Relation between neuropsychological and neuroimaging findings in patients with late whiplash syndrome.

OBJECTIVES: The interpretation of long term cognitive impairment after whiplash injury is still a problem for many physicians. On the grounds of nuclear medicine findings previous research speculated that brain damage is responsible for cognitive problems of patients with whiplash. To test this hypothesis the relation between neuroimaging and neuropsychological findings was analysed. METHODS: Twenty one patients (11 women, 10 men, mean age 42.2 (SD 8.6) years) with the late whiplash syndrome (average interval of trauma 26.1 (SD 20.7) months) referred for diagnostic action to the Department of Neurology were investigated. Assessment included computer assisted assessment of working memory and divided attention, neuroimaging (by the means of [99mTc]-HMPAO-SPECT, [15O]-H2O-PET and [18F]-FDG-PET), testing of emotional functioning (depression and anxiety ratings), and pain intensity at the time of testing. RESULTS: On average, scoring on tests of cognitive functioning was very low. However, no significant correlations were found between regional perfusion or metabolism in any brain area and the scores of divided attention or working memory. By contrast, significant relations were found between indices of impaired emotional functioning (state anxiety) and divided attention. In addition, low scoring in divided attention was significantly correlated with pain intensity at the time of testing. CONCLUSIONS: The present data do not provide evidence of a significant relation between detectable morphological or functional brain damage and impaired cognitive performance in the late whiplash syndrome. Results indicate triggering of emotional and cognitive symptoms on the basis of initial injury of the cervical spine.

Motor evoked potentials: appropriate positioning of recording electrodes for diagnosis of spinal disorders.

The interpretation of normal and pathological findings of motor evoked potential obtained by the use of transcranial magnetic stimulation depends on adequate examination technique, including the appropriate positioning of the recording electrodes over the muscle. On the basis of knowing the location of the motor end plate zones in muscles, magnetic stimulation of the motor cortex of 30 healthy adults was performed in order to explore the influence of the position of the surface recording electrodes on potential parameters and to establish the standard location of the recording electrodes over the biceps brachii, medial vastus, anterior tibial and abductor hallucis muscles for diagnostic use in spine disorders. The cortical latencies and peak-to-peak amplitudes of the evoked potentials were analysed by varying the location of the recording electrodes and the stimulus intensities. The latencies were significantly shorter when the different electrode lay more proximally over the muscle belly. Reproducible potentials with sharp negative onset and maximum amplitude were recorded with a separation of 5-7.5 cm between the different electrode, located over the motor end plate area, and the different electrode, located over the distal myotendinous junction. This implies that the parameters of evoked potentials depend on the position and separation distance of the recording electrodes over the muscles and that it is possible to record the potentials using a lower stimulus intensity and, above all, on relaxed muscles, which may prove to be applicable for intraoperative monitoring of the spinal cord using magnetic stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of plate and screw fixation in occipitocervical fusion in rheumatoid arthritis.

STUDY DESIGN: In a clinical retrospective study, the results of occipitocervical fusion in patients with rheumatoid arthritis were studied and analyzed. OBJECTIVES: The results of two different operative techniques were compared. The advantages of screw fixation compared with wiring techniques in this population of patients were investigated. SUMMARY OF BACKGROUND DATA: Numerous different implants have been presented in the literature for occipitocervical fusion in patients with rheumatoid arthritis. The use of wires being the standard fixation technique. METHODS: Occipitocervical fusion was performed in patients with rheumatoid arthritis: 26 patients with the wiring technique and 33 patients with a new Y-plate fixation. The results were compared at a follow-up period of 24 months and 50 months, respectively. Clinical and radiologic results were investigated. RESULTS: The atlantodental distance could be significantly better reduced in the group with the Y-plate fixation and the neurologic improvement in the wiring group was 40%, whereas in the Y-plate fixation 86% of neurologic improvement was observed. Pseudarthrosis was seen in 27% of the wiring technique and in 6% in the plate and screw fixation technique. CONCLUSIONS: In occipitocervical fusion for patients with rheumatoid arthritis, the screw and plate fixation technique provides superior results than other techniques using wire fixations.

The value of functional computed tomography in the evaluation of soft-tissue injury in the upper cervical spine.

