Decompression of the Greater Occipital Nerve for Persistent Headache Attributed to Whiplash Accompanying Referred Facial Trigeminal Pain.

OBJECTIVE: Persistent headache attributed to whiplash (PHAW) is defined as a headache that occurs for the first time in close temporal relation to whiplash lasting more than 3 months. We investigated the results of decompression of the greater occipital nerve (GON) in patients with PHAW who presented with referred trigeminal facial pain caused by sensitization of the trigeminocervical complex) along with occipital headache. METHODS: A 1-year follow-up study of GON decompression was conducted in 7 patients with PHAW manifesting referred facial trigeminal pain. The degree of pain reduction was analyzed using the numeric rating scale (NRS-11) and percent pain relief before and 1 year after surgery. Success was defined by at least 50% reduction in pain measured via NRS-11. To assess the degree of subjective satisfaction, a 10-point Likert scale was used. Clinical characteristics of headache and facial pain and surgical findings were studied. RESULTS: GON decompression was effective in all 7 patients with PHAW manifesting referred trigeminal pain, with a percent pain relief of 83.06 ± 17.30. The pain had disappeared in 3 of 7 patients (42.9%) within 6 months and no further treatment was needed. Patients' assessment of subjective improvement based on a 10-point Likert scale was 7.23 ± 1.25. It was effective in both occipital and facial pain. CONCLUSIONS: Although chronic GON entrapment itself is an individual constitutional issue, postwhiplash inflammatory changes seem to trigger chronic occipital headaches in GON distribution and unexplained referred trigeminal pain caused by sensitization of the trigeminocervical complex.

Is Delayed Surgery After Unsuccessful Conservative Treatment Beneficial for Spinal Cord Injury Following Whiplash? A Retrospective Study in Elderly Patients.

BACKGROUND The aim of this study was to investigate the clinical outcomes of early and delayed surgery in cervical spinal cord injury following whiplash in elderly patients. MATERIAL AND METHODS Our retrospective review identified elderly patients (≥65 years old) with spinal cord injury following whiplash injury from 2006 to 2015. The neck disability index (NDI), modify Japanese Orthopedics Association (mJOA) score, and visual analogue scale (VAS) score were used to evaluate clinical outcomes preoperatively and during follow-up. The angular range of motion (ROM) for C2-C7 was measured by dynamic flexion and extension lateral cervical radiographs at each observation follow-up time point. Treatment-related complication data were collected, and the complication rates analyzed. RESULTS Forty-six elderly patients (age range 65-82 years) with spinal cord injury following whiplash injury were enrolled in this study. Twenty-four patients underwent early surgery and twenty-two patients (age range 65-78 years) received delayed surgery after conservative treatment failure. During the follow-up period, both groups had significant post-operative improvement in NDI, mJOA, and VAS scores (p<0.05), although the early surgery group had better outcomes than the delayed surgery after unsuccessful conservative treatment group (p<0.05). However, on average, no significant differences in sagittal C2-C7 ROM between the two groups were found during follow-up. Comparison of the two groups showed the incidences of pneumonia and deep vein thrombosis were significantly higher in the delayed surgery group (p<0.05). CONCLUSIONS This study indicated that delayed surgery after unsuccessful conservative treatment provided excellent clinical results for elderly patients; however, timely surgical intervention is necessary for neurological symptom deterioration.

Metallosis after traumatic loosening of Bryan cervical disc arthroplasty: a case report and literature review.

PURPOSE: Cervical disc arthroplasty has been a popular alternative to traditional arthrodesis treatment for maintaining postoperative cervical spine mobility. However, certain adverse reactions to cervical disc arthroplasty have emerged during the last few decades. METHODS: Metallosis or metalloma is a rarely reported complication after spinal fusion or spinal arthroplasty surgery. We report on the first metallosis case occurring in a patient who received Bryan Disc implantation approximately 8 years earlier. She was involved in a traffic accident and sustained a whiplash injury to the cervical spine one and a half years ago. The traumatic Bryan Disc loosening developed after the traffic accident, causing metallosis. RESULTS: To the best of our knowledge, this is the first reported case of spinal metallosis caused by the Bryan Disc. A series of metallosis cases reported in the literature are also reviewed. CONCLUSIONS: Although uncommon, intraspinal metallosis or metalloma should be considered as an infrequent cause of delayed neurological symptoms after spinal surgery involving metallic instrumentation, especially after disc arthroplasty. Once metallosis is suspected, immediate metallic implant removal is mandatory for definite diagnosis and treatment.

