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Acute neck sprain after road traffic accident: a long-term clinical and radiological review
Injury (1993) 24, (2), 79-82
Printed in Great Britain
79
Acute neck sprain after road traffic accident: a long-term clinical and radiological review D. D. Robinson and V. N. Cassar-Pullicino Robert Jones and Agnes Hunt Orthopaedic
and District Hospital, Oswestry,
A retrospective review of 2 1 patients behveen 10 ana’ 19 years after a soft tissue injury to the cervical spine was undertakn. The clinical data showed a persistence of symptoms in 18 (86 per cent) of patients wifhout any deterioration in the dinical signs. The radiological assessmenf did not show any evidence of injuy leading to, or correlating with, the development OY progression of degenerative changes in the ceroical spine.
Introduction Acute soft tissue injury in the neck after a road traffic accident is a common problem seen throughout the motorized world (Juhl and Seermp, 1981). The immediate pathology and resultant long-term effects are not known and ill-understood, hence the treatment of the condition is empirical at best. In order to assess the natural history, long-term follow-up of these patients is required. A series of 21 patients reviewed 13.5 years after injury is presented. The aim is to correlate the clinical and radiological features documented at the initial medicolegal examination (average 8.5 months after injury) with the long-term findings, and to determine whether an association between injury and later development of cervical spondylosis exists.
Method The medicolegal files of a retired consultant were inspected and all cases of acute neck injury from 10 years or more were selected. There were 121 cases identified and 46 of these could be traced within the local area. These patients were invited to attend for a clinical review and plain radiographic assessment of the cervical spine, including lateral flexion and extension views. Of the 46 patients, 21 attended for review, and no conclusions or assumptions were made on the remainder. The repeat examination was styled on the same detailed documentation of their first medicolegal examination after injury, which had been obtained about 8 months after injury. Symptoms were assessed with reference to their effect on daily life and graded into none, mild or severe using a visual analogue pain scale. A score of more than 5, associated with 2 weeks or more off work, and periodic sleep disturbance lasting more than I week were criteria defined as severe. The range of movement in the neck was assessed by measuring flexion, extension, rotation and lateral flexion. These movements were measured as a percentage of the normal range, the resulting figures were summated to give a 0 1993 Butterworth-Heinemann Ltd 0020-1383/93/020079-04
Shropshire,
UK
score out of 600 and the last two digits removed to produce a movement score out of 6. Radiological review was performed on all the patients by two independent assessors. The recently obtained radiographs were analysed first. The maximum height of each intervertebral disc was measured from CZ to C7, as was the width of the spinal canal at C5 and at its narrowest point. The number of osteophytes, anterior and posterior, were counted at each level. The shape of the cervical curve and instability was assessed on the flexion/extension radiographs (Figure I). The original radiographs were then analysed in the same way without reference to the previously recorded radiological or clinical data to minimize any bias. Radiographic review of a matched control group was not pursued as the incidence of degenerative spondylosis with age is well-established (Friedenburg and Miller, 1963; Lawrence, 1969).
Results all, 21 patients (age range 33-70 years) were reviewed at a mean time of 13.5 years after the accident. None of the patients had any previous history of neck trouble. The results of the first review done at an average of 8.4 months after injury are shown in Table I. In
Review appointment At the time of the review appointment, 18 patients still suffered a painful neck in exactly the same pattern as that Table I. Findings at first medical report Onset of symptoms
Site of pain
Time off work
Severity of symptoms
Range of neck movement
Immediate 24h 24 h to I week Neck alone Neck+shoulder(s) Neck + head None I-5 weeks 6-I 0 weeks None Mild Severe 6 (out of 6) 5 4 3 Mean=4.3
9 9 3 a II 2 I3 4 4 4 I0 7 4 7 2 a
(43%) (43%) (14%) (38%) (52%) (10%) (62%) (19%) (19%) (I 9%) (48%) (33%) (19%) (33%) (10%) (38%)
80
Injury: the British Journal of Accident Surgery (1993) Vol. 24/No.
