Longitudinal visibility of MRI findings in living victims of strangulation.

Initial experiences with magnetic resonance imaging (MRI) of living strangulation victims demonstrated additional findings of internal injuries compared to the standard clinical forensic examination. However, existing studies on the use of MRI for this purpose mostly focused on the first 48 h after the incident. The aims of this study were (a) to evaluate the longitudinal visibility of MRI findings after violence against the neck by performing two MRI examinations within 12 days and a minimum of four days between both MRI scans and (b) to assess which MRI sequences were most helpful for the detection of injuries. Twenty strangulation victims participated in this study and underwent one (n = 8) or two (n = 12) MRI scans. The first MRI examination was conducted during the first five days, the second five to 12 days after the incident. Two blinded radiologists assessed the MRI data and looked for lesions in the structures of the neck. In total, 140 findings were reported in the 32 MRI examinations. Most of the findings were detected in the thyroid and the muscles of the neck. T2-weighted SPACE with fat suppression, T1-weighted TSE and T1-weighted MPRAGE were rated as the most helpful MRI sequences. Subjects who showed findings in the initial scan also demonstrated comparable results in the second scan, which was performed on average 8.4 days after the incident. Our results show that even up to 12 days after the incident, the criminal proceeding of strangulation cases may greatly profit from the information provided by an MRI examination of the neck in addition to the standard clinical forensic examination.

Risk Reduction of Concussion in Athletes: Do Neck Size or Neck Strength Make a Difference?

ABSTRACT: Medical provider's ability to detect, diagnose, and treat sport-related concussion has greatly improved in recent years. Although more is known about the biomechanical forces involved in concussion, it is still uncertain whether there are preventative measures athletes can take to prevent a sport-related concussion from occurring. The objective of this review was to determine if either neck size or neck strength is related to a decreased risk of sustaining a sport-related concussion. A literature review was conducted on Google Scholar and Ovid MEDLINE for pertinent articles. Findings indicate that isometric neck strength, but not neck size, has been shown to be a predictor for sport-related concussion prevention. Formal neck strengthening programs are feasible and lead to decreased sport-related concussion risk. Additionally, there may be greater opportunity to increase neck strength in amateur athletes compared to professional. In conclusion, cervical strengthening programs have been shown to be feasible and beneficial for athletes to decrease their risk of sustaining a sport-related concussion, though the optimal duration, intensity, and frequency has yet to be determined.

Assessment of potential strain injury to rectus capitis posterior minor muscles during whiplash type distortions of the cervical spine.

CONTEXT: Whiplash type injuries resulting from a rear end motor vehicle accident (REMVA) are thought to be caused by excessive loading and displacement of structural components of the cervical spine. On impact, the seat propels the driver's torso forward relative to the head, resulting in forced flexion of the occipitoatlantal (OA) joint, accompanied by forced stretching of the rectus capitis posterior minor (RCPm) muscles. Flexion of the OA joint and stretching of the RCPm muscles continues to increase until the vehicle's headrest strikes the back of the driver's head. It is known that externally applied forces that attempt to move the OA joint beyond its anatomic barrier can result in fracture, dislocation, or soft tissue damage to its structural components. However, the magnitude of headrest backset, defined as the distance between the driver's head and the vehicle's headrest, that would result in RCPm muscles being stretched to a length that would put them at risk for a muscle strain injury is unknown. OBJECTIVES: To quantify the relationships among flexion of the OA joint, RCPm muscle stretch, and backset, and to quantify the biomechanical response of RCPm muscles to increasing levels of axial load due to stretching. METHODS: Unembalmed head and neck specimens from three White females aged 85, 63, and 70 years were obtained from the Anatomical Services Division at the University of Maryland. Donors had provided written consent allowing use of their body for research purposes. Using an analytic model of the OA joint, the relationships between flexion of the OA joint and RCPm muscle stretch as a function of backset were estimated. RCPm muscles were removed from the cadavers and forcibly stretched using a servomechanism controlled hydraulic testing machine to quantify the load/displacement properties. After testing, the tissues were sectioned, mounted, and stained using Masson's trichrome to selectively stain muscle fibers red and collagen blue. RESULTS: Forced flexion of the OA joint was seen to be directly related to the magnitude of headrest backset. For values of backset greater than 7.2 cm, biomechanical testing of the RCPm muscles revealed that strain injuries ranged from the tearing of a few muscle fibers to complete rupture of the muscle and separation of the tendon at the posterior process of C1. CONCLUSIONS: Results showed that headrest backset at the time of vehicle impact is an important factor in estimating the risk of muscle strain injury to RCPm muscles. Muscle strain injury would be expected to impact the functional relationship between the RCPm muscles and the pain sensitive spinal dura. Physicians should be alert to the possibility that cervicogenic pain patients who have experienced whiplash associated with REMVA may show clinically relevant structural damage to the RCPm muscles on MRI.

