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The post-traumatic painful neck
FoTensic Science,
3 (1974) 1-18 0 Elsevier Sequoia S.A., Lausanne - Printed in The Netherlands
THEPOST-TRAUMATICPAINFULNECK G.T. du TOIT Department of Orthopaedics, Medical School, University of Witwatersrand, Johannesburg
(South Africa)
SUMMARY The problem of post-traumatic
neck pain in the absence of obvious skeletal or neurolo-
gical damage is discussed. Conservative gesics) plus adequate operation
rehabilitation
is not clearly indicated.
treatment
(bed-rest,
traction,
results in marked improvement Operative treatment
sedatives and analin most cases where
is reserved for a small minority
of
cases, and it is stressed that, although fusion may in some cases produce dramatic relief, it should be limited
to those cases where the precise location
lished. The value of discography as a diagnostic technique
Those responsible confronted
for assessing the end results of neck injuries
by patients who continue
to complain
they run the risk of losing their objectivity. previous
therapy
of the injury can be estab-
in such cases is still in question.
There is a subconscious
and to assume that better
are every so often
despite much and varied therapy that tendency
to decry the
results could have been achieved with dif-
ferent methods. It is essential to disabuse oneself of this prejudice problem which has many obscure aspects.
in dealing with a
VULNERABILITY OF THE CERVICAL SPINE The wide range of motion of the upper cervical spine allows considerable stresses to be absorbed without neurological or soft-tissue damage. The atlanto-occipital joint permits only flexion and extension but the more complex atlanto-axial joint allows flexion, extension, rotation, vertical up and down approximation and lateral gliding. Flexion and extension occur at both the atlanto-occipital and the atlanto-axial joints, as much as 15s at each level. The anterior arch of the atlas retains a close relationship with the odontoid as it glides vertically up and down. Widening of more than 2 or 3 mm of space between the odontoid and the anterior arch of the atlas suggests damage to the transverse ligament (Fig. 1). Rotation about the odontoid process is as much as 45” to each side. During rotation considerable offset develops between the inferior articular surface of the axis and the
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Fig. 1. Forward
subluxation
of the atlas on the axis.
atlas. Cineradiography demonstrates that there is a decrease in the vertical height in the neutral position, Le. with rotation there is a screwing down and in the neutral position there is a lengthening. With lateral gliding, the odontoid process appears to be asymmetrically placed between the 2 lateral masses of the atlas; a mistaken diagnosis could thus be easily made (Fig. 2). An asymmetrical facet of the articular (Hohl’). Between
position
of the odontoid
process and the lateral
surfaces in the absence of a fracture does not indicate a subluxation
the second and the seventh
cervical vertebrae
there are flexion,
extension,
rotation and lateral flexion movements, which are greater in the upper part of the cervical spine and greater in children than in adults. In flexion and extension the superior surfaces of these vertebrae
(which face backwards
and upwards) articulate
with the inferior pro-
cesses of the next vertebrae facing downward and forward. This arrangement produces a normal anterior vertebral shift in flexion and a posterior shift in extension. This means that the disc space widens posteriorly in flexion and narrows anteriorly as the vertebra slides forward, provided the discs are normal. According to Fielding’ about 50% of rotation takes place at the atlanto-occipital joint and the remaining 50% is shared by the lower 5 interspaces. With these lateral motions the disc structures narrow on the concave side and widen on the convex side as they undergo torsional
stress, provided
again that
the discs are normal. The human head, weighing about 10 lb, is held upon a column of small, articulating vertebrae held. together with ligaments, joint capsules and muscles, balanced with adjustable standing rigging of symmetrically arranged structures, and protecting the spinal cord by suspending it in a column of fluid without touching the sides and yet allowing considerable range of mobility. The central supporting column carries the lines of communication and the self-compensating vascular systems. This complicated structure continues to function for a lifetime with few outward evidences of mechanical failure. The grouping together of so many structures regulating vital functions connected with survival, probably explains the historical interest in neck problems.
POST-TRAUMATIC PAINFUL NECK
3
Fig. 2. A (top). Asymmetry of the atlas in relatic )n tc) the odontoid. This is a kormal phenomenon in rotation. B (bottom left). Congenital fusion of C 2-3 and C5-7. C (bottom right). Localized stress at C4-5 (arrow).
PREDISPOSING CAUSES
A vertebral
column with segmental fusion or arthrodesis shows an exaggeration
of the
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Fig. 3. Kinking of the cord. Complete reduction will be deceptive on X-ray.
normal expected movement vertebral
above and below the fused segments. In osteoarthritis,
segments are less mobile than normal.
In proportion
some
to the extent of mobility,
compensatory motion occurs above and below the stiff segments. When traction is made on such a diseased cervical spine, the arthritic vertebrae do not separate to any percep tible degree, but the uninvolved normal interspaces above and below open up much more significantly (Fig. 2B). In sporting injuries it is not uncommon for congenital anomalies and fusions of the cervical spine to be discovered when cases of neck injury are X-rayed for the first time. These neck injuries tend to occur adjacent to the fused areas.