A small group Whiplash-Associated-Disorders (WAD) patients with central neck pain and movement induced stabbing pain, the painful segment determined by mechanical provocation: Fusion surgery was superior to multimodal rehabilitation in a randomized trial.

BACKGROUND: The majority of patients suffering from a whiplash injury will recover, but some will have symptoms (Whiplash Associated Disorders, WAD) for years despite conservative treatment. Some of these patients perceive neck pain that might come from a motion segment, possibly the disc. In comprehensive reviews no evidence has been found that fusion operations have a positive treatment effect on neck pain in WAD patients. PURPOSE: Our aim was to evaluate the possibility of (a) selecting a subgroup of chronic WAD patients based on specified symptoms possibly indicating segmental pain, and (b) treating said segmental pain through fusion operation based on non-radiological segment localization. The hypothesis was that fusion operation in this selected subgroup of chronic WAD patients could alleviate perceived neck pain. METHODS: Eligible patients for the study had a traffic accident as the origin for their neck pain, and no previous neck symptoms. Neck pain should be the predominant symptom and the pain origin reported to be in the midline, being dull, aching in character and at sudden movements combined by a stabbing pain in the same area. Forty-nine patients with these specified symptoms were identified among a large number of chronic WAD patients. Those selected had pronounced symptoms for a median of around 50 months and had previously been investigated and fully treated within the ordinary healthcare system without success. No neurological abnormalities were to be found at clinical examination and no specific changes to be seen on X-ray and MRI. The patients were randomized to either cervical fusion operation or multimodal rehabilitation. By using a mechanical provocation test the level/s to be fused were identified. In all but one patient the surgery was performed anteriorly using microsurgical technique and a right-sided Smith-Pedersen approach and plate fixation. The multimodal rehabilitation at the Clinic of Medical Rehabilitation, Karolinska Hospital, Stockholm, included outpatient treatment for four days a week for six weeks and included treatment by physician, physiotherapists, occupational therapist, psychologists, social-service worker and nurses. Perceived change in neck pain was assessed using the Balanced Inventory for Spinal Disorders questionnaire at the 2-year-follow-up. RESULTS: Mean age of the patients was 38 and 40 years (surgery and rehabilitation groups, respectively), the most common type of accident being rear-end collision. At clinical examination muscle tenderness was not an outstanding sign. In most patients the mid-cervical region appeared to be the painful area but one patient localized the pain to C1. At follow-up 67% of the patients in the surgery group and 23% in the rehabilitation group assessed improvements in the ITT analysis. Corresponding proportions in the per protocol analysis were 83% and 12%, respectively. CONCLUSIONS: The results support the supposition that among patients with central neck pain for long periods of time following a whiplash injury there are some in whom the neck pain emanates from a motion segment, probably the disc, a situation suitable for fusion surgery. IMPLICATIONS: Thorough individual symptom evaluation in patients with chronic WAD may identify patients who will benefit from cervical fusion surgery.

Clinical and medicolegal characteristics of neck injuries.

