Below are extracts from the 33 A4 pages of the section on Cervical Spine (including Whiplash Injury). Injury comes first, then Post-Trauma Problems, and last References
Most cervical spine injuries are from a single traumatic incident. And the commonest of these is the traffic accident - the rear shunt or the head-on collision. The general name for the resulting injury is a 'Whiplash Injury'. In the literature it is often called the 'Whiplash Injury Syndrome' or 'Whiplash Assocoiated Disorder', because there are so many things that the people complain of. But another way of looking at it is to realise that in a significant whiplash injury a lot of different structures receive a considerable trauma. It is not surprising that someone with multiple injuries complains of multiple problems.
However problems - and pains - can develop over a long time when the neck is held fixed in some strained and extreme position. This happens when the body is held in a continuous poor posture. A typical example of this is the bent neck and pushed forward face of the surgeon. This position is sometimes held for two or three hours, Here there may be stretching and 'creep' of the collagen ligments together with microscopic damage from compression of the blood supply. Stiffness and tenderness develop, with (over visible joints like the wrist) redness and swelling. It can come up fast, say in six weeks, if there is a a huge amount of overwork, or slowly - in six years - when the stress is less obvious. It is still called Repetitive Strain Injury, a name that helped sufferers to understand it. It was re-named Cumulative Trauma in an article from the U.S. of A (who else ?!), which helps the clinicians to understand it ! ( Clin Biomechanics June 1998)
Pain or problems coming on without an injury could be due to previous cervical spine injury - to either joint or ligament or disc or bone, or even to nerve. Or It could be due to some generalised process that is showing up locally, such as infection or an arthritic process (see Hot Red Swollen Joint, on the Home Page).
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In the young, pain or problems coming on without an injury may be due to some tiny derangement in an insignificant part of the spine. A painful incident can even occur in a normal neck from a normal movement and be of no consequence whatever. However if the spine is already damaged, otherwise trivial incidents of trauma can cause great pain, and may take a much longer time to recover than normal.
Just as in other joints, injuries to the cervical spine can sprain and tear the local structures, giving pain; the pain may be felt locally (in the neck), or maybe along the arm or up into the back of the head. Serious trauma can lead to major ligament tears, so that the neck is unstable. In this case the patient may be uneasy in certain positions (say, leaning forward over a basin to shampoo your hair, or leaning back to look at blossom on a tree on a beautiful Spring day). Sometimes they can actually feel it to be unstable. Other structures in the neck can get hurt, either in the original incident or because the neck is unstable.
Small fractures can cause a lot of pain, but not be significant (ie. not endangering the stability of the neck or the spinal cord, or nerves or arteries). But fractures or dislocations are usually significant and serious, because the patient may be at risk of compressing arteries of nerves, or even the spinal cord. Or, at worst, may already have done so.
Causes: Neck injuries come from road accidents, accidents at work, from falling off things (bikes, horses, ladders) and from things falling on to heads. Neck injuries can form a significant part of the problems following a head injury, and are one of the causes of osteoarthritis of the neck - a common and painful scourge of the over-sixties.
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Reasons for problems: A hurt neck can cause many symptoms: Symptoms occur for the following reasons:
- Immediate damage to local structures - ligaments, joints, bone, nerve etc. There is pain, from the damage and the bleeding; there are changes in strength and sensation, from pressure on nerves.
- Immediate damage to structures passing through - the nerves to the arm (changes in strength and feeling in shoulder, arm or hand), the spinal cord (changes in strength or feeling in the legs, or possibly, incontinence), or one of the arteries to the brain (not very often),
- Delayed swelling, from one to four days later. Can cause tingling from nerve compression. Usually affects the lipper limb only.
The chief symptom from the injury is pain - this can be felt :
- Locally - in the neck at the level of the injury
- Radiating out from the neck
- up the neck, down the back, and out towards the shoulder.
- If nerves are involved the pain may be felt anywhere in the shoulder or arm, or up into the back of the head.
- Injury to a cervical nerve may cause weakness and patchy numbness in the arm . Even more serious symptoms are tingling, patchy numbness and weakness in the leg or arm, caused by compression effects on the spinal cord. And the same type of symptoms in the face, but with dizziness, caused by compression of one of the arteries to the brain.
Neck injuries can also be catastrophic or fatal.
END OF PREVIEW for INJURIES SECTION
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The Questions to be Answered
The questions we hope are answered in this section are:
(i) I have pain (or other problems) in my neck, or shoulder, or headache, or pain in my face. Is this expected after a Whiplash Injury?
(ii) I suffer from other things besides the pain - is this the sort of thing that happens or is it all 'in my head'.
(iii) People keep telling me that all whiplash sufferers exaggerate their symptoms for the compensation - do they really believe this of me?
(iv) What is it that causes all this ? What could be causing all these problems - the doctors looked very carefully at the X-ray and there was nothing wrong.