which resulted from their accident. All of the patients with pain had sought further medical advice during the intervening period with no patient gaining any significant benefit. No patient had been offered invasive investigation or surgical intervention. Two patients had had to give up work due to persistent symptoms, one of them a policeman. Five patients had had periods off work due to neck pain, but no other patients had
had to change the nature of their work because of their symptoms. All of these patients had been graded as having severe symptoms at the time of their original assessment. The physical signs in the patients were unchanged with the average score for neck movement remaining at 4.5 (out or of 6), while none of the patients had deterioration developed objective neurological signs. The mean time to settlement of legal action was 2 years after the injury. Nine patients were not satisfied by the legal settlement and 12 were satisfied. Three patients had no symptoms after settlement but 18 had residual symptoms of intermittent pain in the same distribution, but of lesser severity than the pain following the injury to the present day. There was no correlation between patient satisfaction and persistence of symptoms. It proved impossible to assess the results of treatment for their injuries, due to the widely differing regimens of treatment that were offered. All treatment had been nonoperative and no patient had been offered surgery. At final review, no patient was still receiving treatment; this reflected the little or no effect on the long-term outcome as described by the patients, rather than any success that could be attributed to the treatment received. Radiological
Figure 1. Parameters measured on radiographs. a, Maximum
intervertebral disc height. b, Spinal canal width. c, Spinous process to lateral mass.
2
review
None of the patients had a bony injury as a result of their accident; six patients were noted to have a fixed kyphosis at one level on their original films; three at C5/6, three at C6/7. Two other patients had abnormalities of alignment; one patient had a loss of lordosis with osteophyte formation at C5K6, which became a fixed kyphus in the later radiograph, and another patient had a retrolisthesis at C4/5, which was unchanged in the later radiographs. A comparative assessment of the intervertebral disc heights, and the spinal canal dimensions from C2 to C7 are summarized in Table II. The average number of osteophytes at the original report was 1.27 and 2.3 at the time of review. The distribution and numbers of osteophytes are shown in Table III. Radiographs of 19 patients were assessed, of which 12 original films were described as normal, while seven had a significant degenerative abnormality with 11 radiographs remaining normal. Of
Table II. Radiographic measurements
(a) Measurements of maximum invertebral disc height Average height in mm Disc
Original report
C2/3 c3/4 c4/5 C5/6 C6/7
5.5(rt1.4) 5.2( f 1.4) 4.9( f 1.2) 4.5( f 1.7) 4.7( +2.6)
Review appointment 5.7( 5.4( 4.6( 4.0( 4.4(
f f f f f
1.8) 2.4) 1.8) 2.2) 3.2)
(b) Measurements of spinal canal dimensions Average height in mm Level
Original report
Review appointment
c5 Narrowest Spinous process to lateral mass
17.22( A3.7) 15.6 (+3.2) 5.11( f 2.8)
17.21 ( f 3.4) 15.1 (+3.2) 5.2 (k2.3)
None of the measurements above show a statistically significant difference using the Mann-Whitney
Utest.
Robinsonad Cassar-Pullicino: Acute neck sprain after road traffic accident
81
Table III. Osteophyte disturbance and number Number of osteophytes level
Original report
Review appointment
C2J3 c3/4 c4/5 C5/6 C6/7
0 0 1 (5%) 12 (52%) 10 (43%)
0 3 10 20 12
Total
23 (100%)
45 (100%)
(7%) (22%) (44%) (27%)
the seven patients with demonstrable degenerative changes, four showed progression of these spondylitic appearances at the same and other levels (TableII and Table III). However, the demonstrable changes were within the expected range when related to the respective age groups as defined by Lawrence (1969) and Friedenberg and Miller (1963). For examples of cases see Figures 2-4. The six patients with significant degenerative spondylosis as shown by a fixed kyphus were also those with the most persistent pain and limitation of movement at the final review. They had been awarded the most money in the way of settlement (mean f 1725 as opposed to f 1027 for the remaining patients) and were uniformly pleased with the outcome of litigation.
Figure 2. Patient 1: Radiographs 10 years apart showing minor changes in both films.
Figure 3. Patient 2: C6/7 kyphus showing no progression over
13 years.
Figure 4. Patient 3: Multiple level degenerative changes showing an increase in the number of osteophytes, but no further loss of disc height or progression of canal stenosis after 19 years.
