Dr. Christopher Quigley Presents: The Info You Need In A Low Velocity Collision Case
- What factors precipitate Whiplash Associated Disorders after low velocity collisions
- How to show that patients with no immediate discernable damage develop crippling chronic pain weeks or months after collisions
- Knowing why current methods of assessing damage (X-ray’s, MRI’s, EMG’s, etc.) are unsuitable for predicting or disproving Whiplash Associated Disorders
- Why velocity of impact is not useable as a means to prove or disprove Whiplash Associated Disorders
Dr. Christopher Quigley:
Good afternoon, everyone. Welcome to our little research review class. Today’s research article is Pathology or Treatment of Traumatic Cervical Syndrome, “Whiplash injury.” This is from the Advances in Orthopedics in February 28, 2018. Now, in the whiplash literature, most of the really good stuff has been done years ago. So it’s nice to see new articles coming out. There aren’t that many of them, so it’s good to get them and see what they have to say.
Dr. Christopher Quigley:
This one’s interesting because they critique one of the major whiplash documents that’s come out in the last 20 years. Actually, this was 25 years ago called the Quebec Task Force on Whiplash Associated Disorders. This task force, it was very slanted towards the insurance industry. They tended to use data from Canada, where they use a lot of the criteria for resolving the injury is whether they went back to work or not. Going back to work has nothing to do with how we feel. So it’s an odd criteria to use, but that’s what they use in insurance industry up in Canada to determine whether a case is handled or not. Obviously, it distorts the data. There’s some decent points to this task force thing, but in general, it’s a negative for the plaintiff industry, meaning for people who have been hurt.
Dr. Christopher Quigley:
This article does a nice job surveying the four grades of injury. They also say that a lot of things have been added since then. One of the things that they talk about is that, “Most whiplash injuries occur during a rear end auto accident, but injury can also result from a sport’s accident, physical abuse, or other trauma. Whiplash symptoms may appear in the absence of any visible injuries,” which is a key component because most of the injuries can be internal. All right, I’m not going to go through the grades here for you, but you can assume that it’s zero to a four, and they get worse and worse.
Dr. Christopher Quigley:
What I did want to review today, though, was talking about neurological symptoms. This is mainly in a grade four situation. They talk about migraine headache, tension headache, cervicogenic headache, temporomandibular joint derangement, greater occipital neuralgia, and third occipital headache in the C3 nerve root. So your occiput is the back of your head. You can have damage to the nerve, which comes out of the back of the head and that’s occipital neuralgia. Occipital headache, there are several nerves that come up through that area, and when the muscles go into spasm, they can cause a headache type condition.
Dr. Christopher Quigley:
Interesting enough, they said that, “Symptoms such as dizziness, tinnitus, headache, memory loss, swallowing and and temporomandibular joint pain can appear at any grade of injury.” One thing that I find fascinating in here is they talk about, they say, “Most typical symptoms of traumatic cervical syndrome are neck pain, cervical discomfort. Neck pain occurs in 65% of the patients within six hours, 93% of the patients within 24 hours, and 100% within 72 hours after neck injury. I don’t quite jive with that. I’ve had several patients, over the years, who days, weeks, even months later have pain from whiplash injury. I just had someone come in, a young guy, got hit two weeks ago, and his neck started flaring up this week. That’s not a 100% rule, hard and fast rule I wouldn’t say.
Dr. Christopher Quigley:
“Factors that influence the extent and location of injury include vehicle speed, impact direction, use or non-use of safety equipment, and the prior state of the victim’s cervical spine.” Those are all great points. I think the last one’s probably the most important of the bunch. You can have someone with a great spine, get in a car accident and walk away and not have any problems, whereas someone’s got arthritis or previous degeneration, and you’re going to see big problems, even with a small accident. I could speak to my own experience. I was sitting in my car, a side street in Boston, and some guy backed out of a parking space right into my car. Totally shocked, but it was a side impact. My neck was screwed up for the next couple of weeks. Now, I’ve been in several car accidents myself, so my neck isn’t the best in the world. It definitely messed me up for a couple of weeks and it was a low impact. I was surprised, but again, my cervical spine does have previous arthritis and it from those previous injuries. So that’s a good point.
Dr. Christopher Quigley:
“Typical clinical characteristics of the injury include patient not complaining of neck pain immediately after the accident, but then complaining of neck pain a few hours or the next day.” Again, it could be later. A nice point they do make is that, “The timeline can be explained by synovitis or inflammation of the facet joints, where the synovial tissue involved in the facet joint has been damaged by non-physiological behavior during collision, which may induce synovitis, again, irritation of the facet joint after several hours leaving neck pain and limited range of motion.”