A functional rotatory computed tomography (CT) study of 423 whiplash patients with cervical spine soft-tissue injury was undertaken to determine its diagnostic value. The results are correlated with previous CT studies on normal subjects, and an evaluation of paradox motion, in which the lower vertebra rotates more than the vertebra immediately superior to it, is given. Asymmetrical left/right rotation reached the pathological value in 36% of the patient population at the level of C0-1. Twice as many patients had hypermobile rotation to the left as compared with the right, perhaps indicating that the right alar ligament is more often damaged in injuries involving the whiplash mechanism. A higher percentage of pathological values for hypermobile rotation was found at the level of C0-1 than at C1-2. Patients exhibiting paradox rotation had a significantly higher amount of rotation to the contralateral side than did those who exhibited no paradox rotation. These findings validate the use of functional rotatory CT in the evaluation of soft-tissue damage of the upper cervical spine resulting from whiplash injury.

[External fixator of the cervical spine--a new diagnostic tool]. / Fixateur externe an der Halswirbelsäule--ein neues diagnostisches Mittel.

Soft tissue injuries of the neck may cause severe long-standing pain. The clinical findings are sparse and the identification of the painful segments with conventional diagnostic tools is often impossible. Temporary segmental external fixation for a soft tissue injury of the cervical spine was performed as a diagnostic procedure in 24 patients. The instrumentation was applied according to the established techniques of the insertion of facet screws in the cervical spine. The segments to be instrumented were evaluated by clinical and radiological findings, such as local pain and increased mobility in the functional X-rays. However, none of these findings were convincing enough to proceed directly to fusion for pain relief. Evaluation of external fixation consisted of alternatively fixing different instrumented segments and having the patients rate their pain on a visual analogue pain scale. External fixation of the suspected segments resulted in marked pain relief, which was recorded subjectively by the visual analogue pain scale in 68% of the patients. The pain relief (8.2 points preoperatively--2.6 points postoperatively on average) could be permanently established by successful fusion of these segments in 17 patients. Four of the patients indicated no relief of pain at the follow-up (12.9 months postoperatively). No fusion was performed in 3 patients in whom the diagnostic procedure with external fixation allowed no conclusion about the painful segment. As it is an invasive procedure, external fixation of the cervical spine should be reserved for cases, in which conventional methods have failed to established a clear diagnosis of segmental instability and conservative therapy could not relieve the symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical validation of functional flexion/extension radiographs of the cervical spine.

The aim of this study was to determine the clinical validity of functional flexion/extension radiographs of the cervical spine in a defined patient population. Sixty-four adults with functional disorders of the cervical spine underwent passive flexion/extension radiographic examinations. The radiographs were analyzed using a computer assisted method to calculate segmental motion parameters, such as rotations, translations, and centers of rotation. The patients were separated into three groups based on their specific functional disorders, and their motion parameters were compared with those of a healthy population. The three groups consisted of patients with degenerative changes, those with radicular syndrome, and those with whiplash trauma. Most of the patients displayed trends toward hypomobile segmental motion. This trend is displayed more substantially in the groups with degeneration and radicular syndrome. Hypomobility in segmental rotation was significant at C6-C7 for the degenerative and radicular groups. The trauma group showed trends toward hypermobility in the upper and middle cervical levels, and the locations of the centers of rotation were shifted in the anterior direction when compared with those of the healthy population.

Surgical management of the subaxial cervical spine (C3-T1) in rheumatoid arthritis.

In the process of skeletal changes in rheumatoid arthritis (RA) the lower cervical spine may characteristically be affected by subluxation, discoligamentous insufficiency and bone resorption. These may cause severe pain and important neurological deficit and necessitate surgical intervention. Out of a series of 122 RA patients who underwent surgery of the cervical spine, in 23 the subaxial cervical spine was operated on. Pain was the leading symptom in all patients. In only six were there no pathological neurological findings, and all showed marked kyphotic deformity of the cervical spine. Fourteen patients were operated by a posterior approach, one by a ventral approach, and in eight patients the surgical procedure consisted of anterior decompression and dorsal stabilization. A mean of 21.3 months after surgery, clinical and radiological evaluation was performed. In two patients the sensomotor deficit improved, and out of 16 patients with cervical myelopathy, nine improved. No pseudoarthrosis was noted, and moderate loss of correction was seen in only three patients. In a subjective evaluation, 14 patients rated their result as good, six as fair and none as poor. In conclusion, following decompression, we noted good recovery from myelopathic symptoms. Sufficient stability in patients with RA is achieved by a combined anterior and posterior approach, the main goal of the anterior approach being decompression by vertebrectomy and that of the posterior approach stabilization by plate and screw fixation.