Cytokine and Growth Factor Response in a Rat Model of Radiation Induced Injury to the Submental Muscles.

Submental muscles (i.e., mylohyoid and geniohyoid) play a vital role during swallowing, protecting the airway from ingested material. To design therapies to reduce the functional deficits associated with radiation treatment relies in part on our understanding of the changes in the cytokine and growth factor response that can impact muscle function. The purpose of this study is to quantify changes in the inflammatory, pro-fibrotic, and pro-angiogenic factors following 48 Gy of fractionated radiation to the mylohyoid muscle. We hypothesized that (1) irradiation will provoke increases in TGF-1ß and MMP-2 mRNA in the mylohyoid muscle; and (2) muscles surrounding the target location (i.e., geniohyoid and digastric muscles) will exhibit similar alterations in their gene expression profiles. Rats were exposed to 6 fractions of 8 Gy using a 6 MeV electron beam on a clinical linear accelerator. The highest dose curve was focused at the mylohyoid muscle. After 2- and 4-weeks post-radiation, the mylohyoid, geniohyoid, and digastric muscles were harvested. Expression of TNF-α, IFNγ, IL-1ß, IL-6, TGF-1ß, VEGF, MMP-2, and MMP-9 mRNA was analyzed via PCR and/or RT-PCR. TGF-1ß, MMP-2, and IL-6 expression was upregulated in the irradiated mylohyoid compared to non-irradiated controls. No notable changes in TNF-α, IFNγ, and IL-1ß mRNA expression were observed in irradiated muscles. Differing expression profiles were found in the surrounding muscles post-radiation. Results demonstrated that irradiation provokes molecular signals involved in the regulation of wound healing, which could lead to fibrosis or atrophy in the swallowing muscle after radiation.

Joint Helmet-Mounted Cueing System and Neck Muscle Activity During Air Combat Maneuvering.

BACKGROUND: The aim of the study was to determine the characteristics of cervical muscle activity in different head postures when using helmet-mounted display in one fighter vs. two aircraft air combat within visual range (WVR).METHODS: Cervical EMG was measured with eight F/A-18 pilots using the Joint Helmet Mounted Cueing System (JHMCS) during air combat maneuvering. In-flight Gz acceleration and continuous head position were recorded. EMG activity is divided and presented in a matrix with three-class rotation and five-class flexion-extension postures.RESULTS: The mean muscle activity in sternocleidomastoids and cervical extensors was 28.9% of maximal voluntary contraction (MVC) and 44.8% MVC, respectively. Cervical flexor and extensor muscles are subjected to loading over MVC during high Gz sorties. Cervical rotation combined with extension exceeded muscle force-producing capacity during high Gz, resulting in a decline in muscle activity.DISCUSSION: Awkward postures, especially rotational ones, are more prone to increase loading over muscles' capacity. Overloading of muscles increases the risk of muscular and ligamentous injury. In addition, the lack of muscular support potentially leads to the Gz loading being transferred to spinal structures via intervertebral discs and the vertebral column. The JHMCS helmet seems to change the pattern of most loading muscles toward the extensor (posterior) neck muscles.Sovelius R, Mäntylä M, Heini H, Oksa J, Valtonen R, Tiitola L, Leino T. Joint helmet-mounted cueing system and neck muscle activity during air combat maneuvering. Aerosp Med Hum Perform. 2019; 90(10):834-840.

