Whiplash

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Classification according to ICD-10
S13.4 Sprain and strain of the cervical spine
ICD-10 online (WHO version 2019)

Symptoms of illness (headache and neck pain, dizziness, speech disorders, unsteady gait and many others) are referred to as whiplash , acceleration trauma of the cervical spine or cervical spine distortion ( whiplash injury ), which generally occur within 0 to 72 hours after an acceleration and hyperextension of the Head, usually during a car accident, typically a rear impact - without direct damage to the skull , brain , spinal cord and cervical spine . It is the most common complication after car accidents and a dreaded cause of chronic disorders, although the reason for this chronicity, which occurs in some accident victims, is still unknown, but is highly controversial. A report by the Cochrane Collaboration defines whiplash as an acceleration-deceleration mechanism with energy transfer to the neck region as a result of rear or side impact traffic accidents, but also diving accidents.

classification

The term whiplash (whiplash) was first introduced in 1928 by the American orthopedic surgeon Harold Crowe to describe a clinical picture after indirect trauma to the cervical spine in connection with traffic accidents. A very common classification of severity is the so-called Quebec classification:

  • 0 - no discomfort, no symptoms
  • 1 - neck discomfort, stiffness of the neck
  • 2 - Discomfort and muscle tension, restricted mobility, muscle tension
  • 3 - complaints and neurological findings
  • 4 - fracture (s) or dislocation (s)

However, the proposal of the Swedish working group already quoted above from 2008, according to which levels 0 and 4 are superfluous, appears particularly useful because "whiplash" is by definition indirect damage and a fracture must be classified differently ; renouncing level “0” does not mean any loss of information.

It is undisputed that after a whiplash the symptoms usually subside within days to weeks without therapy. In about 10% or more of the cases, however, a chronic whiplash disease develops, some authors speak of 13–67%. The disorder is called chronic if symptoms are present for more than 6 months after the accident. This problem has been increasing in frequency for thirty years. An enormous controversy has arisen about this chronic " whiplash associated disorder " (WAD, whiplash associated disorder ), the exact etiology (cause) of which is still unknown today (see section below .) If one or more facet joints of the cervical spine in the accident were drawn affected, one can facet syndrome arise.

Etiology (causes)

The acceleration trauma of the cervical spine is caused by energy transfer in the context of an acceleration-deceleration mechanism. The most common cause of this are car rear-end collisions, but side impacts as well as non-traffic-related events, e.g. B. after jumping into shallow water, injuries in martial arts or general blows to the head.

Symptoms

The main symptoms of simple whiplash are the effects of muscle tension in the neck and neck muscles, which lead to headache and neck pain. The symptoms often last longer and can become chronic. The following symptoms are often given:

  • Dizziness ( vertigo )
  • Drowsiness and quantitatively higher-grade attention disorders ( vigilance )
  • Burning or stabbing pain in the back of the head
  • Hearing and vision disorders, restrictions of the visual field
  • Disorientation
  • Quick exhaustion and feeling of weakness
  • sleep disorders
  • Pain and / or discomfort in the face and arms
  • Unsteadiness
  • Muscle dysfunction
  • Spasms

course

Symptoms after an acute whiplash usually heal without consequences. In Quebec, of 1,551 casualties, 87% recovered within 6 months and 97% within a year. However, this insurance study is accused of equating healing with cessation of insurance benefits. Other sources say that 14–42% of the accident victims do not recover, the disorders become chronic (WAD - whiplash associated disorder , German: whiplash associated disorder ) and 10% report constant pain. In a study on 586 whiplash patients, 7% were permanently unable to work. In a second, ongoing Quebec study by Bergholm, Cassidy, Holm it is found that even 7 years after the accident, whiplash victims had significantly more health impairments than a healthy comparison group.

Prognostic factors : The most conclusive predictor for poor healing results is neck pain in the acute phase, but also restrictions in neck mobility. Factors from the accident reconstruction have limited informative value when it comes to the question of the chances of recovery. State of health before the accident, possible wear and tear, genetic inclined position of the cervical spine is more prone to injury. Psychological factors such as pain tolerance, disaster , fear-avoidance behavior play a role, but also post-traumatic stress disorder (PTSD).