Discussion The term ‘whiplash’ is emotive; therefore we prefer the term ‘acute neck sprain’ (Porter, 1989) to be used in the absence of demonstrable pathology. It has been suggested that the term ‘whiplash’ should be used for pure hyperflexion injuries arising from a direct rear-end impact (Hodgson and Grundy, 1989). This type of car collision is rare, represents 8 per cent of road traffic accidents (MacKay, 1970) and various authors (Maimaris et al., 1988) have found no evidence to suggest that these injuries behave differently to those which involve a rotational element. The pathology of an ‘acute neck sprain’ is not understood. Animal experiments have identified a spectrum of pathology (MacNab, 1971; La Rocca, l977), while investigations on human sufferers have not shown any consistently reproducible lesion. The vast majority of cases receive only cursory investigation and are then dismissed and discharged from further management, usually ending in litigation. The more severe cases may have either associated bony damage or signs of an acute cervical disc prolapse (La Rocca, 1977) and then receive further investigation and treatment. Treatment of the minor cases usually consists of a soft collar with or without physiotherapy. Norris and Watt (1983) defined three groups of increasing severity of injury. In group I,56 per cent of patients will be symptom-free at 18 months after injury, while group 3 patients showed recovery in only 10 per cent at 2 years. The pathology in this group may be related to a problem such as an annular tear in a disc, although other authors consider that the persistent symptoms are related to a post-traumatic necrosis, Hodge (1971); only 19 per cent of group 2 patients were entirely symptom-free at 2 years. Using the Norris and Watts (1983) criteria, all our patients were group 2 at the initial examination. Despite the significantly longer time of follow-up (13.5 years) compared with the Norris and Watts (1983) study (2 years), the incidence of persistent and disabling symptomatology in this group is essentially the same (86 per cent Robinson and Caspar-Pullicino; 8’1 per cent Norris and Watt (1983)). The long-term outcome of these injuries is at best controversial (Gotten, 1956; Hodgson and Grundy, 1989), while Norris and Watt (1983), and Hodgson and Grundy (1989) showed that litigation had little influence on out-
82
Injury: the British Journal of Accident Surgery (1993) Vol. 24/No.
come. In our series, there is no correlation between patient satisfaction in the court case and resolution of their symptoms. The patients with the worst clinical outcome in the long term were those with pre-existing degenerative changes in the cervical spine, and these were the patients awarded the highest amounts of compensation. They were uniformly happy with the outcome of litigation. Despite the relatively common occurrence of acute post-traumatic neck sprains, organized follow-up of the long-term effects is sporadic and commonly deals with small groups (Hodgson and Grundy, 1989). Our series is selected on the basis of the patients having been litigants in the past; nevertheless, an evaluation of the long-term results after settlement of compensation is an essential exercise, providing an objective and independent audit on medicolegal beliefs, statements and trends. The percentage (85 per cent) of patients suffering from persistent pain is much higher than in previously reported series (Gotten, 1956; MacNab, 1964; Norris and Watt, 1983; Deans et al., 1987; Hodgson and Grundy, 1989), which may be a reflection of the selective nature of our series. However, these patients have no radiological evidence of injury or neurological signs, yet they still have long-lived symptoms and disability without deterioration. The results of the comparative analysis of the plain radiographs are quite consistent in their findings. An acute neck sprain does not lead to cervical spondylosis, accelerated or otherwise, nor does it lead to worsening of pre-existing degenerative changes. In our group there is no evidence that injury induces further degenerative changes at any particular level nor the development of canal stenosis. This is not to deny that these patients have continuing pain, but it is not due to progressive cervical spondylosis. The relationship between radiological degenerative disc changes and symptoms has beeninvestigated in the past, but there is only an association when the radiological changes are more severe than those encountered in our series (Friedenberg and Miller, 1963; Lawrence, 1969). Hohl(1974) showed that 58 per cent of patients with radiologically evident disc degeneration were asymptomatic after injury, while 44 per cent of patients who remained symptomatic had no evidence of disc degeneration. It seems that a review at 8-12 months after injury is a useful predictor of long-term outcome. Hohl (1974) had showed that 83 per cent of patients whose claims were settled within 6 months of injury remained asymptomatic compared with those patients with longer-lasting symptoms.