The predominance in performing surgery of major spine injuries by neurosurgeons usually has the consequence of treating all types of spine injuries by neurosurgeons - neurotraumatologists. In the neurosurgical wards of Clinical Hospital Rijeka, we take care of the majority of these patients, following both the major, as well as minor--whiplash injuries of the neck. This article is an overview of the patients admitted in the one year period (October 1st 2009-October 1st 2010) where 1077 cases of neck injuries were analyzed. Vast majority of these injuries were due to traffic accidents (over 94%), and only a small proportion were serious injuries that needed a surgical approach--decompression and stabilization (c1%). We analyzed minor neck injuries thoroughly both because of the increasing number of whiplash neck injuries and because more complicated diagnostic and therapeutic protocols occupy too much time in the ambulatory practice of our neurotraumatologists each year thus representing a growing financial burden to the health organizations and to the society as a whole. Our results proved that the majority of the injured are male (over 60%), young and active (almost two thirds 21-40 years of age), had commonly sustained a Quebec Task Force (QTF) injury of grades 2 and 3 (almost 90%), and, if properly treated, recovered completely after a mean therapy period of ten weeks. Only a minority complained of prolonged residual symptoms, some of them connected with medico-legal issues (less than 20%). The results shown are in contrast with the general opinion that malingerers in search of financial compensation prevail in these cases, and leads to the conclusion that minor neck injuries (including whiplash) as well as Whiplash Associated Disorder (WAD) are real traumatological entities, that have to be seriously dealt with.

["Isolated injury" of the alar ligaments: MRI diagnosis and surgical therapy]. / "Isolierte Verletzung" der Ligamenta alaria : Kernspintomographische Diagnostik und operative Therapie.

UNLABELLED: Spinal distortions caused by traffic collisions play a large role in medical expert opinions. Prolonged or chronic conditions present particular difficulties. The radiologist E. Volle developed and published a system for the classification of isolated injuries of the alar ligaments. As a result, surgery on the craniocervical junction was carried out in a large number of patients and the results published on multiple occasions. This article describes the anatomy of the alar ligaments, complicated injuries, the concept of the isolated lesion of the alar ligaments and their surgical management. German and international publications are evaluated. RESULT: It was impossible to substantiate isolated injuries to alar ligaments. According to current knowledge, the published results are based on a misinterpretation of MRI findings. These results are to be considered as artefacts. There is no anatomical correlation for the classification of isolated injuries to alar ligaments. Surgical stabilisation due to an allegedly isolated injury to the alar ligaments is therefore not indicated. This statement does not apply to injuries sustained in high-speed trauma in combination with complex injuries of the atlanto-occipital and atlanto-dental-joint (joint capsules, atlanto-occipital membrane) with clear signs of instability.

[Clinical research of delayed hyperextension injury concomitance spinal cord injury of cervical spine].

OBJECTIVE: To discuss Clinic feature and turnover of delayed hyperextension injury concomitance spinal cord injury of cervical spine. METHODS: The clinic data of 30 patients delayed hyperextension injury of cervical spine were reviewed and analyzed. Course of disease was from 3 months to 8 years. Thirty patients were divided into three groups according to course of disease. The first group, 3 - 6 months, 17 cases; the second group, 6 - 12 months, 8 cases; the third group, 12 months-8 years, 5 cases. Neurological function improvement rates were evaluated according to the JOA scores at preoperative, 3 months and 1 year post operation, and complications were observed in three groups. Twenty-six cases were treated with anterior decompression, bone graft and plate fixation. Four cases were treated with posterior decompression, bone graft and plate fixation. RESULTS: The patient number of the three group exist with statistical significance. Thirty patients were followed up for 18 - 39 months, 23 months on average. Neurological function recovery rates were 23.8% in the first group, 53.9% in the second group and 54.3% in the third group at 1 year post operation. JOA scores of the first group and the second group with statistical significance at 3 months and 1 year post operation. JOA scores of the first group and the third group with statistical significance at 3 months and 1 year post operation. JOA scores of the second group and the third group without statistical significance at 3 months and 1 year post operation. CONCLUSIONS: Incidence of hyperextension injury associated with spinal cord injury of cervical spine would degrade along with course of disease prolong. If delayed spinal cord injury occurred earlier, the patient's condition was severer and badly improvement rate.

Pulsed radiofrequency of cervical medial branches for treatment of whiplash-related cervical zygapophysial joint pain.