Patients after cervical spine distortion were examined after 1 week, after 1 month, after 3 months, after 6 months and after 12 months (physical examination in the University Hospital, no questionnaires, Aarhus University Hospital / Denmark). The greatest risk factors for the transition from acute injury to long-term complaints are: restrictions in neck mobility and acute neck or headaches, but also symptoms of pre- and post-traumatic stress. Seizures of dizziness, tinnitus, hyperacusis, sleep problems etc. also played a certain role.

  • Average restriction of movement: 5–6 out of 10 points
  • Neck pain and headache: 6–7 out of 10 points
  • Numerous non-painful complaints such as tinnitus, dizziness 5–6 out of 10 points

In subgroup 1, most of the patients (approximately 98%) had recovered after one year. In addition, non-recovery can also depend on genetic factors. The Danish Whiplash Study Group "Risk Assessment Score" recommends an early clarification of risk factors a) movement restrictions of the cervical spine b) pain in the neck and head c) other complaints such as dizziness, tinnitus, insomnia, nausea etc. This evaluation can optimize the treatment.

Australian studies have looked at the healing process after cervical spine distortion. After 3 months around 75% still had health problems, after 6 months around 60%. This 60% remained almost constant until 12 months after the accident. (Diagrams: 269) The medical examinations were carried out in the University Hospital of Sydney, there were no questionnaires e.g. B. as in the Lithuania study. The main focus was on criteria with which precision such long-term studies should be carried out. Differentiated according to the risk of chronification (light, medium, severe), the following picture emerges: Statement: There are all constellations of long-term consequences, it is forbidden - just like with the so-called harmlessness limit - to take a general view: After 3 months, complaints still occur in approx. 60% in patients with a low risk of chronification, 80% in patients with a medium risk of chronification and 95% for patients with a high risk of chronification. After 6 months there were still complaints: approx. 50% with a low risk, 60% with a medium risk and 90% with a high risk of chronification. After 12 months there were still complaints: 40 percent with a low, 60% with a medium and 70 percent with a high risk of chronification.

therapy

The prescription of a neck brace , which used to be a common practice, is clearly inferior to exercise therapy used from the start, as a study published in 2004 on 200 patients showed. There is evidence that such passive therapies contribute to the chronification of the course of the disease. Supportive analgesics / anti-inflammatory drugs such as diclofenac or ibuprofen as well as - to relieve muscular tension - muscle relaxants can be prescribed.

After a thorough medical examination, after a simple acute whiplash, the patient should be told that the disorder is harmless and that any "catastrophicization" should be avoided. Therapy includes explaining the symptoms sensibly (examples: dizziness is caused by rapid head movement; jaw pain because of the local proximity of the neck and chin muscles, whereby muscle damage after accidents naturally have a pronounced ability to self-heal; concentration disorders because you Pain, not because their brain has been permanently damaged, etc.) It should be pointed out that the symptoms pass faster the sooner relieving postures are given up and one actively returns to earlier mobility, while, in contrast, with longer inactivity and avoidance behavior the The risk of chronification is greater.

A study published in 2012 found that patients with sufficient pain medication and a declaration that the injury was painful but harmless can be discharged home. Intensive advice and physiotherapy would not bring any clear advantages.

Accident Mechanics - Biomechanics

This section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

The impact of a vehicle driving up or from the side leads to the transmission of the movement to the occupants. This takes place after a short latency , while the crumple zones of the vehicle are first deformed and the vehicle itself is set in motion according to the force of the impact. This acceleration is transferred to the occupants via the car seat (see impulse force or impulse conservation ).

Since all speeds are relative to the observer, one can put oneself in the moving coordinate system of the occupant. Here the occupant and his vehicle rests (A). A vehicle (D) colliding with a moving vehicle (C) leads to the same effect as in the case of a vehicle (B) colliding with a stationary vehicle (A): the inertial mass of the occupant, especially the head, wants to remain in place . The vehicle (A) of the occupant is now accelerated by the impact of vehicle (B). The occupant's body is accelerated (“carried away”) via the backrest of the seat, while the head lingers longer. Comparison: Behavior of the wobbly Elvis when braking / accelerating. The moving body accelerates (“tears”) the sluggish head that remains in its position because it is tied around the neck.

