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Prognostic factors in soft tissue injuries of the cervical spine
Letters to the Editor
71
Prognostic factors in soft tissue injuries of the cervical spine Dear Sir If my reading of the paper by Watkinson et al. (Injury 1991: 22: 307-309) is correct then although 35 patients agreed to radiographic examination only 33 were included in the analysis. This means that only a little over half of the original patients (54%) were available for study. The loss of almost half of the original group must have had some effect on the results and it would be interesting to know how well the remaining patients matched the group that were missing. When the incidence of degenerative change is discussed we are not given the numbers of patients in each age group. Given that the total group studied is only 33 then the numbers in each group will be quite small. I would also appreciate more information about the control group and how they were matched to the group being studied. The reference to Friezenburg and Miller 1963 presumably refers to another study which had a controlled group, the complete reference is not given. Neck pain following road traffic accidents is an extremely common complaint and the subject of much litigation. Assessing the severity of symptoms and their relationship to the accident can be extremely difficult for the doctor as there is no truly objective test for this condition. The fact that the patient continues to complain of symptoms many years after an injury is not proof in itself that the condition is organic. This does not, of course, mean that the patient is not genuine. Psychological factors will play a part in some patients, but clearly not all. Medico-legal opinion often falls into opposing camps of ‘hawks and doves’. The more research that is done on the subject will increase the objectivity of medico-legal reporting in this difficult condition and more studies of this kind are to be welcomed and encouraged. A. D. Redmond Consultant in Accident
and Emergency
Medicine
chosen to represent the natural incidence of degenerative cervical spine disease in a similar cohort to the Study Group. The full reference of the American Study quoted is: Friedenberg 2. B., Miller W. T. Degenerative disease of the cervical spine (1963) A comparative study of Asymptomatic and Symptomatic patients. 1. Bone ]oinf Surg. (1963) 45A, 7171-1178. We agree that this is a difficult area but the study indicates that our Group of Patients had organic symptoms. We hope we have contributed to a rather limited data base with respect to long term follow up of whiplash injuries. A. Watkinson Senior Registrar X-Ray Department
Exposed war wounds Dear Sir, We read with interest Robin M. Coupland’s ‘A management algorithm for chronically exposed war wounds of bone’ (Injury 1990; 21, 101-103). We have considerable experience of this kind of neglected war wound and would like to comment as follows: Question I of the algorithm should be modified to read ‘is the limb threatening life after radical wound excision and/or attempted haemostasis?’ We have found that even in the presence of life-threatening gas gangrene or catastrophic secondary haemorrhage, aggressive excision surgery or effective vessel ligation can bring about a dramatic immediate improvement and limb salvage. Hence, in this situation, amputation is required either because excision is impossible because of the extent of the damage or the infection, or because arterial ligation must be such as to produce a non-viable limb. We feel that the way in which question I is presented will tend to advise the inexperienced surgeon to amputate even for life-threatening situations which can be dealt with satisfactorily by excisional and haemostatic surgery. Professor N. D. Reis, FRCS, Chairman, Department Orthopaedics B, Rambam Medical Centre, Haifa, Israel.
