Demonstration of transverse ligament on 3D SPACE MRI in whiplash-associated disorder and nontraumatic conditions.

PURPOSE: This study aims to delineate the three-dimensional (3D) SPACE MRI findings of the transverse ligament (TL) in whiplash-associated disorder (WAD) patients, and to compare them with those from a nontraumatic group. METHODS: A retrospective analysis was performed on cervical spine MRI scans obtained from 46 patients with WAD and 62 nontraumatic individuals. Clinical features, including the WAD grade and stage, were recorded. The TL's morphological grade and the symmetricity of the lateral atlantodental interval was assessed using axial 3D T2-SPACE images. The morphological grading was evaluated using a four-point scale: 0 = homogeneously low signal intensity with normal thickness, 1 = high signal intensity with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures. Additionally, the number of cervical levels exhibiting degeneration was documented. RESULTS: When comparing the WAD and nontraumatic groups, a significant difference was observed in the proportion of high-grade TL changes (grade 2 or 3) and the number of degenerated cervical levels. Logistic regression analysis revealed that high-grade TL changes and a lower number of degenerative levels independently predicted the presence of WAD. Within the WAD group, the subset of patients with high-grade TL changes demonstrated a significantly higher mean age than the low-grade group (grade 0 or 1). CONCLUSION: High-grade morphological changes in the TL can be detected in patients with WAD through the use of 3D SPACE sequences. Clinical relevance statement 3D SPACE MRI could serve as an instrumental tool in the assessment of TL among patients with WAD. Integrating MRI findings with patient history and symptomology could facilitate the identification of potential ligament damage, and may help treatment and follow-up planning.

Shape modelling of the oropharynx distinguishes associations with body morphology but not whiplash-associated disorder.

Characterization of the oropharynx, a subdivision of the pharynx between the soft palate and the epiglottis, is limited to simple measurements. Structural changes in the oropharynx in whiplash-associated disorder (WAD) cohorts have been quantified using two-dimensional (2D) and three-dimensional (3D) measures but the results are inconsistent. Statistical shape modelling (SSM) may be a more useful tool for systematically comparing morphometric features between cohorts. This technique has been used to quantify the variability in boney and soft tissue structures, but has not been used to examine a hollow cavity such as the oropharynx. The primary aim of this project was to examine the utility of SSM for comparing the oropharynx between WAD cohorts and control; and WAD severity cohorts. The secondary aim was to determine whether shape is associated with sex, height, weight and neck length. Magnetic resonance (MR) T1-weighted images were obtained from healthy control (n = 20), acute WAD (n = 14) and chronic WAD (n = 14) participants aged 18-39 years. Demographic, WAD severity (neck disability index) and body morphometry data were collected from each participant. Manual segmentation of the oropharynx was undertaken by blinded researchers between the top of the soft palate and tip of the epiglottis. Digital 3D oropharynx models were constructed from the segmented images and principal component (PC) analysis was performed with the PC weights normalized to z-scores for consistency. Statistical analyses were undertaken using multivariate linear models. In the first statistical model the independent variable was group (acute WAD, chronic WAD, control); and in the second model the independent variable was WAD severity (recovered/mild, moderate/severe). The covariates for both models included height, weight, average neck length and sex. Shape models were constructed to visualize the effect of perturbing these covariates for each relevant mode. The shape model revealed five modes which explained 90% of the variance: mode 1 explained 59% of the variance and primarily described differences in isometric size of the oropharynx, including elongation; mode 2 (13%) primarily described lateral (width) and AP (depth) dimensions; mode 3 (8%) described retroglossal AP dimension; mode 4 (6%) described lateral dimensions at the retropalatal-retroglossal junction and mode 5 (4%) described the lateral dimension at the inferior retroglossal region. There was no difference in shape (mode 1 p = 0.52; mode 2 p = 0.96; mode 3 p = 0.07; mode 4 p = 0.54; mode 5 p = 0.74) between control, acute WAD and chronic WAD groups. There were no statistical differences for any mode (mode 1 p = 0.12; mode 2 p = 0.29; mode 3 p = 0.56; mode 4 p = 0.99; mode 5 p = 0.96) between recovered/mild and moderate/severe WAD. Sex was not significant in any of the models but for mode 1 there was a significant association with height (p = 0.007), mode 2 neck length (p = 0.044) and in mode 3 weight (p = 0.027). Although SSM did not detect differences between WAD cohorts, it did detect associations with body morphology indicating that it may be a useful tool for examining differences in the oropharynx.