The spine is first elongated during so-called ramping (climbing the upper body on the backrest). The head 'presses' downwards through its mass. The intervertebral discs are 'compressed' (compressed, distorted ). After a few milliseconds, further strong forces act on the spinal column, which is already weakened as a result, which increases the risk of injury considerably, since a spinal column that is compressed and stretched in this way is much more susceptible to lateral movements. Only now is the impact acceleration converted into a forward movement for the occupants. The upper body of the occupant is held back by the seat belt while the head tries to snap forward. However, this is not in a previously assumed pure whiplash movement (Engl. Whiplash ) instead, but in a translational movement , ie horizontal shearing movement with the highest risk of injury for all structures of the neck (cervical spine) and thoracic (BWS). So you see in motorsport races, u. a. the Formula 1 , for several years the black placing racks on the shoulders of the driver, where the helmet is fastened with ropes to this translation movement to prevent and thus to protect the driver ( HANS system ).

Protection systems in cars

In order to prevent whiplash injuries in a traffic accident, insurance associations recommend that the headrest be adjusted to a distance of less than four centimeters from the back of the head if possible. Since 2009, the Swiss Insurance Association's “Protecting Headrests” campaign has been providing information about the desired headrest setting.

Some vehicles are equipped with so-called “active” headrests that move in the direction of the head in the event of a rear-end collision in order to cushion it earlier. The whiplash protection system WHIPS from the Swedish car manufacturer Volvo was developed in the 1990s and moves the entire front seats in the event of a rear impact. It has received numerous awards from traffic safety authorities and has been standard equipment since 2000. Other so-called anti-whiplash systems (anti-whiplash systems) were developed by Delphi Automotive Systems and Autoliv and are used by various original equipment manufacturers .

The whiplash controversy

Ultimately, it is still unknown today why some people develop pronounced and protracted symptoms after a whiplash injury. Attempts to analyze this phenomenon range from claims of organic damage to certain structures by the trauma to cultural, psychological and psychosocial explanations. So could z. For example, the renowned “Lithuania Study” shows that it is less the car accident as such than the (culture-related) expectations, family history and misinterpretation of pre-existing symptoms that determine the persistence of a whiplash injury.

Uncertainty often arises when - mostly uncontrolled - pathological-anatomical examinations describe pathological changes to the intervertebral discs after whiplash in patients with WAD symptoms in a higher percentage compared to symptom-free accident victims. Their results can practically never be reproduced in controlled examinations. In a prospective magnetic resonance imaging study, Ronnen's work group did not find a single case of cervical disc damage caused by whiplash in 100 patients. The same applies to damage to the ligaments, especially the anterior longitudinal ligament (ligamentum longitudinal anterius). Damage to this ligament has been described in experimental studies, but prospective magnetic resonance imaging studies on patients have never demonstrated damage to the intervertebral disc.

Likewise, the facet joints or muscles were often seen as the source of complaints after whiplash. Previous studies have described damage to these joints as a consequence of trauma and are often cited. However, these were accident victims who had died after serious traffic accidents and direct trauma.

Some researchers believe that chronic whiplash disorders (WAD) cannot be explained by previous trauma, but rather sensational reports, the widespread notion that acute whiplash is a serious event, and the prospect of compensation leads to misprocessing in some casualties , which is responsible for the chronification. What is certain is that in countries which have neither medical treatment nor appropriate financial compensation after acute whiplash and pay little attention to the topic, chronic consequences in the sense of a WAD are almost unknown.

literature

  • Michael Graf, Christian Grill, Hans-Dieter Wedig: Acceleration injury of the cervical spine. Whiplash trauma. Steinkopf-Verlag , Berlin 2009, ISBN 978-3-7985-1837-7 .
  • Hans Schmidt, Jürgen Senn (Hrsg.): Whiplash - the latest state. Medicine, biomechanics, law and case management. Expert knowledge for lawyers, doctors, those affected and insurance dealers. Head and Collar Association, Küstnacht (Zurich) 2004, ISBN 3-033-00172-6 .
  • S1 guideline acceleration trauma of the cervical spine of the German Society for Neurology (DGN). In: AWMF online (as of 2012)