Author’s reply Dear Sir In reply to Mr Redmonds letter. The distribution of mild, moderate and severe injuries in the Study Group was almost the same as in the Patient Group lost at follow up. The anticipated attendance of those ‘with persisting symptoms’ and non attendance of those who were ‘symptom free’ was not evident. The control group consisted of 100 patients who were matched for age and sex who had attended the Casualty Department complaining of the sensation of a foreign body (most commonly a fish bone) in the hypo-pharynx or upper oesophagus. These patients had lateral cervical spine radiographs in the neutral position. This group of patients was
of
Author’s reply Dear Sir, I thank Professor Reis for his comments on ‘A management algorithm for chronically exposed war wounds of bone’. (Injury 1990; 21, 101-103). I agree that question 1 should only apply after wound excision and thank him for clarifying this. The importance of wound excision was stressed ho paragraphs before. However, it must be pointed out that those of us who appreciate the absolute necessity of excision of dead tissue from large wounds are criticized when such words as ‘radical’ or ‘aggressive’ are used to describe the operation. The term ‘careful and complete’ is more appropriate, clinical and instructive. Robin M. Coupland, The British Red Cross Society
71
Prognostic factors in soft tissue injuries of the cervical spine Dear Sir If my reading of the paper by Watkinson et al. (Injury 1991: 22: 307-309) is correct then although 35 patients agreed to radiographic examination only 33 were included in the analysis. This means that only a little over half of the original patients (54%) were available for study. The loss of almost half of the original group must have had some effect on the results and it would be interesting to know how well the remaining patients matched the group that were missing. When the incidence of degenerative change is discussed we are not given the numbers of patients in each age group. Given that the total group studied is only 33 then the numbers in each group will be quite small. I would also appreciate more information about the control group and how they were matched to the group being studied. The reference to Friezenburg and Miller 1963 presumably refers to another study which had a controlled group, the complete reference is not given. Neck pain following road traffic accidents is an extremely common complaint and the subject of much litigation. Assessing the severity of symptoms and their relationship to the accident can be extremely difficult for the doctor as there is no truly objective test for this condition. The fact that the patient continues to complain of symptoms many years after an injury is not proof in itself that the condition is organic. This does not, of course, mean that the patient is not genuine. Psychological factors will play a part in some patients, but clearly not all. Medico-legal opinion often falls into opposing camps of ‘hawks and doves’. The more research that is done on the subject will increase the objectivity of medico-legal reporting in this difficult condition and more studies of this kind are to be welcomed and encouraged. A. D. Redmond Consultant in Accident
and Emergency
Medicine
chosen to represent the natural incidence of degenerative cervical spine disease in a similar cohort to the Study Group. The full reference of the American Study quoted is: Friedenberg 2. B., Miller W. T. Degenerative disease of the cervical spine (1963) A comparative study of Asymptomatic and Symptomatic patients. 1. Bone ]oinf Surg. (1963) 45A, 7171-1178. We agree that this is a difficult area but the study indicates that our Group of Patients had organic symptoms. We hope we have contributed to a rather limited data base with respect to long term follow up of whiplash injuries. A. Watkinson Senior Registrar X-Ray Department
Exposed war wounds Dear Sir, We read with interest Robin M. Coupland’s ‘A management algorithm for chronically exposed war wounds of bone’ (Injury 1990; 21, 101-103). We have considerable experience of this kind of neglected war wound and would like to comment as follows: Question I of the algorithm should be modified to read ‘is the limb threatening life after radical wound excision and/or attempted haemostasis?’ We have found that even in the presence of life-threatening gas gangrene or catastrophic secondary haemorrhage, aggressive excision surgery or effective vessel ligation can bring about a dramatic immediate improvement and limb salvage. Hence, in this situation, amputation is required either because excision is impossible because of the extent of the damage or the infection, or because arterial ligation must be such as to produce a non-viable limb. We feel that the way in which question I is presented will tend to advise the inexperienced surgeon to amputate even for life-threatening situations which can be dealt with satisfactorily by excisional and haemostatic surgery. Professor N. D. Reis, FRCS, Chairman, Department Orthopaedics B, Rambam Medical Centre, Haifa, Israel.
Author’s reply Dear Sir In reply to Mr Redmonds letter. The distribution of mild, moderate and severe injuries in the Study Group was almost the same as in the Patient Group lost at follow up. The anticipated attendance of those ‘with persisting symptoms’ and non attendance of those who were ‘symptom free’ was not evident. The control group consisted of 100 patients who were matched for age and sex who had attended the Casualty Department complaining of the sensation of a foreign body (most commonly a fish bone) in the hypo-pharynx or upper oesophagus. These patients had lateral cervical spine radiographs in the neutral position. This group of patients was
of
Author’s reply Dear Sir, I thank Professor Reis for his comments on ‘A management algorithm for chronically exposed war wounds of bone’. (Injury 1990; 21, 101-103). I agree that question 1 should only apply after wound excision and thank him for clarifying this. The importance of wound excision was stressed ho paragraphs before. However, it must be pointed out that those of us who appreciate the absolute necessity of excision of dead tissue from large wounds are criticized when such words as ‘radical’ or ‘aggressive’ are used to describe the operation. The term ‘careful and complete’ is more appropriate, clinical and instructive. Robin M. Coupland, The British Red Cross Society