2
Acknowledgement Our thanks to Mr A. K. Mitting files.
for allowing
us to use his
References Deans G. T., Magalliard J. N., Kerr M. et al. (1987) Neck sprain a major cause of disability following car accidents. Injl*y 18, 10. Friedenberg Z. B. and Miller W. T. (1963) Degenerative disc disease of the cervical spine. 1. Bone]oinf Surg. 45A, 1171. Gotten N. (1956) Survey of 100 cases of whiplash injury after settlement of litigation. JAMA 162, 865. Hodge J. R. (1971) The whiplash neurosis. Psychosomafics12,245. Hodgson S. P. and Grundy M. (1989) Whiplash injuries: their long-term prognosis and its relation to compensation. NeuroOrfkop. 2, 88. Hohl M. (1974) Soft tissue injuries of the neck in automobile accidents: factors influencing prognosis. J. BoneJoint Surg. 56A, 1675. Juhl M. and Seerrup K. K. (1981) Cervical spine injuries: epidemiology investigation. Medical and social consequences. In: Proceedingsof fke 6fk Infer&ional IRCOBI (International Road Congress on Biomechanics of Impacts), Conference on Biomechanics of Impacts. France: Bron, 49. La Rocco H. (1977) Acceleration injuries of the neck. Clin. Neuroswg. 25,209. Lawrence J. S. (1969) Disc degeneration: its frequency and relationship to symptoms. Ann. Rketrm. Dis. 28, 121. MacKay G. M. (1970) The nature of collisions. TechnicalAspectsof Road Safefy 43, 1. MacNab I. (1964) Acceleration injuries of the cervical spine.J. Bone ]oinf Surg. 46A, 1797. MacNab I. (1971) The ‘whiplash syndrome’. Orfkop. Clin. Nurfk Am. 2,389. Maimaris C., Barnes M. R. and Allen M. J. (1988) Whiplash injuries of the neck: a retrospective study. Injuw 19,393. Norris S. H. and Watt I. (1983) The prognosis of neck injuries resulting from rear-end vehicle collisions. I. BoneJoint Surg. 65B, 608.
Porter K. M. (1989) Neck sprains after car accidents. Br. Med. J. 298,973.
Paper accepted 4 June 1992. Requests for reprints should be uhhssed to: Mr D. D. Robinson, IA The Old Creamery, Pipegate, Market Drayton, Shropshire TF9 4HX, UK.
Printed in Great Britain
79
Acute neck sprain after road traffic accident: a long-term clinical and radiological review D. D. Robinson and V. N. Cassar-Pullicino Robert Jones and Agnes Hunt Orthopaedic
and District Hospital, Oswestry,
A retrospective review of 2 1 patients behveen 10 ana’ 19 years after a soft tissue injury to the cervical spine was undertakn. The clinical data showed a persistence of symptoms in 18 (86 per cent) of patients wifhout any deterioration in the dinical signs. The radiological assessmenf did not show any evidence of injuy leading to, or correlating with, the development OY progression of degenerative changes in the ceroical spine.
Introduction Acute soft tissue injury in the neck after a road traffic accident is a common problem seen throughout the motorized world (Juhl and Seermp, 1981). The immediate pathology and resultant long-term effects are not known and ill-understood, hence the treatment of the condition is empirical at best. In order to assess the natural history, long-term follow-up of these patients is required. A series of 21 patients reviewed 13.5 years after injury is presented. The aim is to correlate the clinical and radiological features documented at the initial medicolegal examination (average 8.5 months after injury) with the long-term findings, and to determine whether an association between injury and later development of cervical spondylosis exists.
Method The medicolegal files of a retired consultant were inspected and all cases of acute neck injury from 10 years or more were selected. There were 121 cases identified and 46 of these could be traced within the local area. These patients were invited to attend for a clinical review and plain radiographic assessment of the cervical spine, including lateral flexion and extension views. Of the 46 patients, 21 attended for review, and no conclusions or assumptions were made on the remainder. The repeat examination was styled on the same detailed documentation of their first medicolegal examination after injury, which had been obtained about 8 months after injury. Symptoms were assessed with reference to their effect on daily life and graded into none, mild or severe using a visual analogue pain scale. A score of more than 5, associated with 2 weeks or more off work, and periodic sleep disturbance lasting more than I week were criteria defined as severe. The range of movement in the neck was assessed by measuring flexion, extension, rotation and lateral flexion. These movements were measured as a percentage of the normal range, the resulting figures were summated to give a 0 1993 Butterworth-Heinemann Ltd 0020-1383/93/020079-04
Shropshire,
UK
score out of 600 and the last two digits removed to produce a movement score out of 6. Radiological review was performed on all the patients by two independent assessors. The recently obtained radiographs were analysed first. The maximum height of each intervertebral disc was measured from CZ to C7, as was the width of the spinal canal at C5 and at its narrowest point. The number of osteophytes, anterior and posterior, were counted at each level. The shape of the cervical curve and instability was assessed on the flexion/extension radiographs (Figure I). The original radiographs were then analysed in the same way without reference to the previously recorded radiological or clinical data to minimize any bias. Radiographic review of a matched control group was not pursued as the incidence of degenerative spondylosis with age is well-established (Friedenburg and Miller, 1963; Lawrence, 1969).
