WHIPLASH INJURY

Intervertebral discs

Interspinous ligaments

Supraspinous ligaments

Headache Headache is a common pain experienced after whiplash injury. This may be caused by muscle contraction or tension but it may be secondary to other tissue injury in the cervical spine. The headache may be unilateral and throbbing in nature which suggests a vascular cause. The headaches can resemble migraines or they may be focal and stabbing in nature.

© 2003 Primal Pictures Ltd Figure 1: Structures involved in whiplash injury

A number of these symptoms have been collectively called the Barré-Lieou syn- drome. In 1925, Jean Alexandre Barré, MD, a French neurologist, and in 1928 Yong-Choen Lieou, a Chinese physician, each independently described a syndrome with a variety of symptoms thought to be due to a dysfunction in the posterior cer- vical sympathetic nervous system. The posterior cervical sympathetic syndrome became known as Barré-Lieou syndrome.

Symptoms that characterise the syndrome include: ■ headache ■ neck, facial, ear and dental pain ■ tinnitus ■ vertigo ■ nausea ■ vomiting ■ blurred vision ■ watering of the eyes ■ sinus congestion.

Other symptoms may include swelling on one side of the face, localised cyanosis of the face, facial numbness, hoarseness, shoulder pain, dysaesthesia of the hands and forearms, muscle weakness and fatigue. These symptoms correlate very closely with those experienced after some whiplash type injuries and may indeed be part of the spectrum of WAD.

Whiplash injury can certainly trigger emo- tional and cognitive changes, including:- ■ Travel anxiety ■ Post traumatic stress disorder ■ Depression ■ Fear of movement ■ Sleep disturbance

www.sportex.net ■ Lower levels of concentration.

The evidence suggests that the develop- ment of chronic symptoms is influenced more by psychological, social or cultural factors.

PATHOPHYSIOLOGY Autopsy studies have shown that in severe whiplash, damage is caused by the sheer force to bone, joints, ligaments, muscles, and nerves. Haemorrhages and haem- atomas occur in the neck muscles along with tears in the inter-spinous and supra- spinous ligaments (Fig.1).

The main clinically important structures involved are the apophyseal joints, the intervertebral discs and the intervertebral ligaments. Often there is immediate pain or the onset may be delayed for up to 48 hours. This implies a more neuromuscular origin to the pain. The delayed onset improves the prognosis.

The nerves that may be involved include the accessory nerve, the cervical sympa- thetic chain and the vertebral nerves. There may be a resultant vertebral artery spasm and ischaemic effects on the brain stem. Temporo-mandibular joint function may also be disturbed due to the mechan- ical forces during the injury. Very often MRI and CT scans, along with radiographs are mostly normal as are electromyograms.

PROGRESS OF SYMPTOMS Most patients recover within about two months but in a significant minority the symptoms may continue for years or indefinitely.

Nerve-related symptoms Some patients also complain of pain, numbness, tingling, coldness or weakness in one or both arms. Other symptoms include dysphagia, blurred vision, Horner’s syndrome, tinnitus, hearing loss, dizzi- ness, fatigue and cognitive deficiencies. These symptoms may be related to dam- age of the cervical sympathetic chain.

Low back pain

Low back pain can occur in 42% of acci- dents and this type of low back pain will often come on several days or weeks after the accident.

Data from retrospective studies suggests that persistent symptoms are more likely to develop if the patient has pain or parasthaesia in the arms or if there is evi- dence of pre-existing degenerative change on x-ray. If there is a reversal of lordosis or if abnormal neurological signs are pre- sent, these may also be indicators of a poor prognosis.

Behaviour-related problems There is increasing evidence that a pro- portion of victims develop behavioural or psychiatric problems, for example, in a study of 63 whiplash victims with no other injury, 18% had a phobic anxiety at three months and 12% at one year after the accident. 5% had post traumatic stress disorder at one year and 18% suf- fered from travel anxiety. Compensation did not predict these outcomes.

MECHANISMS INVOLVED IN WHIPLASH Different mechanisms have been suggest- ed as a cause of prolonged symptoms after whiplash type injury.

Apophyseal joint instability Facet joints may be separated excessively during a rear end collision and may never recover their stable apposition. Chiropractors, osteopaths and many phys-

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