Imaging in Whiplash-Associated Disorders.

"Whiplash," a term describing the severe acceleration and deceleration forces applied to the head, craniocervical junction (CCJ), and cervical spine during trauma, is one of the most frequent mechanisms of injury to the CCJ. The CCJ is a complex region at the transition of the cranium and the cervical spine, essential for maintaining craniocervical stability. In whiplash injuries, the CCJ may be compromised due to underlying ligamentous or, less frequently, osseous, intravertebral disk and/or muscular lesions. Imaging is crucial in detecting acute lesions but may also play a role in the follow-up of chronic pathology because soft tissue lesions and progressive disk pathology could contribute to a whiplash-associated disorder.

Injury of the Spinothalamic Tract Following Whiplash Injury: A Diffusion Tensor Tractography Study.

OBJECTIVES: Using diffusion tensor tractography (DTT), we demonstrated the spinothalamic tract (STT) injury in patients with central pain following whiplash injury. Our primary hypothesis is that fractional anisotropy (FA) and tract volume (TV) of the STT in injured people differ from non-injured people. Our secondary hypothesis is that the direction of the collision results in a different type of injury. METHODS: Nineteen central pain patients following whiplash injury and 19 normal control subjects were recruited. The STT was reconstructed by the DTT, the FA and TV of the STT were measured. In addition, different characteristics of the STT injury according to the collision direction were investigated. RESULTS: The FA value did not differ significantly between the patient and control groups (p > 0.05). However, the significantly lower value of the TV was observed in patient group than the control group (p < 0.05). The onset of central pain was significantly delayed (13.5 days) in patients who were involved in a frontal collision, compared to patients with rear-end collision (0.6 days) (p < 0.05). In contrast, the Visual Analogue Scale was higher in the patients with rear-end collision (p < 0.05). CONCLUSIONS: We found the STT injury mild traumatic brain injury (TBI) who suffered central pain after whiplash injury, using DTT. In addition, we demonstrated different characteristics of the STT injury according to the collision direction. We believe that injury of the STT would be usefully detected by DTT following whiplash injury.

Morphology and composition of the ventral neck muscles in individuals with chronic whiplash related disorders compared to matched healthy controls: a cross-sectional case-control study.

BACKGROUND: OBJECTIVE: Studies of cross-sectional area (CSA) (morphology) and muscle fat infiltration (MFI) (composition) in ventral neck muscles is scarce in patients with chronic whiplash associated disorders (WAD), especially for men and those with severe WAD compared with matched healthy controls. The aim was to compare CSA and MFI of sternocleidomastoid (SCM), longus capitis (LCA) and longus colli (LCO) in patients with chronic right-sided dominant moderate (Neck Disability Index: NDI < 40) or severe WAD (NDI ≥ 40), compared to age- and sex-matched healthy controls. METHODS: Cross-sectional case-control study with blinded investigators. Thirty-one patients with chronic WAD (17 women and 14 men, mean age 40 years) (SD 12.6, range 20-62)) and 31 age- and sex-matched healthy controls underwent magnetic resonance imaging of ventral neck muscles segmental level C4. RESULTS: Unique to the severe group was a larger magnitude of MFI in right SCM (p = 0.02) compared with healthy controls. There was no significant difference between the groups with regards to the other muscles and measures. CONCLUSIONS: Individuals with severe right-sided dominant WAD have a higher MFI in the right SCM compared to healthy controls. No other differences were found between the groups. The present study indicates that there are changes in the composition of muscles on the side of greatest pain.

Echo-intensity, fatty infiltration, and morphology ultrasound imaging assessment in healthy and whiplash associated disorders populations: an observational study.