Results all, 21 patients (age range 33-70 years) were reviewed at a mean time of 13.5 years after the accident. None of the patients had any previous history of neck trouble. The results of the first review done at an average of 8.4 months after injury are shown in Table I. In
Review appointment At the time of the review appointment, 18 patients still suffered a painful neck in exactly the same pattern as that Table I. Findings at first medical report Onset of symptoms
Site of pain
Time off work
Severity of symptoms
Range of neck movement
Immediate 24h 24 h to I week Neck alone Neck+shoulder(s) Neck + head None I-5 weeks 6-I 0 weeks None Mild Severe 6 (out of 6) 5 4 3 Mean=4.3
9 9 3 a II 2 I3 4 4 4 I0 7 4 7 2 a
(43%) (43%) (14%) (38%) (52%) (10%) (62%) (19%) (19%) (I 9%) (48%) (33%) (19%) (33%) (10%) (38%)
80
Injury: the British Journal of Accident Surgery (1993) Vol. 24/No.
which resulted from their accident. All of the patients with pain had sought further medical advice during the intervening period with no patient gaining any significant benefit. No patient had been offered invasive investigation or surgical intervention. Two patients had had to give up work due to persistent symptoms, one of them a policeman. Five patients had had periods off work due to neck pain, but no other patients had
had to change the nature of their work because of their symptoms. All of these patients had been graded as having severe symptoms at the time of their original assessment. The physical signs in the patients were unchanged with the average score for neck movement remaining at 4.5 (out or of 6), while none of the patients had deterioration developed objective neurological signs. The mean time to settlement of legal action was 2 years after the injury. Nine patients were not satisfied by the legal settlement and 12 were satisfied. Three patients had no symptoms after settlement but 18 had residual symptoms of intermittent pain in the same distribution, but of lesser severity than the pain following the injury to the present day. There was no correlation between patient satisfaction and persistence of symptoms. It proved impossible to assess the results of treatment for their injuries, due to the widely differing regimens of treatment that were offered. All treatment had been nonoperative and no patient had been offered surgery. At final review, no patient was still receiving treatment; this reflected the little or no effect on the long-term outcome as described by the patients, rather than any success that could be attributed to the treatment received. Radiological
Figure 1. Parameters measured on radiographs. a, Maximum
intervertebral disc height. b, Spinal canal width. c, Spinous process to lateral mass.
2
review
None of the patients had a bony injury as a result of their accident; six patients were noted to have a fixed kyphosis at one level on their original films; three at C5/6, three at C6/7. Two other patients had abnormalities of alignment; one patient had a loss of lordosis with osteophyte formation at C5K6, which became a fixed kyphus in the later radiograph, and another patient had a retrolisthesis at C4/5, which was unchanged in the later radiographs. A comparative assessment of the intervertebral disc heights, and the spinal canal dimensions from C2 to C7 are summarized in Table II. The average number of osteophytes at the original report was 1.27 and 2.3 at the time of review. The distribution and numbers of osteophytes are shown in Table III. Radiographs of 19 patients were assessed, of which 12 original films were described as normal, while seven had a significant degenerative abnormality with 11 radiographs remaining normal. Of
Table II. Radiographic measurements
(a) Measurements of maximum invertebral disc height Average height in mm Disc
Original report
C2/3 c3/4 c4/5 C5/6 C6/7
5.5(rt1.4) 5.2( f 1.4) 4.9( f 1.2) 4.5( f 1.7) 4.7( +2.6)
Review appointment 5.7( 5.4( 4.6( 4.0( 4.4(
f f f f f
1.8) 2.4) 1.8) 2.2) 3.2)
(b) Measurements of spinal canal dimensions Average height in mm Level
Original report
Review appointment
c5 Narrowest Spinous process to lateral mass
17.22( A3.7) 15.6 (+3.2) 5.11( f 2.8)
17.21 ( f 3.4) 15.1 (+3.2) 5.2 (k2.3)
None of the measurements above show a statistically significant difference using the Mann-Whitney
Utest.
