Imaging in Whiplash Injuries

Johan Van Goethem, Luc van den Hauwe, Paul Parizel

European Course in Neuroradiology, 14th Cycle Module 4 Antwerp, May 6, 2018

Overview• introduction

• definition, numbers, diagnosis, grading

• imaging

• discs

• bone and muscles

• upper cervical spine ligaments

Whiplash - introduction• whiplash-type neck distortions are quite

common, with an annual incidence between 1 and 4 per 1,000 inhabitants.

• whiplash can result from rear-end vehicle collisions but is also seen in side-impact and front impact collisions, and can also occur in other mishaps.

Whiplash - definition

Whiplash is an acceleration deceleration mechanism of energy transfer to the neck that may result in bony or soft tissue injuries, which in turn may lead to a variety of clinical manifestations known as whiplash-associated disorders (WAD).

Whiplash - diagnosis• WAD is a clinical diagnosis. The main symptoms include:

• neck pain, immediately or within 24 h after trauma is the cardinal manifestation.

• neck stiffness

• headache

• dizziness, vertigo, auditory symptoms, visual disturbances

• concentration and memory problems

• psychological problems

Numbers and cost of whiplash injuries

• 10,800,000 MVA (USA, 2009)

• 2,217,000 injuries

• of these at least 800,000 include cervical ‘sprains’, mainly in rear-end collisions

• rear-end collisions cause upto 85% of all whiplash injuries

• whiplash

• whiplash is the single most frequently recorded injury in MVA

• upto 50% of those with a whiplash injury following a motor vehicle collision will fail to fully recover

• accounts for 40% of the total incurred cost estimated with claims now exceeding €10bn (EU), £2,5bn (UK), $8,5bn (US)

Grading• The Québec Task Force (QTF) has divided whiplash-associated

disorders into five grades:

• Grade 0: no neck pain, stiffness, or any physical signs are noticed

• Grade 1: neck complaints of pain, stiffness or tenderness only but no physical signs are noted by the examining physician.

• Grade 2: neck complaints and the examining physician finds decreased range of motion and point tenderness in the neck.

• Grade 3: neck complaints plus neurological signs such as decreased deep tendon reflexes, weakness and sensory deficits.

• Grade 4: neck complaints and fracture or dislocation, or injury to the spinal cord.

Challenge

• WAD is a clinical diagnosis based on

• subjective clinical findings (neck pain, neck stiffness, headache)

• anamnesis (acceleration deceleration mechanism)

• can imaging help to triage and assess?

Imaging

• plain film/CT to exclude bony lesions

• MRI

• degenerative changes

• bone and muscle injuries

• ligamentous lesions at the craniovertebral junction

MR findings• Anderson et al, Radiology (2012)

• 100/100

• <48hrs

• bone abnormalities of vertebral bodies, occult fractures (0.2%) and bone contusions (1.0%)

• muscle abnormalities, strains (1.2%) or tears and/or hematomas (0.1%)

• non-specified ligament strains (90/51) and tears (10/4) were twice as frequent

• Pettersson et al. (1997) • 39 • 11d, 2years • disc pathology seems to be one contributing factor

• Ulbrich et al, Injury (2014) • 50/50 • 48hrs, 3mo, 6mo • could not find any trauma related changes of cervical disc signal intensities

• Matsumoto et al, Injury (2013) • 133/223 • 10 year follow-up • while Modic changes became more common in whiplash patients in the

10-year period after the accident, they occurred with a similar frequency in control subjects.

Disc lesions Disc lesions

• Karlsson et al. (2016) • significantly greater levels of multifidus fat infiltration in

persistent severe pain-related disability after a whiplash injury

• Elliott et al. (2011) • development of fatty in infiltrates in the neck muscles

following whiplash injury: an association with pain and posttraumatic stress

• Elliott et al. (2015) • rapid and progressive degeneration of the cervical

multifidus in whiplash

Muscle lesions Mechanics

• hypertranslation of the head: participation in the whiplash injury mechanism (Penning et al.) / alar/CCJ ligaments (Kaale et al., Maak et al.)