COMMON MECHANISMS OF INJURY
Similar injuries backward
occur in rear-end vehicle collisions and after blows on the head with
and upward force3. The head and neck go into hyperextension
and the spinal
and articular processes are forced together and act as a fulcrum causing the anterior longitudinal ligament to rupture. Separation then occurs between the cancellous bone of the vertebral body and the adjacent cartilaginous endplate or between the endplate and the disc proper. The intact posterior longitudinal ligament may strip away from the vertebral body, thus carrying the spinal cord backward against the sharp edge of the lamina of the lower vertebrae, and causing a contusion or transection of the cord at this level (Fig. 3). Spontaneous reduction occurs easily in this type of case, with subsequent deceptively normal radiography. Quite often a small chip of bone may be pulled off the anterior inferior edge of the vertebral body at the point of rupture of the anterior longitudinal ligament. This may be the only tell-tale evidence of the previous gross displacement. Other types of neck injuries occur when the head accelerates in relation to the trunk
POST-TRAUMATIC PAINFUL NECK
5
backwards, forwards and sideways. Even when the head is thrown forward, this range of motion is so well within physiological limits that serious injury is usually avoided. When the head is thrown laterally, the lateral flexion movements stop when it hits the shoulder and it need not produce significant damage to the neck, but lateral structures may give way. In extension-acceleration, however, there is nothing to stop the backward movement until the occipit hits the posterior chest wall. This is far beyond the normally permitted range of motion and damage may be serious. This is the type of injury which may be minimized in a car by a head-rest or a backward tilting of the back of the seat. Gross injuries of the cervical spine are very adequately dealt with in the orthopaedic literature and fall outside the scope of this paper. These major injuries have classical clinical and radiological features which determine treatment and most survivors make an adequate adaptation to their residual disabilities. The varieties of bulging and prolapsed discs commonly dealt with by the neurosurgeon are not under discussion here. A small percentage have persistent painful necks because of damage to joints, malalignment or instability, and can be dealt with effectively. Most of these cases reach a plateau of recovery in 2 years or so, as do most severe fractures and joint injuries in the body. Our main concern is with the group of neck injury cases in which no obvious skeletal or neurological damage is discovered in the early days after traurna. Usually the patient and his doctor underestimate the severity of the injury. The patient tries to resume his
Fig. 4. Left: Lateral view: normal appearances. Centre: Subluxation of C4 on C.5 on tlexion. Right. Appearance after interbody fusion of C4-5, showing good alignment.
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activities but, disappointingly, tragically
if not submitted
subluxations
or dislocations
fails in his efforts and may even deteriorate to a well-planned which undergo
hopelessly and
regime. Some really serious momentary
spontaneous
reduction
are missed because of
failure to look for evidence in forward tilting films (Fig. 4). In rear-end unawares
collisions,
the driver and passengers
and cannot brace themselves
not in common the extended
in the front
cars are often
for the impact. Furthermore,
caught
fitted head-rests are
use. The body moves forward and the head becomes hyperextended
on
neck. Lateral collisions may cause neck injuries, but quite often also skull
and brain injuries.
Roll-over accidents
commonly
result in skeletal and soft tissue injuries
of the neck, The victim may delight in explaining his lucky escape, unaware that the X-rays will reveal a bony injury the next day. The disrupting force is maximal at the moment of impact. All structures are stretched, some grossly ruptured, others only to the extent of a steppage lesion. There may be minor pinprick haemorrhages and massive haematomas. Even the neck-injury
victim with the most minor complaint
one day will wake up with
a stiff neck the next day. Pain and stiffness often become progressively worse for a week. The minor cases clear up quickly in a matter of weeks, but a substantial
number have pain
for 2-3 weeks and only improve slowly over 3 months
or so. In many cases no definite
regime of therapy
stiffness
is followed
and painful
symptoms,
and increasing
anxiety
persist for many months. With adequate conservative care, most cases return to normal in 12-24 months. In a few, severe and disabling symptoms persist. It would be incorrect to classify these soft-tissue neck injuries into hyperflexion injuries are asymmetrical
and too complicated
and hyperextension
in a mechanical
injuries. Most
sense.
DIAGNOSIS
The degree of force in the accident as determined by the history is significant, but it is surprising how severe a neck injury can be caused in a low-speed accident. The demonstrable severity of injuries basis of the history.
in fatal cases usually greatly exceeds that anticipated
on the
Even in moderate injuries to soft tissues, much haemorrhage may occur. Muscles may be torn at the occipital insertions, or other bony attachments. A prevertebral haematoma sometimes displaces the oesophagus and trachea forward and may cause dysphagia. Demonstration by radiography or thermography is evidence of severity of damage which may not be suspected. Injuries in the sagittal plane may narrow intervertebral foramina. Compression of intervertebral foramina may cause major or minor disruption, especially if there is pre-existing pathology. Partial, barely detectable cord injury may occur with damage to the posterior columns of Go11 and Burdach and, if found, is proof of the genuineness and severity of the injury. Hyperextension may cause the buckled ligamentum flavum to press on the posterior columns of the cord. Irritation to the sympathetic plexus around the vertebral artery or
POST-TRAUMATIC PAINFUL NECK
Fig. 5. Asymptomatic congenital fusion of C2-4 and rheumatoid C5-7. Minor surgery could produce serious consequences.