Avoidance of scapular winging while approaching tumors of the middle scalene region.

BACKGROUND: Large tumors arising from the middle scalene region can displace the middle scalene muscle and distort regional anatomy, placing nerves at risk. Understanding the surgical anatomy of these nerves is key to approaching pathology of the middle scalene muscle and avoiding damage to the dorsal scapular, long thoracic, and spinal accessory nerves, each of which can cause scapular winging and associated morbidity if injured. METHODS: IRB approval was obtained for this study, allowing cases with relevant pathology to be reviewed and presented to highlight the relevant surgical technique. Anatomical depictions were created to correlate intraoperative images with known anatomical relationships. RESULTS: Key to this approach is consideration of the regional anatomy in a standard supraclavicular approach, the superficial plane, containing the anterior scalene muscle and brachial plexus, and the oblique plane containing the middle scalene muscle, long thoracic, spinal accessory, and dorsal scapular nerves. Identification and mobilization of each of these structures prior to lesion removal can not only provide likely boundaries of the tumor, but also allow for protection of the nerves to avoid injury that may lead to scapular winging with associated morbidity and functional impairment of the upper extremity. CONCLUSIONS: Lesions of the middle scalene region often split two important anatomical planes, the superficial and deep, creating an advantageous surgical corridor through an anterolateral approach. Through early identification of known anatomy, these two planes can be developed, and a safe approach to the lesion of the middle scalene region can be exploited.

Does Extension Dysfunction Affect Postoperative Loss of Cervical Lordosis in Patients Who Undergo Laminoplasty?

STUDY DESIGN: Retrospective study. OBJECTIVE: To investigate whether loss of cervical lordosis (LCL) after laminoplasty can be predicted from specific preoperative dynamic radiograph measurements. SUMMARY OF BACKGROUND DATA: Recent studies have focused on the correlation between LCL after laminoplasty and T1 slope. These studies explain this correlation through the injury of the posterior neck muscular-ligament complex (PMLC); however, this muscle injury model could not explain the less kyphotic change in high T1s patients, as reported in some studies as controversy. We have focused on the PMLC constriction reservoir which was represented by extension function (EF). METHODS: We retrospectively analyzed 50 consecutive patients who underwent open-door laminoplasty (>1-year follow-up). EF is defined as extension C2-7 Cobb angle (CA) minus neutral C2-7 CA (Ext CA - CA). LCL is defined as follow-up CA minus preoperative CA (CA [FU] - CA [PRE]), and significant kyphotic change was defined as LCL smaller than -10°. RESULTS: The distribution of LCL was -3.70 ±â€Š7.98 and the significant kyphotic change occurred in 20% of the patients (10/50). EF, C2-7 sagittal vertical axis (PRE), and C2 slope (PRE) were found to be risk factors for LCL by multiple linear regression analysis. The receiver operating characteristic curve analysis revealed that EF could predict the significant kyphotic change well than previously known risk factors. The cutoff value of EF was 14°. No significant kyphotic change occurred at EF greater than or equal to 14°. Upon limiting the number of patients with preoperative straight curvature (n = 28), there is also no significant kyphotic change occurred in any patient whose EF was greater than or equal to 14°. CONCLUSION: In our study sample, we found that there is no relation between T1 slope and LCL. We have identified a new factor, EF, that could predict LCL after laminoplasty. No significant kyphotic changes after laminoplasty occurred particularly when the EF was greater than or equal to 14°. LEVEL OF EVIDENCE: 3.

A migratory shark bone.