BACKGROUND: Although changes in muscle morphology and quality in deep neck flexors seem to be clear in patients with whiplash-associated disorders (WAD), evidence for deep neck extensors is heterogeneous. In addition, most studies have used magnetic resonance imaging or computer tomography, which is not available for regular practice. OBJECTIVES: To assess differences in deep neck extensors morphology and quality between patients with WAD and controls with ultrasound imaging (US) and to assess the association of imaging findings with clinical features. METHODS: One hundred and sixty brightness-mode images at C4/C5 level were acquired in 41 patients with WAD and 39 pain-free controls. Muscle morphology and quality characteristics of the cervical multifidus (CM) and short rotators (SR), clinical pain features and pressure pain thresholds (PPT) were assessed in a blinded design. RESULTS: Between-groups differences in both CM and SR were observed for fatty infiltration percentage (mean: 4.9%; P < 0.001; mean: 3.5%; P < 0.05, respectively) and mean EI (mean: 4.1; P < 0.001; mean: 3.2; P < 0.05, respectively): patients exhibited higher fatty infiltration than controls. The intensity of neck pain was negatively associated with multifidus CSA and perimeter (P < 0.001); symptoms duration was negatively associated with CM morphology (P < 0.001), CM mean EI (P < 0.05) and SR morphology (P < 0.05); pain-related disability was associated with CM morphology (P < 0.001) and SR mean EI (P < 0.05); and PPTs was associated with CM mean EI (P < 0.01) and FI (p < 0.05) and SR morphology (P < 0.001). No significant effect of gender was found in any analysis. CONCLUSION: US assessment of deep cervical extensors revealed greater fatty infiltration, but no differences in muscle morphology, between WAD patients and pain-free controls.

Self-reported Dysphagia and Pharyngeal Volume Following Whiplash Injury.

Difficulty swallowing has been reported following whiplash injury; however, the reasons remain poorly understood. A possible factor may be the observed changes in pharyngeal volume. The current exploratory study was designed to examine the prevalence of self-reported dysphagia after whiplash and the relationship with recovery status and change in pharyngeal volume. Data were available from a longitudinal study of adults with whiplash. Data included magnetic resonance imaging (MRI) of the cervical spine, the Dysphagia Handicap Index (DHI), and Neck Disability Index (NDI) collected over four timepoints (< 1 week, 2 weeks, 3 months, and 12 months post-injury). Initial cross-sectional analysis examined 60 patients with DHI data from at least one timepoint. A second, longitudinal analysis was conducted on 31 participants with MRI, NDI, and DHI data at both early (< 1-2 weeks) and late (3-12 months) timepoints. The pharynx was contoured on axial T2-weighted MRI slices using OsiriX image processing software and pharyngeal volume (mm3) was quantified. In the 60-patient cohort, prevalence of self-reported dysphagia (DHI ≥ 3) was observed in 50% of participants at least once in 12 months (M = 4.9, SD 8.16, range 0-40). In the longitudinal cohort (n = 31), mean total DHI significantly (p = 0.006) increased between early and late stages. There was no relationship (p = 1.0) between dysphagia and recovery status, per the NDI% score. Pharyngeal volume remained stable and there was no relationship between dysphagia and pharyngeal volume change (p = 1.0). This exploratory study supports the need for further work to understand the nature of dysphagia, extent of functional compromise, and the underlying pathophysiology post-whiplash.

[Whiplash injury of the cervical spine]. / Schleudertrauma der Halswirbelsäule.

Whiplash injury is a common trauma of the cervical spine which usually occurs during motor vehicle accidents, especially involving rear-end collisions. The trauma typically results from a sudden biphasic movement of the head and cervical spine (reclination followed by inclination), which may cause an injury of bony, muscular and ligamentous elements. The most common symptoms of whiplash injury are pain, stiffness and tenderness of the neck, which occur with a latency of several hours and may become chronic in some patients. The imaging studies rarely demonstrate morphological changes associated with trauma and there are also no specific imaging findings in whiplash injuries. Plain films and computed tomography are used in acute trauma workup to exclude bony injuries. Magnetic resonance imaging (MRI) may demonstrate occult fractures, bone contusions as well as muscular and ligamentous posttraumatic lesions. The whiplash injuries are classified clinically according to Quebec Task Force-Grading, depending on the symptom severity.

Spinal cord injury is not a feature of chronic whiplash-associated disorder: a magnetic resonance spectroscopy study.