kinking
of the artery may occur. The great mobility
dorsal spine tends to concentrate The G-7 quently
injury
is superimposed however,
of the neck on the relatively
fixed
stress at the levels of great mobility.
levels show the earliest development
(Fig. 5). Discograms,
arthritis with fibrous ankylosis of
on pre-existing
of degenerative
but sometimes
so often demonstrate
disrupted
not been involved in acute trauma that a pathological
changes and not infre-
asymptomatic
pathology
discs in necks that have
cervical discogram as an isolated
item in diagnosis cannot be accepted as proof of fresh disc injury. Combined with localized pressure pain and stiffness
and, perhaps, accurate
reproduction
of the pain com-
plained of, it may be taken as justifying a diagnosis at least of aggravation of the preexisting disc pathology. Previous discogenic neck pathology may predispose to the localization of injury at that site. A proportion of cases qualify for anterior fusion to combat disc pathology aggravated or accelerated by a single traumatic episode. In practice these cases are rare. Injury to the vertebral artery, the brain stem or the brain itself may, of course, occur in survivors. The assumption that headache is often the consequence of neck injury may, however, have other explanations. Pain behind the eyes, associated with a neck injury, has been explained on the basis of a hypothetical nervous connection between the occipital nerves, their cord origins and the trigeminal spinal tract (Fig. 6)4. Headache in the occipital region, the vertex and the forehead is often explained on the basis of tension, anxiety, fatigue and the vicious circle of muscle spasm. The greater and lesser occipital nerves are,
8
G.T. du TOIT
r
L. Fig. 6. Hypothetical ganglionic synapses.
I
-. connexion
between the origin of the occipital nerve roots and the trigeminal
Preg
Fig. 7. Greater and lesser occipital nerves and pain reference. The level of preganglionic section of the posterior nerve roots is indicated by the solid vertical lines.
9
POST-TRAUMATICPAINFULNECK allegedly, implicated
(Fig. 7) and some surgeons perform preganglionic
this reason, although
no pathology
the mechanism
section of C2 for
in the nerve has ever been reported in such a case and
of injury has not been elucidated.
This operation
has not found approval
and acceptance by neurosurgeons. One cannot
dismiss the majority
exaggerated by litigation
of soft-tissue
injuries
of the neck as minor and as
neurosis or anxiety. In many cases of multiple injury the patient
has borne the discomforts
and agonies of limb injuries with equanimity,
admit that the neck is any better. Humbugs intent on magnifying
but refuses to
their claims for damages
would probably not readily admit regression of pain in some parts and not in others. The occasional brilliant cure of a neck-ache by a single manipulation, a solitary injection or a simple one-level
fusion
must surely prove that the cause may be organic if it can be
localized with precision.
A. Discography Reputable
observers such as Simmons’
pain in a particular anaesthesia
of Toronto
find that precise reproduction
of
disc level coupled with precise referred pain and relieved by local
in the same disc will localize the lesion satisfactorily.
The need for precise
technique is stressed. On the other hand, Klafter and Colli@ report that the diagnostic localizing accuracy of the cervical discogram is controversial and the significance of the pain response is particularly indeterminate. This point of view is also supported by Holt7, who states that
there are errors of technique
apparent situation is that techniques described.
as well as errors in interpretation.
cervical discs do not lend themselves
to evaluation
The by the
B. Fusion Fusion
of narrow
cogenic degenerations
disc spaces with osteophytes are asymptomatic.
may also be unreliable.
There is a tremendous
difficulty
Many dis-
in choosing the
spaces to be bridged by bone graft and, not infrequently, the wrong levels are fused. In a personal case, a relatively normal level was fused and a grossly pathological disc with narrowing and gross osteophytes left untreated; yet the patient alleged that the operation had cured his post-traumatic painful neck. Careful immobilization, analgesic therapy, complete rest, sympathetic nursing and a happy tempo of rehabilitation may have played a part. In some cases, disc spaces to be bridged may be determined more readily. C Arteriography Despite quite severe bony damage the vertebral artery may escape injury. Where rotation or flexion of the neck has caused headache, giddiness and faintness, a vertebral arteriogram may show a kinking of the artery correlated with particular positions. Symp
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Fig. 8. Excision of Luschka (unto-vertebral)
facet and anterior decompression
of the vertebral vessels.
toms in such cases may be alleviated by external bracing, by fusion, or by decompression of the vessel (Fig. 8) as described by Jung’. D. Neurological signs
In an occasional case in which the positional sense of the patient has been lost and where the patient’s balance has been disturbed after trauma to the neck, it does happen that fusion of that level of the cervical spine has resulted in marked alleviation of symptoms. The whole syndrome of cervical discogenic myelopathy (Fig. 9) so ably analysed by Lord Brain7 can, of course, be aggravated by even mild injury. This is especially likely when old people fall down stairs. Not infrequently, progressive deterioration with widespread spinal cord involvement becomes inevitable. These are then desperate problems for the neurosurgeons and need hardly be included in a discussion of the post-traumatic painful neck.
