauma following which there’ll be pain in case of Whiplash injury, swelling and inability to maneuver the neck. There will be tenderness over the involved spinous process and there might be a palpable gap.
There may be signs of neurological involvement. Determine the level of cord injury by examining the affected spine. The injuries to the medulla spinalis at the cervical region can manifest within the following ways:
Nerve Root Involvement
Individual nerve roots might be affected at their respective intervertebral foramen. All the features of peripheral nerve injury with LMN sort of lesion are seen. The myotome and therefore the dermatome should be assessed to understand the basis involvement.
Cord involvement could be:
Complete: This leads to quadriplegia or quadriparesis.
Incomplete: Here the central cord, lateral cord, anterior or posterior cord could be involved.
Rectal sensation: Loss of sensation around the anus.
Rectal motor: Sphincter contracts, over a gloved finger.
Bulbocavernosus reflex: Bulbocavernosus reflex involves S1, S2 & S3 nerve roots. Squeeze the glans penis, anal sphincter contracts around the gloved finger.
Initially, following the injury, the above reflexes are absent, indicating spinal shock. Usually, it returns within 24 hours. If not a presumptive diagnosis and determination of a root or cord lesion is made. A diagnosis of a complete or incomplete syndrome is documented.
Radiography: Lateral view is important. If an adequate lateral radiography reveals no fracture or dislocation, then an entire radiographic examination including anteroposterior, open mouth and oblique projections are performed.
Myelography is useful in incomplete lesion who fails to point out progressive improvement.CT scan makes an accurate diagnosis of hidden fracture. It is not helpful in assessing the soft tissue injury.
MRI evaluates cord injuries better. MRI is found to be very reliable and helpful in assessing the bony, soft tissue damages and injury to the cord very accurately.
General laboratory investigations: Like Hb percentage, blood group, bleeding time, clotting time, electrolyte status, etc. are done.
At the Accident Site Resuscitation and transport is important. In a person lying still without using his neck after an RTA, cervical spine injury is always suspected until proved otherwise.
The patient is transported with utmost care over a stretcher to the hospital. All unnecessary neck movements should be totally avoided. If the patient needs resuscitation, it has to be carried out with a lot of care.
• Stable cervical spine with no neurological injury. A rigid cervical brace or halo for 8-12 week is usually sufficient.
• Stable fracture of vertebral bodies and undisplaced fracture of laminae, lateral masses or spinous process.
• Unilateral facet dislocations reduced in traction could also be immobilized during a halo vest for 8-12 weeks.
Skeletal traction: Reduction with traction is completed for unstable fracture. Urgency of reduction is predicated on neurological loss.. Traction is given for 3-6 weeks and once satisfactory reduction is achieved, the patient is mobilized with a collar, corset or jacket.
Halo Vest Immobilization: Many unstable cervical spine injuries can initially be managed by cervical traction through a halo ring. After obtaining the alignment of the cervical spine, halo vest may be completed.
Indications: Unstable injuries with or without neurological damage require surgery.
• In most patients early open reduction and internal fixation (ORIF) is indicated to obtain stability. Cervical spine is stabilized through an anterior or posterior approach.Usually, a posterior approach is used with triple wire stabilization and fusion with iliac bone grafting. This allows rapid mobilization of the patient during a cervical orthosis.
• Anterior decompression consists of removal of the disk and is suggested when disk prolapse is present.
• Anterior cervical plating allows for immediate rigid fixation after decompression and bone grafting. The plates used are H-type or Caspar plates. Recently cervical spine locking plate(CSLP) and reflex anterior cervical plate are providing better fixation and faster rehabilitation.