BACKGROUND: The aim of this study is to assess the efficacy of pulsed RF lesioning of cervical medial branches in patients with whiplash-related chronic cervical zygapophysial joint pain in whom other conservative treatments failed. METHODS: Cervical zygapophysial joint pain was confirmed in 14 patients undergoing double diagnostic blocks. These patients underwent pulsed RF lesioning of the cervical medial branches. Pulsed RF procedures were performed in 2 cycles of 180 seconds after localization under fluoroscopy guide. RESULTS: Twelve (85.7%) patients had substantial pain relief at 1 month. Eleven (78.3%) patients still had more than 60% pain relief at 6 months. Only 5 (35.7%) patients recurred within 12 months. At 12-month follow-up, 9 (64.3%) patients had significant pain improvement. Medication requirements decreased in 13 (92.8%) patients at 1 month, 12 (85.7%) patients at 6 months, and 10 (71.4%) patients at 12 months. CONCLUSIONS: Pulsed RF of cervical medial branches is a potential treatment for patients with chronic whiplash-related cervical zygapophysial joint pain that failed other conservative treatments. This treatment provides long-lasting pain relief and reduces pain medication requirements.

[Exploration of approach in surgery for cervical hyperextension injury].

OBJECTIVE: To explore the reasonable approach in surgery for cervical hyperextension injury. METHODS: Sixty-seven patients of hyperextension injury of cervical spine, 31 males and 16 females, aged 41 approximately 57, underwent surgery via anterior approach (n = 25), posterior approach (n = 27), or combined approach (n = 13) according to the different operation methods 8 days (3 days approximately 3 weeks) after the injury and then followed up for 6 approximately 12 months. The therapeutic effects were compared. RESULTS: After the operation, the Frankel grade was ascended in all patients of the anterior approach group, and was descended in some patients in the posterior approach and combined approach groups. The ASIA grade of the anterior approach and combined approach groups were both ascended in comparison with that of the posterior approach group (both P < 0.05) however, there was not significant difference between the anterior approach and combined approach groups. CONCLUSION: Anterior decompression-graft-internal fixation is the preferred consideration to treat hyperextension injury of cervical spine, and posterior one is only the secondary choice. Combined approach should be strictly selected according to the concrete situation.

Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw.

STUDY DESIGN: We evaluated the trajectories of atlantoaxial transarticular and C2-pedicle screws in 3 dimensions using computerized tomography. OBJECTIVE: To compare the anatomic risk for vertebral artery injury associated with C2-pedicle and atlantoaxial transarticular screws. SUMMARY OF BACKGROUND DATA: The atlantoaxial fixation technique using C1-lateral mass screws combined with C2-pedicle screws is considered a safer technique for preventing vertebral artery injury than atlantoaxial transarticular fixation. However, few reports have compared the anatomic risk of vertebral artery injury associated with C2-pedicle screws with that of transarticular screws. METHODS: A total of 62 consecutive patients with cervical lesions were evaluated using 3-dimensional images reconstructed by a computer-assisted navigation system. We compared the maximum possible diameters of the atlantoaxial transarticular screw and C2-pedicle screw trajectories, and examined whether the maximum possible diameters were limited by the height or width of the bony structure in screw trajectories < or = 4 mm in diameter. RESULTS: Mean maximum possible diameters did not differ significantly between the trajectories of 124 atlantoaxial transarticular and 124 C2-pedicle screws. In screw trajectories < or = 4 mm in diameter, 57.1% of transarticular screw trajectories were limited by the height of the bony structure, and all pedicle screw trajectories were limited by the width. CONCLUSIONS: C2-pedicle screw placement has nearly the same anatomic risk of vertebral artery injury as transarticular screw placement. Preoperative 3-dimensional evaluation may be useful for choosing the best surgical technique.

[Chronic whiplash syndrome is no indication for craniocervical fixation]. / Kronisk nakkeslengsyndrom er ingen indikasjon for kraniocervikal fiksasjon.