THERAPY
The ultimate prognosis in neck injuries of the type being discussed is good, provided uninterrupted rest in bed is given until acute symptoms have subsided and provided adequate tranquillizers are given to keep the patient lying flat on his back with only one pillow most of the time. In some cases with severe, persistent physical discomfort, more localized therapy may be indicated, such as local anaesthetic blocking and treatment with ice packs. Scar tissue formation in the neck will probably not lead to prolonged or any serious degree of disability. Interspinous ligament injury and disc injury are probably part of an injury to the intervertebral complex. The main portion of this joint is the disc itself and, since it carries such important stresses in the neck, it is conceivable that it will
11
POST-TRAUMATIC PAINFUL NECK
Fig. 9. Cervical myelopathy verse osteophytes. occasionally
reasonable produce
be injured.
due to indentation
of the cord anteriorly by ridging produced by trans-
In cases where joint capsules are damaged and ligaments torn, it is
to believe that the disc has, at least, been subjected some damage, be it cracks in the endplates
discoverable
pathology
years later.
In a carefully
to enough trauma
to
or tears which may only produce
observed case the osteophytes
took
3 years to develop. When the patient first gets out of bed and lacks confidence is concerned, Commerell
an adequate
as far as posturing
the neck
cervical brace may well be used for a time. In South Africa the
brace is in common
use; it is a satisfactory,
adjustable
brace. Many of the
other supports on the market do not prevent flexion. Some cases of persistent pain in the neck with local tenderness may respond to local anaesthetics such as cortisone. If, after 3 or 4 injections, the response is not that of total relief, more drastic measures may be needed. It is recognized that certain traumatic neck-aches will respond to excision of the disc and fusion” ,il. The great difficulty is to choose the cases which are likely to benefit from such treatment, and some unnecessary fusions are possibly done. The essentials in successful operative surgery are, presumably, that the patient should be prepared to accept the operation as a cure, that the correct level should be fused, and that the operation be technically sound. In other words, there are many pitfalls even in this approach. It should be recognized that conservative therapy and adequate rehabilitation with isometric contractions of the neck muscles over a long period will result in
12
G.T. du TOIT
marked
improvement
treatment
in most cases where operation
is reserved for a small minority,
is not clearly indicated.
Operative
possibly 5%, of injured necks.
FUSION
If the symptoms brought
and physical findings and local tenderness
are precise, and if the pain is
on by activity and by sudden jerks such as in coughing and sneezing, and if there
is improvement
after splintage,
traction
therapy
pain is likely and fusion will probably succeed. Definite localized tenderness in the midline
and rest, then a mechanical anteriorly
and posteriorly
basis for the is common
cases suitable for fusion. This is also usually the area in which X-rays show narrowing disc. Percussion
on the vertex of the head, reproducing
neck, must be regarded as confirmatory Occasionally
cases for operation.
Discography,
the pain in the exact spot in the
information.
there may be evidence
root at the same level. Myelography
in of a
of nerve root irritation
has not been particularly
an important
technique,
of one particular
nerve
helpful in deciding on the
is a very disputed
method
of
investigation. There are dogmatic and experienced opinions which condemn discography for determining the level of the patient’s complaints. On the other hand Simmons3 has found that if cervical discography
is precisely performed
so that the needle is accurately
placed in the nucleus and not in the annulus, then the injection of saline which raises the pressure in the disc will produce the constant pain pattern which the patient has complained
of, and this would be regarded as of diagnostic
significance.
If the injection
disappears into the soft tissues or spreads up and down in front of the posterior common ligament, then the localizing value of the discographic examination has been nullified. In Macnab’s analysis of 57.5 cases of extension-flexion injuries of the neck 2 years or more after settlement of all litigation, 45% still presented symptoms12. This indicates that one is indeed probably dealing with a condition which, although organic, is extremely difficult to pinpoint. There are cases of vascular complications
in neck injuries which can only be demon-
strated by arteriography. In one year we found 3 cases of obliteration of the vertebral artery and in one the obliteration was intermittent. In each case the block was at the level where there was demonstrable bony pathology. These cases had persistent headache and giddiness and, in the intermittent case, flexion produced fainting attacks which disappeared when a brace was worn habitually. Vascular damage has to be suspected before it can be diagnosed by arteriography. Some cases are missed as the investigation is avoided because of fear of discomfort or complications. Recently we have seen occasional cases of elderly patients (without radiological evidence of injury after falls) who developed severe neurological involvement of upper and lower motor power of arms and hands with escape of the lower extremities. There may be a central cord lesion with extensive damage arising from vascular pathology precipitated
by neck injury13.
POST-TRAUMATIC PAINFUL NECK
= Cervical T = Thoracic L = Lumbar S = Sacral
Gracilis Cuneatus /
Fig. 10. A cross-section of the cord to illustrate the various tracts.