PURPOSE: Injury to the cervical spinal cord has been suggested as a mechanism that may underpin chronic whiplash-associated disorder (WAD). This study aimed to assess metabolite concentrations indicative of neuronal injury or pathology in the cervical cord in people with chronic WAD. METHODS: Forty-one people with chronic WAD (mean [SD] age 39.6 [11.0] years, 25 females) and 14 healthy controls (39.2 [12.6] years, 9 females) underwent cervical spinal cord magnetic resonance spectroscopy to measure the metabolites N-acetylaspartate (NAA), creatine (Cr) and choline (Cho). Participants with WAD completed clinical questionnaires on pain intensity (Visual Analogue Scale), disability (Neck Disability Index) and psychological factors (Pain Catastrophising Scale, Post-traumatic Diagnostic Scale), and underwent cervical range of motion assessment and pain threshold testing to cold and pressure stimuli. Data were analysed using hypothesis testing and Spearman correlations (p < 0.05). RESULTS: There were no differences between the WAD and control groups for NAA/Cr (median [IQR] WAD 1.73 [1.38, 1.97], controls 2.09 [1.28, 2.89], p = 0.37), NAA/Cho (WAD 1.50 [1.18, 2.01], controls 1.57 [1.26, 1.93], p = 0.91) or Cr/Cho (WAD 0.84 [0.64, 1.17], controls 0.76 [0.60, 0.91], p = 0.33). There were no significant correlations between NAA/Cr, NAA/Cho or Cr/Cho and any clinical variable (p ≥ 0.06). CONCLUSIONS: Findings are consistent with major metabolic changes not being present in chronic WAD.

Age-related changes to the craniocervical ligaments in asymptomatic subjects: a prospective MR study.

PURPOSE: The craniocervical junction (CCJ) is a complex of bony and ligamentous structure stabilizing CCJ. Nearly one-third of all traumatic injuries to the cervical spine involve the CCJ. Only little literature is available on this topic, and most of the studies are focused on anatomy, biomechanics or ligamentous injury in whiplash-associated disorders. We conducted a prospective study to investigate age-related changes in the craniocervical ligaments. METHODS: We included asymptomatic volunteers between 16 and 99 years old who had no history of whiplash or other cervical trauma. Volunteers underwent a three-dimensional turbo spin-echo proton density-weighted sequence with variable flip-angle distribution focused on the craniocervical ligaments. The six main ligaments of the craniocervical junction were evaluated for grade of degeneration on a four-point scale by two independent readers, blinded for age and sex. RESULTS: We included 102 volunteers. The mean age was 50.03 (16-94). Fifty-nine (58%) patients showed degeneration of at least one ligament of the CCJ. High-grade anomalous changes and multiligamentous involvement had a positive correlation with age (p < 0.001). The inter-rater agreement was fair to moderate, and the intra-rater agreement was moderate to substantial. CONCLUSION: The craniocervical ligaments show a variable degree of signal intensity and thickness in asymptomatic adults. We postulate that these changes can be due to normal aging or due to repetitive microtrauma. We propose a new grading system to evaluate changes to the craniocervical ligaments in asymptomatic volunteers. These slides can be retrieved under Electronic Supplementary Material.

Road traffic whiplash injury in the elderly: Clinical and video-nystagmographic features.

PURPOSE: Whiplash is a type of trauma typically caused by a rear end collision in a road accident. About one in two patients who experience whiplash report dizziness and balance problems, which can severely affect their activities in daily life. In industrialized countries, the number of elderly people with a driving license has increased in recent years. The aims of the present study were to describe the video-nystagmographic features in a consecutive series of elderly patients experiencing whiplash injury in a road accident, comparing them with similar injuries in a group of young adults. METHODS: Twenty-seven patients aged 65 years or more and a control group of 32 young adults between 18 and 21 years old were retrospectively selected. All patients underwent oto-vestibular assessment and video-nystagmography. RESULTS: After whiplash trauma, vertigo was more common in elderly patients with decreased peak velocity during the saccadic ocular motricity test (p = 0.017) and with evidence of bilateral vestibular hypofunction after caloric stimulation (p = 0.033). Comparing the two age groups, neck pain after the trauma was reported significantly more by young adults (p = 0.003), who also showed more frequently bilateral vestibular hypofunction (p = 0.025). CONCLUSION: Clinical and instrumental findings seem to support the hypothesis of a functional lesion to the brainstem regions after a whiplash injury. There is an undeniable need, however, for tools capable of objectively assessing the functional or anatomical damage resulting from whiplash-associated disorders, for both clinical and medico-legal reasons.

Cervical spine findings on MRI in people with neck pain compared with pain-free controls: A systematic review and meta-analysis.