Robinsonad Cassar-Pullicino: Acute neck sprain after road traffic accident
81
Table III. Osteophyte disturbance and number Number of osteophytes level
Original report
Review appointment
C2J3 c3/4 c4/5 C5/6 C6/7
0 0 1 (5%) 12 (52%) 10 (43%)
0 3 10 20 12
Total
23 (100%)
45 (100%)
(7%) (22%) (44%) (27%)
the seven patients with demonstrable degenerative changes, four showed progression of these spondylitic appearances at the same and other levels (TableII and Table III). However, the demonstrable changes were within the expected range when related to the respective age groups as defined by Lawrence (1969) and Friedenberg and Miller (1963). For examples of cases see Figures 2-4. The six patients with significant degenerative spondylosis as shown by a fixed kyphus were also those with the most persistent pain and limitation of movement at the final review. They had been awarded the most money in the way of settlement (mean f 1725 as opposed to f 1027 for the remaining patients) and were uniformly pleased with the outcome of litigation.
Figure 2. Patient 1: Radiographs 10 years apart showing minor changes in both films.
Figure 3. Patient 2: C6/7 kyphus showing no progression over
13 years.
Figure 4. Patient 3: Multiple level degenerative changes showing an increase in the number of osteophytes, but no further loss of disc height or progression of canal stenosis after 19 years.
Discussion The term ‘whiplash’ is emotive; therefore we prefer the term ‘acute neck sprain’ (Porter, 1989) to be used in the absence of demonstrable pathology. It has been suggested that the term ‘whiplash’ should be used for pure hyperflexion injuries arising from a direct rear-end impact (Hodgson and Grundy, 1989). This type of car collision is rare, represents 8 per cent of road traffic accidents (MacKay, 1970) and various authors (Maimaris et al., 1988) have found no evidence to suggest that these injuries behave differently to those which involve a rotational element. The pathology of an ‘acute neck sprain’ is not understood. Animal experiments have identified a spectrum of pathology (MacNab, 1971; La Rocca, l977), while investigations on human sufferers have not shown any consistently reproducible lesion. The vast majority of cases receive only cursory investigation and are then dismissed and discharged from further management, usually ending in litigation. The more severe cases may have either associated bony damage or signs of an acute cervical disc prolapse (La Rocca, 1977) and then receive further investigation and treatment. Treatment of the minor cases usually consists of a soft collar with or without physiotherapy. Norris and Watt (1983) defined three groups of increasing severity of injury. In group I,56 per cent of patients will be symptom-free at 18 months after injury, while group 3 patients showed recovery in only 10 per cent at 2 years. The pathology in this group may be related to a problem such as an annular tear in a disc, although other authors consider that the persistent symptoms are related to a post-traumatic necrosis, Hodge (1971); only 19 per cent of group 2 patients were entirely symptom-free at 2 years. Using the Norris and Watts (1983) criteria, all our patients were group 2 at the initial examination. Despite the significantly longer time of follow-up (13.5 years) compared with the Norris and Watts (1983) study (2 years), the incidence of persistent and disabling symptomatology in this group is essentially the same (86 per cent Robinson and Caspar-Pullicino; 8’1 per cent Norris and Watt (1983)). The long-term outcome of these injuries is at best controversial (Gotten, 1956; Hodgson and Grundy, 1989), while Norris and Watt (1983), and Hodgson and Grundy (1989) showed that litigation had little influence on out-
82
Injury: the British Journal of Accident Surgery (1993) Vol. 24/No.