Web links

Wiktionary: Whiplash  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ Alphabetical directory for the ICD-10-WHO version 2019, volume 3. German Institute for Medical Documentation and Information (DIMDI), Cologne, 2019, p. 782
  2. ^ S. Carette: Whiplash Injury and Chronic Neck Pain . In: New Engl J Med 1994, 30: 1083-1084
  3. ↑ a b Jansen et al .: Whiplash injuries: diagnosis and early management. The Swedish Society of Medicine and the Whiplash Commission Medical Task Force. In: Eur Spine J . 2008; 17 Suppl 3: pp 355-417
  4. ^ Verhagen AP, Scholten-Peeters GGGM, van Wijngaarden S, de Bie R, Bierma-Zeinstra SMA: Conservative treatments for whiplash. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No .: CD003338. doi : 10.1002 / 14651858.CD003338.pub3 PMID 17443525
  5. ↑ Crowe HE: Injuries to the cervical spine. Meeting of the Western Orthopedic Association, San Francisco 1928
  6. ^ A b Spitzer WO et al .: Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders cohort study: redefining "whiplash" and its management . In: Spine 20: 1S-73S, 1995
  7. ↑ Rodriguez AA et al .: Whiplash: pathophysiology, diagnosis, treatment and prognosis. In: Muscle Nerve 2004; 29: 768-81
  8. ^ Barnsley L et al .: Whiplash injury. In: Pain 1994; 58: 283-30;
  9. ↑ Carroll LJ et al .: Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD) . In: Spine 2008: 33 Suppl: S83-92
  10. ↑ Harth M: Stopping Late Whiplash: Which Way to Utopia? In: The Journal of Rheumatology 2008; 35: 2303-5
  11. ↑ Leidel BA: Trauma of the cervical spine. In: Der Orthopäde 2008, 37: 414-423
  12. ↑ Barnsley L et al .: Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. In: New Engl J Med . 1994 330: 1047-50.
  13. ↑ Gozzard C et al .: Factors Effecting imployment after whiplash injury. In: J Bone Joint Surg Br 2001, 83: 506-509
  14. ↑ Michele Sterling: Does Knowledge of Predictors of Recovery and Nonrecovery Assist Outcomes After Whiplash Injury? (257-262)
  15. ↑ Helge Kasch, Erisela Qerama, Alice Kongsted et al .: The Risk Assessment Score in Acute Whiplash Injury Predicts Outcome and Reflects Biopsychosocial Factors (263-267)
  16. ↑ Steven J. Kamper, Mark J. Hancock, Christoper G. Maher: Optimal Designs for Prediction Studies of Whiplash (268-274)
  17. ↑ Schnabel M et al .: Randomized, controlled outcome study of active mobilization compared with collar therapy for whiplash injury. Emerg Med J 2004; 21: 306-310
  18. ^ Ferrari R. Prevention of chronic pain after whiplash . In: Emerg Med J 2002; 19: 526-530; McClune T et al. Whiplash associated disorders: a review of the literature to guide patient information and advice . In: Emerg Med J 2002; 19: 499-506
  19. ↑ Lamb et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomized controlled trial . In: The Lancet , 2012. doi : 10.1016 / S0140-6736 (12) 61304-X .
  20. ↑ Whiplash - counseling and physiotherapy are not very effective, [1]
  21. ↑ Headrests - The correct setting protects the cervical spine. Report on the notification of the General Association of the German Insurance Industry (GDV). In: Der Spiegel . February 23, 2004, accessed November 13, 2013 .
  22. ↑ Imprint of the website www.kopfstuetzen.ch
  23. ↑ Michael Noll-Hussong: Whiplash Syndrome Reloaded: Digital Echoes of Whiplash Syndrome in the European Internet Search Engine Context . In: JMIR public health and surveillance . tape 3 , no. 1 , March 27, 2017, p. e15 , doi : 10.2196 / publichealth.7054 , PMID 28347974 .
  24. ↑ H. Schrader, D. Obelieniene, G. Bovim, D. Surkiene, D. Mickeviciene, I. Miseviciene, T. Sand: Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 1966, 347: 1207-11.
  25. ↑ a b K. Petterson et al .: Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation. Spine 1997, 22: 283-87.
  26. ↑ a b HR Ronnen et al .: Acute whiplash injury: is there a role for MR imaging? A prospective study of 100 patients. Radiology 201 (1): 93-96.
  27. ↑ PC Ivancic et al .: Injury of the anterior longitudinal ligament during whiplash simulation. Eur Spine J 2004, 1361-68.
  28. ^ H. Jonsson et al .: J Spine disorders. 1991, 4: 251-263.
  29. ^ R. Ferrari et al .: The late whiplash syndrome. A biopsychical approach. J Neurol Neurosurg Psych 2001, 70: 722-726.
  30. ↑ D. Obeliniene et al .: Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psych 1999, 66: 279-283
  31. ↑ M. Partheni et al .: A prospective cohort study of the outcome of acute whiplash injury in Greece. In: Clin Exp Rheumatol 2000, 18: 67-70.