BACKGROUND: There is uncertainty regarding the clinical significance of findings on MRI in patients with whiplash associated disorder (WAD) or nonspecific neck pain (NSNP). PURPOSE: To compare the presence of cervical spine MRI findings in people with WAD or NSNP with pain-free controls. STUDY TYPE: Systematic review and meta-analysis. POPULATION: Adults with WAD (n = 994), NSNP (n = 715), or pain-free controls (n = 2323). FIELD STRENGTH: 0.5T, 1.5T, and 3.0T. ASSESSMENT: Medline, EMBASE, CINAHL, Web of Science, SCOPUS, and Cochrane CENTRAL databases were searched. Two independent reviewers identified studies for inclusion and extracted data. Risk of bias was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Overall quality of the evidence from meta-analysis was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. STATISTICAL TESTS: Meta-analysis was performed using a random-effects model to calculate odds ratios or standard mean differences (SMDs) for binary and continuous data. RESULTS: In total, 31 studies were included (eight comparing acute WAD to controls, 14 comparing chronic WAD to controls, 12 comparing chronic NSNP to controls) comprising 4032 participants. Rectus capitis posterior major cross-sectional area was smaller in people with chronic NSNP than controls (two studies: SMD -1.18 [95% confidence interval [CI] -1.65, -0.71]). The remaining meta-analysis comparisons showed no group differences in MRI findings. The quality of evidence was mostly low due to small sample sizes and high heterogeneity. DATA CONCLUSION: Given the typically low-quality evidence, definitive conclusions cannot be drawn on the presence of MRI findings in individuals with WAD or NSNP compared with pain-free controls. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018.

A 20-year prospective longitudinal MRI study on cervical spine after whiplash injury: Follow-up of a cross-sectional study.

BACKGROUND: Some patients suffer from long-lasting symptoms after whiplash injury. However, there are few reports on the long-term changes in the cervical spine after whiplash injury using imaging tests. The purpose of this longitudinal study was to determine the changes on MRI of the cervical spine 20 years after whiplash injury, and to examine the relationships between changes in the cervical spine on MRI and changes in related clinical symptoms. METHODS: Eighty-one subjects finally participated in this study (follow-up rate 16%). The mean follow-up duration was 21.7 years. All subjects filled out a questionnaire about their clinical symptoms. The MRI findings were assessed using numerical grading system applied in the original study. Statistic analyses were used to investigate whether the progression of each MRI finding was associated with the severity of neck pain, stiff shoulders, dizziness and tinnitus. RESULTS: All subjects had complained of some clinical symptoms in the original study: 71 had neck pain, 53 stiff shoulders, and others. In the present study, 66 subjects (81.5%) complained of some clinical symptoms: 57 had stiff shoulders, 20 neck pain, and others. The progression of degeneration on MRI was observed in 95% of the subjects, with C4/5 and 5/6 being the most frequently involved levels. Changes in the severity of neck pain, stiff shoulders, dizziness and tinnitus over 20 years were not significantly associated with the progression of degenerative changes in the cervical spine on MRI. CONCLUSIONS: Twenty years after whiplash injury, 95% of the subjects showed a progression of degeneration in the cervical spine. The progression of the intervertebral disc degeneration in the cervical spine on MRI after whiplash injury was not significantly associated with changes in the severity of related clinical symptoms, indicating that the degenerative changes on MRI may reflect the physiological aging process rather than post-traumatic sequelae.

Pathophysiological interrelated deactivation/activation processes in the exhausted brain after whiplash injury.

In this paper pathophysiological interrelated deactivation/activation phenomena are set out in the example of whiplash injury. These phenomena could have been underestimated in previous positron emission tomography studies as their focus was on hypoperfusion rather than hyperperfusion. In addition, statistical parametric mapping analysis of cerebral studies is normally not fine-tuned to special interesting areas rather than to obvious clusters of difference.

Differences in white matter structure and cortical thickness between patients with traumatic and idiopathic chronic neck pain: Associations with cognition and pain modulation?