Fig. 11. Central necrosis of the (After Hardy, ref. 13.)
cervical
cord affecting the upper limb with escape of the lower limbs.
14
G.T. du TOIT
Fig. 12. Section of the cervical cord showing central necrosis. (After Hardy, ref. 13.)
Fig. 10 illustrates
a cross-section
cord affects the upper extremities,
of the spinal cord. Central necrosis of the cervical while the lower escape (Fig. 11). Fig. 12 shows less
damage at a lower levelr3.
VENOUS PLEXUSES
In 1964 Trevor-Jones’4
described
neck. I have had two patients
the remarkably
who complained
extensive
venous plexuses
in the
of headache relieved by pressure on the
back of the neck. This is admittedly a very obscure and difficult problem. In each case an exploration of the neck with partial stripping of the paravertebral muscles, diathermy coagulation of numerous vessels in the area and closure of the wound resulted in complete cure of the neckache and the headache. This is an aspect of the functional anatomy of the neck requiring further investigation. Hirsch” has found cervical discography unreliable, but myelography of greater value as a diagnostic technique before cervical disc resection.
RADIOLOGICAL INVESTIGATION
The patient who walks into hospital with pain in the neck after a road accident should be X-rayed routinely and mobility tests should also be carried out.
POST-TRAUMATIC
15
PAINFUL NECK
Loss of the normal cervical lordosis should be regarded as due to an organic lesion and is often the consequence
of muscle spasm arising from nerve root irritation.
flexion lateral films may show undue
vertebra. This can only occur if the ligaments tially or totally. In a standard
case, the lipping
stabilizing
that joint have given way par-
and sclerosis developed
3 years after the only sign
following trauma was narrowing without reactive changes. Backward displacement of a vertebra with hyperextension to the anterior Abnormally
longitudinal
narrowed
ligament
intervertebral
years to develop in the ordinary
Forward-
forward shift of one vertebra on the next lower
which cannot
stretch
necessarily implies damage at all. It can only rupture.
disc spaces with marginal lipping and sclerosis take
course of life, and only after repeated trauma over long
periods. Such changes cannot be caused by a single, recent trauma. But with loss of disc substance, increased mobility allows localization of stress which may superimpose new pathology
on the old. A narrowed
sclerosis increases the likelihood
disc or a widened disc without
evidence of lipping or
that the lesion is recent.
Narrowed intervertebral foramina due to osteophytic encroachment may pinch nerve roots or embarrass their segmental blood supply, especially in lateral bending strains of the neck. There are many neck lesions in which no evidence of new pathology
may be
reported. Too much value should not be attached to so-called negative X-rays. Mobility studies of the cervical spine are valuable both on still pictures and on cineradiographic study. In the latter, much is gained by being able to visualize the smooth rhythmic motion of the vertebra or the cog-wheel action of a deranged joint. However, much radiographic detail is necessarily lost in the smaller film.
CONCLUSIONS
It is apparent
that the available knowledge
on this difficult
subject has not yet been
crystallized completely. The manner in which the patient is handled makes a substantial difference to the end result. The psychological approach to the patient is important. The general run of post-traumatic neck pain cases may be classified thus: (a) A substantial number have minor injuries which get better in weeks or months; (b) Those with rather more soft-tissue injury require a few weeks of strict hospital bed-rest, some degree of splintage by positioning or light traction, together with analgesics and sedatives; (c) The third group includes those with more complicated pathology such as nerve root injuries, vertebral artery damage, spasm, sympathetic nervous system irritation or disc damage; and there may be headache, giddiness, noises in the ears, flushing of one side of the face, fainting and disturbances of vision. These cases are subjected to specific investigation by the ear, nose and throat, and eye specialists or neurosurgeons, and usually an organic basis for the main symptoms is discovered. In a few cases localized pressure pain anteriorly, discomfort on compression of the
16
@.T. du TOIT
cervical spine vertically, tenderness of a particular interspinous ligament and sometimes the exactly corresponding location of a radiologically abnormal disc space may indicate the need for a stabilization procedure. Anterior fusion over one or more intervertebral levels may bring about dramatic relief. Occasionally, the repeated kinking of a vertebral artery may be prevented by a permanent cervical brace if an elderly patient is unfit for surgery, or by decompression or fusion of the affected disc. Decompression of the vertebral artery with its venae comitantes has been much advocated by Jung’. The fact that cervical fusion has produced relief of pain in the traumatized neck has led to a rather indiscriminate fusion in cases of painful neck. Fusion may succeed with a variety of pathological entities; for example: 1. A simple recurrent subluxation of the neck sometimes results from inadequate primary post-accident immobilization. The patient persuades the medical practitioner against his better judgement to be allowed out of bed. The subluxation recurs and then becomes a recurrent subluxation, easily demonstrable with mobility studies. 