Throughout many years, a large number of publications have focused on structural changes in soft tissues in the cervical spine in patients with whiplash associated disorders I-II. In recent years the development in MRI techniques have made it possible to visualize the small ligaments in the craniocervical junction; a small number of publications have investigated the association between signal changes in these ligaments and whiplash associated disorders I-II. The results are, however, not conclusive, and no prospective studies have demonstrated any causal connection between type of whiplash injury and signal changes in these ligaments. Craniocervical fixation is major surgery with a moderate level of perioperative complications. There is also a theoretical risk of increasing the degenerative process in the level below the fixation. The indications for craniocervical fixation are now serious conditions like instability caused by rheumatic arthritis, tumours and fractures. The scientific evidence for introducing a new indication for craniocervical fixation is lacking, and craniocervical fixation in WAD I-II must be considered experimental surgery.

Thoracic outlet syndrome due to hyperextension-hyperflexion cervical injury.

Posttraumatic brachial plexus entrapment in fibrotic scarring tissue is taken into consideration as the cause of complaints for patients who suffered a hyperextension-hyperflexion cervical injury. All 54 patients included in this analysis where symptom-free before the accident and subsequently complained for pain, paresthesia and slight weakness in the arm. In 14 neurological signs of brachial plexus entrapment were observed. Electroneurophysiological, summary index testing was positive for a brachial plexus involvement in all cases. Conservative measures, comprising physical therapy and vasoactive drugs were applied for a period of 6 to 12 (mean 8.4) months; surgical procedure of neurolysis was then proposed in 39 cases to solve the problem. Thirty-two patients were operated on. Twenty of these had a neat improvement on a 6-month to 1-year follow-up. Seven patients had refused surgery; of these 6 patients had clinical worsening at the same follow-up period while 1 remained unchanged. All patients with clinical symptoms not reversed after some time post-injury should be investigated for a possible brachial plexus entrapment.

Case report: whiplash-associated disorder from a low-velocity bumper car collision: history, evaluation, and surgery.

STUDY DESIGN: Case report of a patient with a whiplash-associated disorder following a bumper car collision. Imaging studies failed to provide an anatomic explanation for the debilitating symptoms. OBJECTIVES: To report a chronic, debilitating pain syndrome after a low-velocity bumper car collision while using complex range-of-motion data for the diagnosis, prognosis, and surgical indication in whiplash-associated disorder. SUMMARY OF BACKGROUND DATA: The controversy of whiplash-associated disorder mainly concerns pathophysiology and collision dynamics. Although many investigations attempt to define a universal lesion or determine a threshold of force that may cause permanent injury, no consensus has been reached. METHODS: Eight years after a low-velocity collision, the patient underwent surgical excision of multiple painful trigger points in the posterior neck. Computerized motion analysis was used for pre- and postoperative evaluations. RESULTS: Surgical treatment resulted in an increase in total active range of motion by 20%, reduced intake of pain medication, doubled the number of work hours, and generally led to a dramatic improvement in quality of life. CONCLUSIONS: This case of whiplash-associated disorder after a low-velocity collision highlights the difficulty in defining threshold of injury in regard to velocity. It also illustrates the value of computerized motion analysis in confirming the diagnosis of whiplash-associated disorder and in the evaluation of prognosis and treatment.

[Accident analytics for structural traumas of the cervical spine]. / Unfallanalytik bei strukturellen Verletzungen der Halswirbelsäule.

The differentiation between degenerative syndromes of the cervical spine and post-traumatic symptoms requires accident analysis. Experiments with human subjects yield data only in the low-energy range, and there are still no accident analyses of structural traumas of the cervical spine. From 1 January 2000 to 30 April 2002, 15 patients with structural injuries to the cervical spine due to car accidents were treated in the Department of Trauma Surgery of the University of Ulm. In 11 of these cases, the DEKRA Ulm completed an appraisal of the accident process.With lateral impacts, structural injuries to the cervical spine can occur even at speeds of only ca 10 km/h. Injuries to the alar ligaments are produced by frontal collisions with substantial differences in speed. Data from accident analysis of structural injuries to the cervical spine must be taken into consideration in causality examinations of distortions of the cervical spine.