The whiplash injury

In the industrialised world we nowadays live in, a lot of accidents happen, partly due to heavy traffic, partly due to the mechanised work environment. An accident can certainly cause injuries of the bones, vertebral bodies or parts thereof, but it can also lead to torn or overexpanded ligaments with corresponding after-effects.

Probably the best-known and most controversial injury is the whiplash injury, called “distortion of the cervical spine” by physicians. ((The German term “Schleudertrauma” is the not very successful translation of “whiplash injury”. Actually it should be called “Peitschenhiebunfall”.)) In fact this means that no impact of the head is involved in it. But due to modern car technology Kopfbewegung nach Auffahrtsunfall (headrests) a head impact mostly occurs. The collision forces do not necessarily have to leave external damages on the head, rather they lead to compact brain injuries. In lethal cases, which appear seldom, greater bleedings of the head callosity can be found during the post mortem examination, even though no injuries can be seen from the outside. Then a whiplash injury by a rear impact accident with a compact brain injury is not an absolute whiplash injury. But also an absolute whiplash injury without head impact can lead to cerebral injuries. This could be proved in 1968 by Ommaya et al. in an experiment with monkeys. So a whiplash injury is a “distortion of the cervical spine with or without cerebral involvement”. According to the Quebec Task Force on Whiplash-Associated Disorders (Spitzer et al. 1995), Behandlungsverlauf nach Unfallperipheral disorders such as pain or stiffness in the neck and cerebral disorders such as headache, dizziness, hearing dysfunctions, ringing in the ears (tinnitus), concentration and memory disorders, deglutition dysfunctions and temporomandibular dysfuncions (functional disturbances in the area of the lower jaw at the passage to the temple) are symptomatic. A fibrillating or blurred sense of vision also appear frequently. These symptoms appear with a characteristic latency (time delay) of 0 to 72 hours. The cerebral symptoms mentioned above are relevant in order to chronify a disease. Unfortunately just these symptoms provoke heavy controversies among physicians during the assessment of the connection with the accident (causality). A whiplash injury can emerge almost everywhere: During a traffic accident, while doing sports or at work. Yes, it can even happen while skiing or in an airplane, although it has to be said that car accidents are by far the most frequent reason for a whiplash injury.
The critical factor for the occurrence of a whiplash injury is not the place, but the mechanism of the accident, i.e. the body has to perform the movement of a whip stroke. The exact course of such a whip movement during a rear-end collision can be seen in the
The common diagnostic method with a whiplash injury of the cervical spine is shown in the adjacent diagram and can be looked up in appropriate medical literature.  But there are examinations that are generally less known in the emergency departments of hospitals:
First, the determination of the brain’s state is mostly missing, even though the appearance of the symptoms mentioned above indicate a damage. Second, the examination of the passage from head to neck is missing.
And also the next problem appears here: The possible injuries of the brain, of the passage from head to neck and also of the jaw area (see above) need an interdisciplinary treatment. Thus, depending on the severity of the case specialists from orthopaedics, neurology, ENT medicine, maxillary surgery and neurosurgery would have to cooperate in the creation of a diagnosis and the corresponding treatment. Mostly a whiplash injury is only treated from the point of view of an orthopaedist. This may be sufficient in light cases of the whiplash injury. However, if the patient’s discomfort does not ease, examinations by the specialists mentioned above to clarify the circumstance would immediately have to be ordered. And this is mostly not done, with fatal consequences for the patient, so that irreparable damage can possibly result.


Injuries at the passage from head to neck

With a whiplash injury, the cervical spine is over-expanded. But not every “whip stroke” happens in the exact “nodding axis of the head”. If you collide with an obstacle e.g. by car in a rather lateral way, or if cars collide on a crossing, then it is absolutely possible that the whip stroke is triggered a little displaced from the normal nodding axis and that it includes a kind of “head shaking”. So it is indeed possible that twists also occur in the cervical spine.
And not only this: We know from the
cervical spine’s anatomy that the cervical spine has a network of ligaments and arteries. Furthermore there is a joint connection (head joint) between the Atlas (C1) and the Axis (C2). This is the most flexible, but also the most unstable part of the spinal column. The Dens is a kind of “buttress” and prevents the head from over-flexion. All other movements like head shaking, nodding, turning the head etc. are secured by the ligaments and capsules. In a whiplash injury sometimes a rather violent and not consciously controllable over-flexion of the head occurred. That way it is possible that the head joint consisting of Atlas and Axis is “opened” more than its anatomical limits allow. Exactly this opening has to be prevented on the Axis by the three ligaments Ligamenta alaria right and left and Ligamenta cruciforme, as well as the Membrana atlantooccipitalis anterior on the Atlas, and they can now at least be over-expanded, but also be partially or completely torn. There is another ligament that can be abnormally expanded or torn apart: the Ligamenta transversum. This ligament prevents the Dens from touching the spinal cord. A “simple” over-expansion or twist of the cervical spine is normally cured after about six weeks, a ligament injury is not.
And this is exactly where in my opinion an unnecessary and sometimes vehement discussion among physicians begins that is too often carried out to the patient’s disadvantage. The latter will hear an opinion from one doctor and from the other one a different opinion again. Why?
The solution of the mystery lies in the exact examination of the patient’s passage from neck to head. Some physicians think that a whiplash injury is a rather light injury. If a damage of the cervical spine were existent, it would be visible on the X-ray images. If there is none, then it is just a whiplash injury. The other physicians have the point of view that the cervical spine can not only become injured in the middle section, but that the head joint and/or the ligaments can also be injured and that this has to be examined.