Brain alterations are hypothesized to be present in patients with chronic whiplash-associated disorders (CWAD). The aim of this case-control study was to examine alterations in cortical thickness and white matter (WM) structure, and the presence of brain microhemorrhages in a patient group encountering chronic neck pain of traumatic origin (i.e., CWAD) when compared with a patient group characterized by nontraumatic chronic neck pain [i.e., chronic idiopathic neck pain (CINP)], and healthy controls. Furthermore, we aimed to investigate associations between brain structure on one hand and cognitive performance and central sensitization (CS) on the other hand. T1-weighted, diffusion-weighted and T2*-weighted magnetic resonance images of the brain were acquired in 105 women (31 controls, 37 CINP, 37 CWAD) to investigate regional cortical thickness, WM structure, and microhemorrhages, respectively. Next, cognitive performance, and CS encompassing distant hyperalgesia and conditioned pain modulation (CPM) efficacy were examined. Cortical thinning in the left precuneus was revealed in CWAD compared with CINP patients. Also, decreased fractional anisotropy, together with increased values of mean diffusivity and radial diffusivity could be observed in the left cingulum hippocampus and tapetum in CWAD compared with CINP, and in the left tapetum in CWAD patients compared with controls. Moreover, the extent of WM structural deficits in the left tapetum coincided with decreased CPM efficacy in the CWAD group. This yields evidence for associations between decreased endogenous pain inhibition, and the degree of regional WM deficits in CWAD. Our results emphasize the role of structural brain alterations in women with CWAD compared with CINP.

Management of Whiplash Associated Disorders in Australian general practice.

BACKGROUND: Whiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments. METHODS: We analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters. Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines. RESULTS: Of 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8). CONCLUSIONS: GPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Whiplash Syndrome- a disorder of the brain?

In the past two decades much has been published on whiplash injury, yet both the confusion regarding the condition, and the medicolegal discussion about it have increased. In this paper, functional imaging research results are summarized using MRIcroGL 3D visualization software and assembled in an image comprising regions of cerebral activation and deactivation.

A rare and lethal case of right common carotid pseudoaneurysm following whiplash trauma.

Whiplash trauma from a car crash is one of the most common causes of neck injury, resulting in pain and dysfunction. We report on an unusual case of post-whiplash pseudoaneurysm of the right common carotid artery, which led to acute massive hemorrhage and death days after the initial trauma. A post-mortem computed tomography angiography showed rupture of the pseudoaneurysm of the right common carotid artery with the contrast agent leaking out into the mouth. The subsequent autopsy confirmed a large hemorrhagic clot extending to the right side of the neck and mediastinum. A rupture of the right wall of the oropharynx was identified with massive bronchial hemoaspiration. The case demonstrates a rare but lethal clinical entity, and is important in providing a better understanding of the potentially fatal consequences of minor trauma, such as whiplash injury, and its physiopathological mechanisms. Thus, changing symptoms after a whiplash injury should be carefully evaluated since they can be related to the underlying severe consequences of a rapid hyperextension-hyperflexion of the neck, as in the reported case.

Do X-ray-occult fractures play a role in chronic pain following a whiplash injury?

PURPOSE: Whiplash trauma in motor vehicle accidents (MVA) may involve various painful soft tissue damages, but weeks/months later a minority of victims still suffers from various long-lasting and disabling symptoms, whiplash-associated disorders (WAD). The etiology is currently unknown, but X-ray-occult fractures may be one cause in some cases. The purpose of this prospective study was to examine the association between occult fractures, as seen on bone single photon emission computed tomography (SPECT), with neck-, head- and arm pain. METHODS: An inception cohort of 107 patients presenting with acute whiplash symptoms following an MVA was invited to have a cervical SPECT shortly post injury and again 6 months later. Associations between occult fractures and pain levels at baseline, 6 and 12 months of follow-up were analyzed. RESULTS: Eighty-eight patients had baseline SPECT performed at median 15 days (range 3-28) post injury, but only 49 patients accepted to have the follow-up SPECT at 6 months. Abnormal SPECT, defined as minimum one area of focal uptake, was seen in 32 patients at baseline, reflecting an occult fracture. Occult fractures were not associated with pain levels, neither at baseline nor at follow-up. CONCLUSION: Occult fractures do not seem to play a role for development of chronic pain after whiplash.

Postmortem MSCT diagnosis of whiplash injuries in a traffic accident: a case report and review of the literature.

A 45-year-old male car driver died in a traffic accident of four cars rear-end collision on the highway. He was found to have died after a respiratory and cardiac arrest at the scene. No sign of skin injuries was observed from the external inspection. The autopsy was not permitted by the family members because of the local culture. Multislice computed tomography (MSCT) was applied to the current case, showing dislocation of C3-4 cervical vertebrae with II degree, C4 vertebral plate fractures, and spinal stenosis. Post-mortem MSCT confirmed the diagnosis as whiplash injuries. MSCT was verified to be effective in showing the severity of whiplash injuries, thus providing certain objective evidence for medicolegal expertise.