come. In our series, there is no correlation between patient satisfaction in the court case and resolution of their symptoms. The patients with the worst clinical outcome in the long term were those with pre-existing degenerative changes in the cervical spine, and these were the patients awarded the highest amounts of compensation. They were uniformly happy with the outcome of litigation. Despite the relatively common occurrence of acute post-traumatic neck sprains, organized follow-up of the long-term effects is sporadic and commonly deals with small groups (Hodgson and Grundy, 1989). Our series is selected on the basis of the patients having been litigants in the past; nevertheless, an evaluation of the long-term results after settlement of compensation is an essential exercise, providing an objective and independent audit on medicolegal beliefs, statements and trends. The percentage (85 per cent) of patients suffering from persistent pain is much higher than in previously reported series (Gotten, 1956; MacNab, 1964; Norris and Watt, 1983; Deans et al., 1987; Hodgson and Grundy, 1989), which may be a reflection of the selective nature of our series. However, these patients have no radiological evidence of injury or neurological signs, yet they still have long-lived symptoms and disability without deterioration. The results of the comparative analysis of the plain radiographs are quite consistent in their findings. An acute neck sprain does not lead to cervical spondylosis, accelerated or otherwise, nor does it lead to worsening of pre-existing degenerative changes. In our group there is no evidence that injury induces further degenerative changes at any particular level nor the development of canal stenosis. This is not to deny that these patients have continuing pain, but it is not due to progressive cervical spondylosis. The relationship between radiological degenerative disc changes and symptoms has beeninvestigated in the past, but there is only an association when the radiological changes are more severe than those encountered in our series (Friedenberg and Miller, 1963; Lawrence, 1969). Hohl(1974) showed that 58 per cent of patients with radiologically evident disc degeneration were asymptomatic after injury, while 44 per cent of patients who remained symptomatic had no evidence of disc degeneration. It seems that a review at 8-12 months after injury is a useful predictor of long-term outcome. Hohl (1974) had showed that 83 per cent of patients whose claims were settled within 6 months of injury remained asymptomatic compared with those patients with longer-lasting symptoms.
2
Acknowledgement Our thanks to Mr A. K. Mitting files.
for allowing
us to use his
References Deans G. T., Magalliard J. N., Kerr M. et al. (1987) Neck sprain a major cause of disability following car accidents. Injl*y 18, 10. Friedenberg Z. B. and Miller W. T. (1963) Degenerative disc disease of the cervical spine. 1. Bone]oinf Surg. 45A, 1171. Gotten N. (1956) Survey of 100 cases of whiplash injury after settlement of litigation. JAMA 162, 865. Hodge J. R. (1971) The whiplash neurosis. Psychosomafics12,245. Hodgson S. P. and Grundy M. (1989) Whiplash injuries: their long-term prognosis and its relation to compensation. NeuroOrfkop. 2, 88. Hohl M. (1974) Soft tissue injuries of the neck in automobile accidents: factors influencing prognosis. J. BoneJoint Surg. 56A, 1675. Juhl M. and Seerrup K. K. (1981) Cervical spine injuries: epidemiology investigation. Medical and social consequences. In: Proceedingsof fke 6fk Infer&ional IRCOBI (International Road Congress on Biomechanics of Impacts), Conference on Biomechanics of Impacts. France: Bron, 49. La Rocco H. (1977) Acceleration injuries of the neck. Clin. Neuroswg. 25,209. Lawrence J. S. (1969) Disc degeneration: its frequency and relationship to symptoms. Ann. Rketrm. Dis. 28, 121. MacKay G. M. (1970) The nature of collisions. TechnicalAspectsof Road Safefy 43, 1. MacNab I. (1964) Acceleration injuries of the cervical spine.J. Bone ]oinf Surg. 46A, 1797. MacNab I. (1971) The ‘whiplash syndrome’. Orfkop. Clin. Nurfk Am. 2,389. Maimaris C., Barnes M. R. and Allen M. J. (1988) Whiplash injuries of the neck: a retrospective study. Injuw 19,393. Norris S. H. and Watt I. (1983) The prognosis of neck injuries resulting from rear-end vehicle collisions. I. BoneJoint Surg. 65B, 608.
Porter K. M. (1989) Neck sprains after car accidents. Br. Med. J. 298,973.
Paper accepted 4 June 1992. Requests for reprints should be uhhssed to: Mr D. D. Robinson, IA The Old Creamery, Pipegate, Market Drayton, Shropshire TF9 4HX, UK.