Frequency of complications of manipulation of the spine. A survey among the members of the Swiss Medical Society of Manual Medicine.

A survey of all members of the Swiss Medical Association of Manual Medicine was undertaken for the year 1989. Informative data were given by 425 respondents on the frequency of complications of manipulation as related to the spine. The number of thoraco-lumbar manipulations during 1989 (225 working days) was 805 for each respondent, and the number manipulations of the cervical spine 354. Thus, the total number of thoraco-lumbar manipulations was 342125, and the total number of cervical manipulations was 150450. The overall incidence of side-effects of transient complications due to cervical spine manipulation such as disturbance of consciousness or radicular signs was 1:16716. Seventeen patients (ratio 1:20125) after manipulation of the lumbar spine presented, in addition to increased pain, a transient sensorimotor deficit with precise radicular distribution. Nine of the 17 patients (ratio 1:38013) developed a progressive radicular syndrome with sensorimotor defict and radiologically verified disc herniation and had to be referred for surgery. Side effects and com- plications of cervical and lumbar spine manipulation are rare. Taking in to account the yearly number of manipulations performed by a single physician in Switzerland and the rate of complications, it can be calculated that a physician practicing manual medicine will encoutner one complication due to manipulation of the cervical spine in 47 years and one complication due to lumbar spine manipulation in 38 years of practice. However, it is important that a careful clinical assessment is carried out to avoid complications due to manipulation carried out on the basis of inappropriate indications. Furthermore, the decision as to which technique is indicated for any particular functional disorder of the spine should be made on the basis of rational criteria resting on a knowledge of clinical biomechanics, functional anatomy and neurophysiology. The authors recommend a prospective morbidity study to be carried out among physicians, chiropractors, osteopaths and physiotherapists, taking into account the different indications and therapeutic techniques in relation to complications.

Age and gender related normal motion of the cervical spine.

The purpose of this study was to develop a clinical method for measuring three-dimensional motion of the cervical spine using the CA 6000 Spine Motion Analyzer (Orthopaedic Systems Inc., Hayward CA). Normal values for passive examinations of flexion-extension, lateral bending, rotation, rotation out of maximum flexion, and rotation out of maximum extension were obtained and analyzed for each gender in a group of 150 normal subjects. Gender classifications were further subdivided into age groups, with each decade containing asymptomatic volunteers. Values for each group were compared for differences with respect to age and gender differences. A detailed error analysis was also performed on the interobserver and intraobserver repeatability, differences between passive and active testing, and the use of different fixation devices. Significantly decreased motion differences were found between age groups within gender, and between gender groups in corresponding decades. Results of rotation out of maximum flexion suggest and support earlier conclusions that the rotation of the C1-C2 segment does not decrease with age, but rather increases slightly to perhaps compensate for the overall decreased motion in the lower segments.

In vivo flexion/extension of the normal cervical spine.

Twenty-two women (age range 25-49 years, average 30.9 years) and twenty-two men (age range 23-42 years, average 31.6 years), all healthy and asymptomatic, underwent passive flexion/extension examinations of the cervical spine. Functional x-rays were taken and analyzed using a computer-assisted method that quantified intervertebral rotations, translations, and locations of the centers of rotation for each level C1-C2-C6-C7. The aim of the study was to establish values for these parameters for a normal population as related to age and gender. In the process, a statistically significant difference was found in the average value of rotation between male and female groups at the C5-C6 level. A new parameter, the ratio between translation and rotation, was also established and may prove useful for clinical diagnoses. This parameter has a smaller error associated with it than do pure translations and may aid the clinician by helping to account for the large variation in rotatory ranges of motion within the population. This translation/rotation ratio indicated highly significant differences in the lower segments of the cervical spine between gender groups.