Fish bone ingestion is a common presentation in ENT. If not managed correctly, it can cause serious complications for the patient and dilemmas for the clinician. A 49-year-old Sri Lankan woman presented to the emergency department following shark bone ingestion with a 'pricking' sensation in her throat. After initial investigation, the bone migrated through to the sternocleidomastoid muscle. After surgical removal of the shark bone she went on to develop a large neck collection, which required surgical drainage. The careful attention to the patient's history and use of imaging facilitated treatment in this case of fish bone ingestion and management of the sequelae.

Evidence for cervical muscle morphometric changes on magnetic resonance images after whiplash: A systematic review and meta-analysis.

INTRODUCTION: Morphometric changes to cervical musculature in whiplash associated disorder have been reported in several studies with varying results. However, the evidence is not clear because only a limited number of cohorts have been studied and one cohort has been reported in multiple publications. The aim of this study was to assess the evidence for cervical muscle morphometric changes on magnetic resonance (MR) images after whiplash using a systematic review with meta-analysis. MATERIALS AND METHODS: PubMed, MEDLINE and Cochrane Library were searched without language restriction using combinations of the MeSH terms "muscles", "whiplash injuries", and "magnetic resonance imaging". Studies of acute and chronic whiplash were included if they compared whiplash and control cervical spine muscle morphometry measurements from MR images. The search identified 380 studies. After screening, eight studies describing five cohorts (one acute, three chronic, one both acute and chronic) met the inclusion criteria. Participant characteristics and outcome measures were extracted using a standard extraction format. Quality of eligible studies was assessed using the Newcastle-Ottawa Scale. Muscle cross-sectional area (CSA) and fat infiltrate (MFI) for acute and chronic whiplash cohorts were compared using mean difference and 95% confidence intervals. Meta-analysis models were created when data from more than two eligible cohorts was available, using inverse-variance random-effects models (RevMan5 version 5.3.5). RESULTS: Quality assessment was uniformly good but only two studies blinded the assessor. Analysis of the acute cohorts revealed no consensus with respect to CSA. MFI was not measured in the acute cohorts. Analysis of the chronic cohorts revealed CSA is probably increased in some muscles after whiplash but there is insufficient evidence to confirm whether MFI is also increased. Because the available data were limited, meta-analyses of only multifidus were performed. In chronic whiplash multifidus CSA was significantly increased at C5 (Z = 3.51, p < 0.01) and C6 (Z = 2.66, p < 0.01); and MFI was significantly increased at C7 only (Z = 2.52, p < 0.01) but the heterogeneity was unacceptably high (I2 = 83%). CONCLUSIONS: The strength of the evidence for cervical muscle morphometric changes on MR images after whiplash is inconsistent for CSA and MFI. Future study designs should be standardised with quantification of three-dimensional muscle morphometry.

Cervical Injuries in Drowning Cases: A Case Report and a Review of Literature.

Discovery of bruises in the muscles of the neck and a fracture of the hyoid bone in a body recovered from water makes the diagnosis and the determination of the manner of death difficult.The aims of this work are to report a case of a drowned body with cervical injuries and to highlight the importance of interpreting these findings accurately.A 39-year-old woman was found dead face down in a 6-m deep well with a 3-m water level. She was mentally disturbed and had a history of suicide attempts. In fact, she had previously attempted to jump into that well in an attempt to put an end to her life. The autopsy revealed bruises in the muscles of the neck and a bruise associated with a fracture of the left horn of the hyoid bone.The mechanism for the origin of drowning-related neck injuries will be discussed.

Exploration about changes of IL-10, NF-κB and MMP-3 in a rat model of cervical spondylosis.