Dr. Christopher Quigley:
The other part of that formula is the inflammatory process. The inflammatory process really gets going, typically after 72 hours. The first phase of healing an injury is the inflammatory process, the first zero to 72 hours. The next phase is the regenerative section, and that’s from six to eight weeks. And the last phase is the remodeling, which is up to 12 to 18 months.
Dr. Christopher Quigley:
“Many patients with traumatic cervical syndrome recover from the symptoms within a few weeks or months, but 20% to 40% will have neck pain and headaches that continue for several years and 3% to 4% will be disabled and not able to return to work. The potential exists for abnormally prolonged arthritis of the synovial membrane, cervical nerve root irritation to the posterior branches, and vestibular reflex abnormality due to vestibular dysfunction, neck muscle tension or fibromyalgia.” Your vestibular system is your balance system. All right, obviously it’s critical component. They do talk about, in this article, some detailed information about that.
Dr. Christopher Quigley:
They talk about headaches, “Headaches presented chronic symptoms in 70% of patients after whiplash. It connects between the upper spine nerve roots and the trigeminal nerve.” Dizziness they talk about. There are two types of dizziness. There’s vertigo, which can be caused by brainstem bleeding, sometimes manifests itself as vertigo, When in fact it’s mostly caused by an inner ear disorder. And then planktonic. “Planktonic dizziness is caused by cervical cranial disorder, a failure of the input system regarding the spinal cord.” So the planktonic is going to be more spine related, whereas the vertigo can be inner ear related. “Dizziness originated from the cervical spine is collectively known as cervical vertigo and may be caused by circulatory failure of the vertebral artery, proprioceptor dysfunction of the cervical spine, or cervical sympathetic nervous system disorders. Cervical lumber propioreception dysfunction may produce vertigo.”
Dr. Christopher Quigley:
“Barré-Lieou syndrome. Barré-Lieou syndrome symptoms include headache, dizziness, and other cervical sympathetic nervous system symptoms, numbness in the head and the face. This is disruption of the trigeminal spinal nucleus and can lead to numbness or loss of sensation around the face. Eye symptoms. Eye symptoms emerge in 35% of traumatic cervical syndrome patient. It could be eye pain due to trigeminal nerve stimulation, eye movement disorder, double vision caused by oculomotor nerve dysfunction, visual deficit to due to optic nerve disorders, and, I’m not sure how to pronounce that, and blepharoptosis due to sympathetic nervous system disorders.
Dr. Christopher Quigley:
Nausea and vomiting founded 17% and 29% of whiplash injured patients. These symptoms persist for more than six months in a third of patients. Limb syndrome symptoms, numbness or the muscle weakness of the upper cervical extremities may appear as nerve root or spinal cord symptoms.” It’s most commonly seen in people who have disc injuries and pain in the shoulder blade area. That’s a really very common symptom in the whiplash area.
Dr. Christopher Quigley:
“Limb symptoms traumatic cervical syndrome often do not produce any findings on imaging studies. Motor evoked potentials should be performed in all patients with persistent pain, even in the absence of objective neurological signs and non-significant changes on imaging.” I do find that a lot of people have muscle weakness. Sometimes, the doctor needs to be very astutely aware or sensitive. Example, I use the young man I saw today. He had some weakness in his arm. It was definitely some weakness there, but it was very subtle. I said to him, “Does that feel a little weak to you?” He says, “Yeah, I was wondering if you notice that.” So again,, I’m going to leave that to the quality exam in many cases.
Dr. Christopher Quigley:
“Fibromyalgia may occur in 21% of patients. Fibromyalgia is a neurosensory disorder characterized with widespread muscle pain, joint stiffness, and fatigue. There’s also no inflammatory findings or abnormalities, which indicate organic disorders, such as bone and joint disease, neurodegenerative disease, rheumatic disease, or malignant tumors. Other common symptoms of fibromyalgia include irritability, sleep disorders, anxiety, depression, and are predominantly seen in women in their fifties,” but obviously not 100% of them. “The mechanism is the following symptoms were clear, ringing in the ears, hearing loss, insomnia, loss of concentration, fatigability, fever, and memory loss, temporomandibular joint pain in general, like chest pain. The Quebec guidelines may not be applicable in all patients for traumatic cervical syndrome.”
Dr. Christopher Quigley:
Nice little article. Talks about some of the focuses and some of the weakness of the Quebec task force. Again, it wasn’t a great document to begin with, but obviously there’s some weakness exposed in this article and many of others. Good to keep in mind, I guess, the key point here is that, whiplash can cause many different problems, symptoms in patients. It’s really important to get a really good thorough exam when dealing with these patients. In my experience, I’ve seen a lot of stuff gets missed. I particularly see that in the younger age group. We got to be really on your game with those patients to make sure you’re getting all the details, all right. Obviously, that’s the number one job in my profession is to get you the details so you can make a stronger case. All right, thank you very much. And we’ll see you next time.