2. The patient with some genuine cord injury, such as damage to the columns of Go11 and Burdach, will often admit improvement after fusion of that level. 3. The patient with a genuine disruption of the annulus or the posterior ligament with nerve root pressure, will admit relief from anterior removal of the whole disc and fusion by an anterior graft. Removal of an osteophyte arising from Luschka’s joint and irritating a nerve root may produce dramatic relief. 4. The patient with previously asymptomatic neck pathology precipitated into a crippled state by aggravation of the pre-existing pathology at one or several levels may feel even better after fusion than before the accident. This has led to an excess of enthusiasm for neck fusion in recent years. Surgeons are notoriously creatures of fashion. Few surgeons can continue to resist a mechanically ingenious operation - be it thoracic sympathectomy, vagotomy or acupuncture. We live in an age of substitution, with ersatz teeth, ersatz knee and hip joints, and even ersatz urinary bladders. Not surprisingly, patients may be fitted with metal ball-bearings, or silastic rubber intervertebral discs in attempts to relieve pain and yet retain some motion (Fig. 13). Out of experimental surgery, much surgical progress has been born. It behoves us to apply scientific criteria, to keep accurate records and to retain our objectivity in such work. The enthusiastic innovator readily plunges into a new field without enough forethought for the consequences. Thus new iatrogenic diseases have developed out of the pain in the neck. The following have been recorded: Ball-bearings escaped from disc spaces and migrating down into the mediastinum; ball-bearings countersunk into vertebral bodies and surrounded with solid bony fusion; dislocated silastic rubber bands woven round spinous processes in the neck, and bathed in secondary infection. There are indeed, some conditions appreciably less tolerable than the original pain in the neck. Such may be the consequences of misguided or unfortunate instrumentation. The value of discography is still controversial. Discography has been widely used and
POST-TRAUMATIC PAINFUL NECK
Fig. 13. Metallic intervertebral discs.
bearings; a failed attempt at mechanical substitution
17
of intervertebral
often misinterpreted. So much is this the case that it has been proposed by Simmons3 that an independent radiologist be trained to carry out discography to avoid errors that may derive from the enthusiasm of the surgeon to find confirmation of the patient’s symptoms. This would avoid misinterpretations of the effects of extravasation in the soft tissues, and spread up and down under the common ligament. Meanwhile, it has not yet been determined whether the technique should be discarded. Perhaps, with greater precision, we are going to be able to sort out this rather difficult traumatic scrapheap of humanity suffering from soft-tissue injuries of the neck.
REFERENCES 1 M. Hohl, Normal motions in the upper portion of the cervical spine, J. Bone Joint Surg., 46A (1964) 1777-1779. 2 J.W. Fielding, Normal and skeletal abnormal motion of the cervical spine from the second cervical: to the seventh vertebra (cineradiography),J. Bone Joint Surg., 46A (1964) 1779 - 1781. 3 A.W.A. Goff and J.H. Aldes, Traumatic Cervical Syndrome and Whiplash, Lippincott, Philadelphia, 1967. 4 J.G. Love, The occipital nerves: A teaching drawing, Staff meetings of the Mayo Clinic, January 2nd, 1963, pp. 18-19. 5 E. Simmons, Localizing value of cervical discography, International Trauma Conference, Johannesburg, June, 1971. 6 L. Klafta and J.S. Collis, The diagnostic inaccuracy of the pain response in cervical discography, Clove. Clin. Q., 36 (1969) 35-39.
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G.T. du T&T
7 E.P. Holt, Jr, Following of cervical discography - report of 50 cases in normal subjects, J Am. Med. Assoc., 188 (1964) 799-801. 8 M.A. Jung, Resection de I’articulation unto-vertebrale et ouverture du trou de conjugaison par voie anterieure dans le traitement de la nevralgie cervico-brachiale, Mem. Acad. Chir., 88 (1963) 361-367. 9 R. Brain, Some unsolved prbblems of cervical spondylosis, Br. Med. J., (1963) 771-777.
10 R.B. Cloward, Cervical discography, technique, indications and use in diagnosis of ruptured cervical discs, Am. J. Roentgenol., 79 (1958) 563-574. 11 R.A. Robinson, and W.O. Southwick, Surgical approach to the cervical spine, Instructional Course Lectures, Vol. 17, American Academy of Orthopaedic Surgeons, St. Louis, 1960, pp. 299-330. 12 I. Macnab, Acceleration injuries of the cervical spine, J. Bone Joint Surg., 46A (1964) 1797-1799. 13 A.G. Hardy, Central cord lesions, International Trauma Conference, Johannesburg, 1971. 14 R. Trevor-Jones, Osteo-arthritis of the paravertebral joints of the second and third cervical vertebrae as a cause of occipital headaches, S. Afr. Med. J., 38 (1964) 392-394. IS C. Hirsch, Cervical disc resection, J. Bone Joint Surg., 46A (1964) 181 l-1 821.