OBJECTIVES: To investigate the relationship and mechanism between IL-10, NF-κB and MMP-3 in cervical degenerative disease induced by unbalanced dynamic and static forces in rats. METHODS: Sixty Sprague Dawley rats were randomized into test (n=45) and control (n=15) groups, which were randomly subdivided into three groups corresponding to one-month, three-month and six-month post-operation. Test group included 10, 15, 20 rats at corresponding postoperative stage and control group had five rats at each time point. By excising cervicodorsal muscles and ligaments of rats to establish unbalanced dynamic and static rat model in test group. The expression of IL-10, NF-κB and MMP-3 in the intervertebral disc tissue samples of both test and control group rats were detected by immunohistochemistry at one-month, three-month and six-month post-operation. The results were analyzed and compared among groups. RESULTS: Compared with the control group, the positive expression of IL-10 in test group was significantly higher at three-month (P<0.05). In the same model group, IL-10 was highest at one-month. Compared with the control group, NF-kB in test group was higher at one-month, three-month and six-month. In the same model group, NF-kB was the highest at one-month, followed by the time at three-month and six-month. And, compared with the control group, MMP-3 was significantly higher in test group at one-month (P<0.05). CONCLUSION: Cervical degeneration may accompanied with the changes of IL-10, NF-κB and MMP-3.

Cervical porcupine quill foreign body involving the spinal cord of a dog: A description of various imaging modality findings.

Although porcupine quill injuries are common in dogs, the detailed appearance of the quill on diagnostic ultrasound, computed tomography, and magnetic resonance imaging has not been sufficiently described. A 4-year-old, intact, female Jack Russel terrier presented with severe neck pain and ataxia after an altercation with a porcupine 2 weeks earlier. Radiology, diagnostic ultrasound, computed tomography and magnetic resonance imaging were all utilised to identify a quill imbedded in the cervical vertebral canal and cervical musculature and were compared to each other. Surgical removal of the quill, guided by imaging findings, led to the resolution of the clinical signs in the patient. Previous ultrasound imaging reports have just stated that the quill consists of paralell hyperechoic lines, and do not mention the finer hyperechoic lines inbetween and do not try to provide a reason for the appearance. Previous computed tomography (CT) reports just mention identifying the quill on CT images (whether or not CT could identify the fragments), but do not go into detail about the attenuating appearance of the quill nor try to relate this to the composition of the quill. This is to the authors' knowledge the first report with detailed imaging descriptions of a case of cranial cervical vertebral canal porcupine quill foreign body in a dog. This is also the first report to allude to a possible difference in imaging findings related to quill structure because of keratin orientation and melanin content. The ideal imaging modality to use remains elusive, but ultrasound, computed tomography and magnetic resonance imaging could all identify the quill.

Injury Threshold of Rectus Capitis Muscles at the Atlanto-occipital Joint.

OBJECTIVE: The objective of this study was to collect muscle stiffness data from the 4 rectus capitis (RC) muscles to better understand their role in stabilizing the atlanto-occipital joint. The passive load displacement properties of these muscles have not been previously reported. METHODS: Rectus capitis muscles were removed from 3 unembalmed head and neck specimens. Passive length-force (stiffness) data were collected by using a servo-controlled hydraulic test machine. Multivariate analysis of variance with Bonferroni correction was used to assess the significance of the differences among passive stiffness within the elastic region of each muscle and the load and strain at the yield points. RESULTS: Rectus capitis lateralis (RCL) muscles failed at significantly higher levels of load and strain compared with the other 3 pairs of muscles. Passive stiffness of both RCL and RC anterior muscles was significantly higher than the other 2 pairs of muscles. CONCLUSION: The anatomic location of the RCL muscles, along with their high levels of passive stiffness, would be expected to facilitate the maintenance of atlanto-occipital joint congruence during normal daily activities. The level at which the RC posterior minor muscles failed could put them at risk of a strain injury during a rear end motor vehicle accident. Diagnostic and treatment protocols that apply forces to the upper cervical spine should be tailored to consider the patient's age, gender, and history of previous injuries to avoid overstretching RC muscles.

MRI Findings of Injury to the Longus Colli Muscle in Patients With Neck Trauma.