Ligamentous lesions

• craniovertebral (in-) stability

• alar ligament restrains rotation

• transverse ligament restricts flexion as well as anterior displacement of the atlas

• tectorial membrane and posterior atlanto-occipital membrane conserve stability in flexion-extension

• ALL of these ligaments restrain horizontal translation

50-year-old in MVA

• Freeman et al, Spine J (2009)

• MRI of whiplash injury in the upper cervical spine: controversy or confounding?

• continuing debate: validity and utility of magnetic resonance imaging of the upper cervical spine after whiplash exposure

Ligamentous lesions ImagingAuthor Year Lesion(s) Citations Journal Patients

Elliott 2006 extensor muscles 140 Spine 79

Pettersson 1997 disc 136 Spine 39

Yoganandan 2001 yellow ligament, 121 Spine 4 cadavers

Krakenes 2006 CCJ ligaments 112 Spine 92

Van Goethem

1996 disc, ligaments 78 EJR review

Johansson 2006 CCJ ligaments 31 Pain Res

Manag 3

Chen 2015 alar - J Cent South 134

Ulbrich 2011 transverse 6 AJR 90

The jury is still out

Author Year Citations Journal Patients Controls Remarks

Ronnen 1996 149 Radiology 100

Borchgrevink 1997 84 Injury 40 20

Myran 2008 53 Spine 59 114 more lesions in WAD

Wilmink 2001 44 Neuroradiology 12 6 0.5T

Dullerud 2010 23 Acta Radiologica 28 27

Lummel 2011 8 AJNR 50

Ligamentous lesions

• craniovertebral instability

• alar ligament rupture in 4.8 % and partial rupture in 12.4 %

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Krakenes J. Whiplash Injury. In: Spinal Imaging. Eds: Van Goethem J, van den Hauwe L,

Parizel P

Optimized imaging

• three-dimensional turbo spin echo with variable flip-angle distribution (SPACE) - Siemens

• Baumert et al., Magnetic Resonance Imaging 27 (2009) 954–960

• 3D TSE PD

Optimized imaging• SIEMENS > knee > programs > general

>pd_space_sag_p2_iso_320 (7’21”)

Orientation Sagittal FoV read 163mm

Phase enc. dir. A>>P FoV phase 100%

Phase 0% Slice resolution 69%

Slice 16,7% Slice thickness 0,65mm

Slices per slab 192 TR 1000

Slice thickness 0,65mm TE 38

Base resolution 320 Flip angle 100°

• 0,5 x 0,5 x 0,65 mm3

• 4’38”

3D PDWI 3D PDWI

Ligamentous lesions

alar ligaments

transverse ligament

tectorial membrane

posterior atlanto-occipital

membrane

WAD 32,9% 33,8% 27,2% 23,3%

control 0% 10,7% 13% 3,8%

Krakenes J. Whiplash Injury. In: Spinal Imaging. Eds: Van Goethem J, van den Hauwe L, Parizel P

Krakenes J. Whiplash Injury. In: Spinal Imaging. Eds: Van Goethem J, van den Hauwe L, Parizel P

Krakenes J. Whiplash Injury. In: Spinal Imaging. Eds: Van Goethem J, van den Hauwe L, Parizel P

Therapy

• reassurance/structured education, resumption of normal activities and home exercises

• multimodal care that includes manual therapy

• occipitocervical stabilisation - 80% success rate in alar ligament lesions (Volle et al., 2001)

Conclusion• MDCT to rule out fractures and dislocations

• MRI is useful in evaluating

• ligamentous lesions of the upper cervical spine (3D PD-sequence)

• bone contusions, muscle lesions (STIR imaging)

• WAD remains a clinical diagnosis

• role of ligamentous lesions of the upper cervical spine in whiplash-injuries is still subject of scientific research