3 (1974) 1-18 0 Elsevier Sequoia S.A., Lausanne - Printed in The Netherlands
THEPOST-TRAUMATICPAINFULNECK G.T. du TOIT Department of Orthopaedics, Medical School, University of Witwatersrand, Johannesburg
(South Africa)
SUMMARY The problem of post-traumatic
neck pain in the absence of obvious skeletal or neurolo-
gical damage is discussed. Conservative gesics) plus adequate operation
rehabilitation
is not clearly indicated.
treatment
(bed-rest,
traction,
results in marked improvement Operative treatment
sedatives and analin most cases where
is reserved for a small minority
of
cases, and it is stressed that, although fusion may in some cases produce dramatic relief, it should be limited
to those cases where the precise location
lished. The value of discography as a diagnostic technique
Those responsible confronted
for assessing the end results of neck injuries
by patients who continue
to complain
they run the risk of losing their objectivity. previous
therapy
of the injury can be estab-
in such cases is still in question.
There is a subconscious
and to assume that better
are every so often
despite much and varied therapy that tendency
to decry the
results could have been achieved with dif-
ferent methods. It is essential to disabuse oneself of this prejudice problem which has many obscure aspects.
in dealing with a
VULNERABILITY OF THE CERVICAL SPINE The wide range of motion of the upper cervical spine allows considerable stresses to be absorbed without neurological or soft-tissue damage. The atlanto-occipital joint permits only flexion and extension but the more complex atlanto-axial joint allows flexion, extension, rotation, vertical up and down approximation and lateral gliding. Flexion and extension occur at both the atlanto-occipital and the atlanto-axial joints, as much as 15s at each level. The anterior arch of the atlas retains a close relationship with the odontoid as it glides vertically up and down. Widening of more than 2 or 3 mm of space between the odontoid and the anterior arch of the atlas suggests damage to the transverse ligament (Fig. 1). Rotation about the odontoid process is as much as 45” to each side. During rotation considerable offset develops between the inferior articular surface of the axis and the
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Fig. 1. Forward
subluxation
of the atlas on the axis.
atlas. Cineradiography demonstrates that there is a decrease in the vertical height in the neutral position, Le. with rotation there is a screwing down and in the neutral position there is a lengthening. With lateral gliding, the odontoid process appears to be asymmetrically placed between the 2 lateral masses of the atlas; a mistaken diagnosis could thus be easily made (Fig. 2). An asymmetrical facet of the articular (Hohl’). Between
position
of the odontoid
process and the lateral
surfaces in the absence of a fracture does not indicate a subluxation
the second and the seventh
cervical vertebrae
there are flexion,
extension,
rotation and lateral flexion movements, which are greater in the upper part of the cervical spine and greater in children than in adults. In flexion and extension the superior surfaces of these vertebrae
(which face backwards
and upwards) articulate
with the inferior pro-
cesses of the next vertebrae facing downward and forward. This arrangement produces a normal anterior vertebral shift in flexion and a posterior shift in extension. This means that the disc space widens posteriorly in flexion and narrows anteriorly as the vertebra slides forward, provided the discs are normal. According to Fielding’ about 50% of rotation takes place at the atlanto-occipital joint and the remaining 50% is shared by the lower 5 interspaces. With these lateral motions the disc structures narrow on the concave side and widen on the convex side as they undergo torsional
stress, provided
again that
the discs are normal. The human head, weighing about 10 lb, is held upon a column of small, articulating vertebrae held. together with ligaments, joint capsules and muscles, balanced with adjustable standing rigging of symmetrically arranged structures, and protecting the spinal cord by suspending it in a column of fluid without touching the sides and yet allowing considerable range of mobility. The central supporting column carries the lines of communication and the self-compensating vascular systems. This complicated structure continues to function for a lifetime with few outward evidences of mechanical failure. The grouping together of so many structures regulating vital functions connected with survival, probably explains the historical interest in neck problems.
POST-TRAUMATIC PAINFUL NECK
3
Fig. 2. A (top). Asymmetry of the atlas in relatic )n tc) the odontoid. This is a kormal phenomenon in rotation. B (bottom left). Congenital fusion of C 2-3 and C5-7. C (bottom right). Localized stress at C4-5 (arrow).
PREDISPOSING CAUSES
A vertebral
column with segmental fusion or arthrodesis shows an exaggeration
of the
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Fig. 3. Kinking of the cord. Complete reduction will be deceptive on X-ray.
normal expected movement vertebral
above and below the fused segments. In osteoarthritis,
segments are less mobile than normal.
In proportion
some
to the extent of mobility,
compensatory motion occurs above and below the stiff segments. When traction is made on such a diseased cervical spine, the arthritic vertebrae do not separate to any percep tible degree, but the uninvolved normal interspaces above and below open up much more significantly (Fig. 2B). In sporting injuries it is not uncommon for congenital anomalies and fusions of the cervical spine to be discovered when cases of neck injury are X-rayed for the first time. These neck injuries tend to occur adjacent to the fused areas.