OBJECTIVE: The longus colli muscle (LCM) forms the bulk of the deep flexor muscles of the neck. To our knowledge, very little information on the effects of trauma on this muscle group has been published. We describe MRI findings related to injury of the LCM in patients with a history of neck trauma. MATERIALS AND METHODS: A radiology department database was searched to identify patient medical records from 2008 to 2013 that included the keywords "longus colli" and "deep flexors." Patients with fractures and ligament injuries were excluded. Patients with other obvious large soft-tissue injuries and nontraumatic conditions were also omitted. A total of 12 patients met the inclusion criterion of having an isolated or predominant injury to the LCM. Five patients had been involved in a motor vehicle accident, and seven patients had fallen. Eleven patients had undergone a CT examination before MRI was performed. RESULTS: No fractures were noted on CT. MRI examinations of the cervical spine were obtained for the following reasons: for increased prevertebral soft-tissue swelling noted on a CT scan plus neck pain (n = 6), for neck pain only (n = 4), or as part of a routine protocol for assessment of obtunded patients (n = 2). Eight of the 12 patients had isolated injury to the LCM. The remaining four patients also had minor injuries to the other neck muscles. The MR image showed swelling and T2 hyperintensity in the LCM and revealed free fluid in the prevertebral space. CONCLUSION: Isolated injury to the LCM may occur in neck injuries. The MRI findings indicating such injury include increased T2 signal, swelling of the muscle, and the presence of prevertebral fluid.

Does muscle morphology change in chronic neck pain patients? - A systematic review.

BACKGROUND: Neck pain is a common disabling worldwide health problem with a high socio-economic burden. Changes underlying the transition to, or the maintenance of a chronic state are still barely understood. Increasing evidence suggests that morphological muscle changes, including changes in cross-sectional area (CSA) or fatty infiltration, play a role in chronic neck pain. However, a structured overview of the current evidence of morphological changes is lacking. OBJECTIVE: To systematically review the morphological muscle changes in patients with chronic neck pain, including those with whiplash-associated disorders (WAD) and chronic idiopathic neck pain. STUDY DESIGN & METHODS: A systematic review using the PRISMA-guidelines. RESULTS: Fourteen of 395 papers were included after extensive screening. Most studies were of moderate methodological quality. A higher CSA was found in all flexor muscles in both patients with WAD and patients with chronic idiopathic neck pain, except for the deeper flexor muscles in patients with chronic idiopathic neck pain. The cervical extensor muscles show an increased CSA at the highest cervical segments in patients with WAD, while most studies in patients with chronic idiopathic neck pain report a decreased CSA in all extensor muscles. Fatty infiltration, which could be accountable for an increased CSA, of both cervical extensors and flexors seems to occur only in patients with WAD. CONCLUSION: Some evidence is available for changes in muscle morphology, however more high quality prospective and cross-sectional research is needed to confirm these changes and to identify potential underlying causes that need yet to be discovered.

Omohyoid Muscle Syndrome in a Mixed Martial Arts Athlete: A Case Report.

Omohyoid muscle syndrome is a rare cause of an X-shaped bulging lateral neck mass that occurs on swallowing. This is a diagnostic case report of a 22-year-old mixed martial arts athlete who acquired this condition.

Study of cervical muscle response and injury of driver during a frontal vehicle collision.

Frontal vehicle collisions can cause injury to a driver's cervical muscles resulting from intense changes in muscle strain and muscle load. This study investigated the influence of collision forces in a sled test environment using a modified Hybrid III 50th percentile dummy equipped with simulated spring-type muscles. Cervical muscle responses including strain and load of the sternocleidomastoid (SCM), splenius capitis (SPL), and trapezius (TRP) were analyzed, and muscle injury was assessed. The SCM, SPL, and TRP suffered average peak muscle strains of 21%, 40%, and 23%, respectively, exceeding the injury threshold. The average peak muscle loads of the SCM, SPL and TRP were 11 N, 25 N, and 25 N, respectively, lower than the ultimate failure load. The SPL endured the largest injury, while the injuries to the SCM and TRP were relatively small. This is a preliminary study to assess the cervical muscle of driver during a frontal vehicle collision. This study provides a foundation for investigating the muscle response and injury in sled test environments, which can lead to the improvement of occupant protections.