(v) It is now weeks / months / years since my accident, and I am still having problems. Will I ever get any better ?
(vi) I have got these problems, and this pain. Is there anything that can be done about It?
What normally Happens to a Whiplash injury ?
At the time of the injury
The clinician will make sure that you are not suffering from the important complications of this injury. These are (i) a nerve being pinched , thus affecting your sensation, power, and reflexes. Also (ii) instability of the neck bones (a vertebra being loose or not properly under control of the ligaments and muscles) which might cause pain and problems later on. So a history is taken, and an examination carried out. If the injury is thought to be very minor, with no complications; and the clinician is not concerned, you will probably be discharged without having had an X-ray.
If an X-ray is requested and it is normal, and your problems are minimal, you will be probably be told what to expect, warned to return if this or that happens, and discharged. If the X-ray is normal but the clinician feels that the injury is significant (may give trouble) he or she will arange to see you again in a follow-up clinic, or request G.P follow-up, or request Physiotherapy.
If the X-ray is seen to be not normal, the receiving doctor will refer upwards, probably to the orthopaedic team.
Current thinking (2002) is that a neck collar is kind to the patient as it helps to prevent the pain of normal movement; but it should not be kept on permanently beyond 10 days or two weeks (Twomey 1991, and personal communication, local physio dept.). Those that do need a collar beyond two weeks should see a clinician.
If you have any weakness / loss of sensation / loss of reflexes in the neurological examination, then you will be considered for admission. Pins and needles are not usually thought to be serious, as they are common even in very minor injuries. But they may accompany other neurological manifestations. Any sign of instability in the spine is usually an indication for admission also. And of course, a fracture seen on the X-ray.
Early Days:-
Your clinician will have explained the problems you might encounter, or the pain. She will usually advise gentle, unforced movements of the neck, possibly in the form of exercises by you. Often this is achieved by doing movements up to, but not into, the pain. These are in the form of regular execises, three or four times a day, that last about half an hour. They vary slightly according to the patient and the injury, but usually you will be asked to move your neck (always within pain) five or ten times in each direction. Very gently at first!
You can move it in six different directions, and if you cannot think of all six, they are these: Look down, then up. Look and turn to the left, then to the right. And move your right ear towards the shoulder, and then the left ear ditto. Later you can combine the movements, like this for instance: Look up and turn to the right, then look up and turn to the left.
All this will begin the process of stretching the scar tissue fibrin, so that it does not finish up causing stiffness in the neck. Although you may feel comforted if a therapist helps you at this stage, the exercises really are best done by you. At this critical stage only the sufferer knows when to stop and when to go on !
Middle Days (six weeks to three months): -
This is the time when the patients tend to separate. About half will gradually become free of problems or pain. Or nearly so. But half of them will still have problems, or pain, that is affecting their lives. The patient and the clinician should be making a decision - can these pains or problems be diminished surgically or medically ? The clinician will generally be applying very carefully graded mobilisations to keep the scar tissue stretched; amd also advice on graded exercises to help the neck muscles to ovecome their inhibition by pain. But both are looking to the future - can - or should - anything more be done ?
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END OF PREVIEW for POST TRAUMA SECTION
These references are taken from the research literature. No doubt we have missed out many, for there is a huge amount of work done on the cervical spine. But these are chosen because they provide evidence and back-up for what is said in our text.
Bogduk N 1986 Anatomy and Pathophysiology of Whiplash. Clinical Biomechanics 1: 92-101
Brain & Wilkinson, Symptomatology, Pathology , chaps 3 & 4, in Cervical Spondylosis publ Heinemann, 1st or 2nd edn.
Chiropractic the "Only Proven Effective Treatment" for Chronic Whiplash. http://www.chiroweb.com/archives/18/1/19.htm/.
Cloward R R 1960 The Clnical Significance of the Sinu-vertebral Nerve of theCervical Spine in Relation to Cervical Disc Syndrome. J Neurol Neurosurg Psychiat 23, 321
Crawford R 2001 Cansultant Spinal Surgeon, Norfolk and Norwich University Hospital, personal communication.
Edmeads J 1978 Headaches and Head pains associated with disease of the cervical spine. .Med Clin N America 62 (3) ; 533-544
Epstein 1976 Section 10 ch 43 - Vertebral Artery Disease, in The Spine - A radiological Text and Atlas 826-832
Gargan M, Bannister G: 1990 Long term prognosis of soft tissue injuries of the neck. J Bone & Joint Surgery 72 B, 5: 901-903
Grieve G P 1981 page 222 Acceleration and Deceleration Trauma - ('Whiplash Injury' ); in Common Vertebral Joint Problems, publ Churchill Livingstone ISBN 0 443 02106 6
Gunn C C 1976 Tennis Elbow and the Cervical Spine Canadian Medical Association Journal 114 (9) 803-805
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END OF PREVIEW for REFERENCES SECTION