How can an injury at the passage from neck to head be determined then?

As you have perhaps already noticed, the diagnosis and therapy of injuries at the passage from head to neck is my special field, which I would like to explain a bit more closely below.
Patients with a whiplash injury of the cervical spine that does not involve an osseous injury or the injury of nerval structures face the problem that these patients are examined by accident surgeons, orthopaedists etc. and that normal X-ray images are made for the examination. These images naturally do not indicate changes of the cervical vertebrae resp. of the affected section since normally a static image is taken.

This situation applies also to modern examination, like e.g. computed tomography or magnetic resonance imaging because these are not functional examinations. With a patient lying still, of course no torn ligaments can be detected. This can be compared with a tear-off of the ligaments at the knee-joint. If the knee-joint ligaments are torn, the patient is not capable of walking. But the X-ray images performed while lying do not result in an abnormal statement. If the knee and also the entire leg were examined by a neurologist because the patient could not walk, then no neurological changes at all would be recognizable here either. But if a stress image of this knee-joint, i.e. a functional one, is taken, a dysfunction of the knee-joint, that is, the enlargement of the knee-joint gap in an abnormal form, can immediately be determined and documented. So the conclusion can be drawn that the ligament on the knee-joint or on the ankle must be injured, since otherwise the gap at the joint would not allow such a wide spread.
Equally, a ligament injury on the cervical spine cannot be proved because most of the produced X-ray and MRI images are not done functionally.

Röntgenbild zeigt seitliche HWS

Röntgenbild zeigt HWS von vorn

X-ray image showing the lateral cervical spine

X-ray image showing the cervical spine from the front

I would like to demonstrate this to you with anonymous X-ray images: Here you see X-ray images, on the right an X-ray image from the front, on the left a lateral view, that were both taken with a C-arm X-ray machine. No injury can be seen at all. You can say that there is no osseous injury. Nevertheless the patient suffered from all the disorders already mentioned above: headache, decrease of memory, partial signs of Funktionelle Aufnahmeparalysis, prickle in the arms or legs, frequent dizziness, ringing in the ears, dysfunctions and pain in the area of the jaw joints, of the ears and eyes. With a C-arm X-ray machine, we now create a functional image from the front through the open mouth. Thereby the head is tilted a bit to the front and to the side. The image can be seen on the right. No osseous injury can be recognized. You can see the Dens, the characteristic of the Axis as the second scervical vertebra. According to anatomy, the Atlas as the first vertebra lies around the Dens. In the image below the contours of the two vertebrae have been emphasized.  And now something noticeable can be discovered: Between the Dens and the Atlas Funktionelle Aufnahmethere is a hollow space, as described on the anatomy page of the cervical spine.
The ligaments on the Axis and the Atlas hold the head joint in a way that there is always a gap with constant dimensions between Dens and Atlas. If now the respective regions on the X-ray image are examined more closely, it can be noticed that the gaps on the right and left of the Dens are asymmetric! The left gap is wider. Similar to the knee-joint you can now conclude from this image that here a ligament injury on the left side is existent. Due to the relatively wide gap on the left it can be assumed that the left lateral ligament (Lig. alaria left) is torn.
That means there is a so-called instability at the craniocervical passage which causes the disorders already mentioned above. Of course this diagnosis can still be confirmed by a functional MRI or CT.

In this case an adequate operation for stabilization can help. The patients with an instability at the passage from head to neck often show the symptoms already mentioned like headache, decrease of memory, partial signs of paralysis, prickle in the arms or legs, frequent dizziness, ringing in the ears, dysfunctions and pain in the area of the jaw joints, of the ears and eyes. These symptoms confirm the suspicion of a structural instability of the passage from head to neck. In order to judge these symptoms better, we have developed a form in which the patient can describe his disorders. That way I am also able to determine changes of the symptoms in the course of time.
Complying with the anamnesis and a whiplash injury the necessary examinations as described and finally the necessary operations can be done.

In the area of the middle cervical vertebrae (from the 2nd cervical vertebra up to and including the 1st thoracic vertebra) fractures can of course occur after accidents, but also over-expansions, dysfunctions or even injuries of the intervertebral discs and the corresponding ligaments, which happens very frequently. The patients complain about permanent pain in the neck, in the shoulder-neck area, also about pain in the neck and back of the head that increase substantially during stress. They can also temporarily involve pain in the arms or prickle. If a whiplash injury of the cervical spine with the mentioned symptoms is existent that does not become better with conservative treatment, a conversation and an examination appointment is advisable, since with the special examination procedure where the cervical vertebrae are examined in motion, such instabilities (like e.g. also at the knee-joint) can be recognized and the necessary stabilizing operation can finally be done.

A whiplash injury can also cause similar damage in the area of the lumbar spine which can then be clarified and treated the same way.

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