SOFT TISSUE INJURIES OF THE CERVICAL SPINE
From: J Bone Joint Surg [Br] 1996;78-B:955-7.
Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing.
Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms.
Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.
Soft tissue neck injuries may give persisting symptoms. While most patients reach their final state after two years, a small percentage improves with time. The symptoms of soft tissue neck injury are often disproportionate to the physical signs, suggesting that there may be a psychological component in overall neck disability.
Classification of the severity of symptoms according to Gargan and Bannister (1990)
A: Asymptomatic
B: Mild symptoms not affecting work or leisure activities
C: Intrusive symptoms interfering with work or leisure. Frequent use of analgesics, orthosis or physiotherapy
D: Severe problems: lost job, continual reliance on analgesics, orthosis. Repeated medical consultations
Patients with symptoms had greater incidence of stiff neck.
Radiological examination of the cervical spine performed showed that at that time 80% of the patients who had deteriorated in the last five years had degenerative changes, compared with 67% of those whose symptoms had stayed the same and 50% of
those who had improved.
In our series 70% of the patients still had symptoms 15 years after a whiplash injury. Although some (18%) had improved over the last five years, a greater number (28%) had deteriorated. Older patients were more likely to continue to experience symptoms, and only 5% of those who were aged over 40 years at the time of the accident were free from symptoms at follow-up. Our finding that neck pain symptoms did not improve after settlement of litigation is consistent with the published literature (Balla and Moraitis 1970; Mendelson 1982).
The pain maps reinforced that radiating pain is associated with more severe disability. The distribution of the pain conforms more closely to radiation from the facet joints (Bogduk and Marsland 1988) rather than dermatomes. The maps fall into two distinct patterns and help to discriminate between mild and intrusive symptoms. The radiating pattern was much more common in patients with intrusive or severe symptoms.
Although there was a trend towards stiffer necks in more patients with more symptoms the degree of stiffness did not discriminate between grades of disability.
Radanov et al (1991) noted disturbances of memory and attention span after whiplash injuries in patients with symptoms. Gargan, Bannister and Main (1992) found that patients were psychologically normal at the time of injury, but if symptoms persisted for three months they developed an abnormal GHQ score. Our study shows an abnormal psychological profile in patients with symptoms after 15 years suggesting that this is both reactive to physical pain and persistent.