COMMON MECHANISMS OF INJURY
Similar injuries backward
occur in rear-end vehicle collisions and after blows on the head with
and upward force3. The head and neck go into hyperextension
and the spinal
and articular processes are forced together and act as a fulcrum causing the anterior longitudinal ligament to rupture. Separation then occurs between the cancellous bone of the vertebral body and the adjacent cartilaginous endplate or between the endplate and the disc proper. The intact posterior longitudinal ligament may strip away from the vertebral body, thus carrying the spinal cord backward against the sharp edge of the lamina of the lower vertebrae, and causing a contusion or transection of the cord at this level (Fig. 3). Spontaneous reduction occurs easily in this type of case, with subsequent deceptively normal radiography. Quite often a small chip of bone may be pulled off the anterior inferior edge of the vertebral body at the point of rupture of the anterior longitudinal ligament. This may be the only tell-tale evidence of the previous gross displacement. Other types of neck injuries occur when the head accelerates in relation to the trunk
POST-TRAUMATIC PAINFUL NECK
5
backwards, forwards and sideways. Even when the head is thrown forward, this range of motion is so well within physiological limits that serious injury is usually avoided. When the head is thrown laterally, the lateral flexion movements stop when it hits the shoulder and it need not produce significant damage to the neck, but lateral structures may give way. In extension-acceleration, however, there is nothing to stop the backward movement until the occipit hits the posterior chest wall. This is far beyond the normally permitted range of motion and damage may be serious. This is the type of injury which may be minimized in a car by a head-rest or a backward tilting of the back of the seat. Gross injuries of the cervical spine are very adequately dealt with in the orthopaedic literature and fall outside the scope of this paper. These major injuries have classical clinical and radiological features which determine treatment and most survivors make an adequate adaptation to their residual disabilities. The varieties of bulging and prolapsed discs commonly dealt with by the neurosurgeon are not under discussion here. A small percentage have persistent painful necks because of damage to joints, malalignment or instability, and can be dealt with effectively. Most of these cases reach a plateau of recovery in 2 years or so, as do most severe fractures and joint injuries in the body. Our main concern is with the group of neck injury cases in which no obvious skeletal or neurological damage is discovered in the early days after traurna. Usually the patient and his doctor underestimate the severity of the injury. The patient tries to resume his
Fig. 4. Left: Lateral view: normal appearances. Centre: Subluxation of C4 on C.5 on tlexion. Right. Appearance after interbody fusion of C4-5, showing good alignment.
6
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activities but, disappointingly, tragically
if not submitted
subluxations
or dislocations
fails in his efforts and may even deteriorate to a well-planned which undergo
hopelessly and
regime. Some really serious momentary
spontaneous
reduction
are missed because of
failure to look for evidence in forward tilting films (Fig. 4). In rear-end unawares
collisions,
the driver and passengers
and cannot brace themselves
not in common the extended
in the front
cars are often
for the impact. Furthermore,
caught
fitted head-rests are
use. The body moves forward and the head becomes hyperextended
on
neck. Lateral collisions may cause neck injuries, but quite often also skull
and brain injuries.
Roll-over accidents
commonly
result in skeletal and soft tissue injuries
of the neck, The victim may delight in explaining his lucky escape, unaware that the X-rays will reveal a bony injury the next day. The disrupting force is maximal at the moment of impact. All structures are stretched, some grossly ruptured, others only to the extent of a steppage lesion. There may be minor pinprick haemorrhages and massive haematomas. Even the neck-injury
victim with the most minor complaint
one day will wake up with
a stiff neck the next day. Pain and stiffness often become progressively worse for a week. The minor cases clear up quickly in a matter of weeks, but a substantial
number have pain
for 2-3 weeks and only improve slowly over 3 months
or so. In many cases no definite
regime of therapy
stiffness
is followed
and painful
symptoms,
and increasing
anxiety
persist for many months. With adequate conservative care, most cases return to normal in 12-24 months. In a few, severe and disabling symptoms persist. It would be incorrect to classify these soft-tissue neck injuries into hyperflexion injuries are asymmetrical
and too complicated
and hyperextension
in a mechanical
injuries. Most
sense.
DIAGNOSIS
The degree of force in the accident as determined by the history is significant, but it is surprising how severe a neck injury can be caused in a low-speed accident. The demonstrable severity of injuries basis of the history.
in fatal cases usually greatly exceeds that anticipated
on the
Even in moderate injuries to soft tissues, much haemorrhage may occur. Muscles may be torn at the occipital insertions, or other bony attachments. A prevertebral haematoma sometimes displaces the oesophagus and trachea forward and may cause dysphagia. Demonstration by radiography or thermography is evidence of severity of damage which may not be suspected. Injuries in the sagittal plane may narrow intervertebral foramina. Compression of intervertebral foramina may cause major or minor disruption, especially if there is pre-existing pathology. Partial, barely detectable cord injury may occur with damage to the posterior columns of Go11 and Burdach and, if found, is proof of the genuineness and severity of the injury. Hyperextension may cause the buckled ligamentum flavum to press on the posterior columns of the cord. Irritation to the sympathetic plexus around the vertebral artery or
POST-TRAUMATIC PAINFUL NECK
Fig. 5. Asymptomatic congenital fusion of C2-4 and rheumatoid C5-7. Minor surgery could produce serious consequences.
kinking
of the artery may occur. The great mobility
dorsal spine tends to concentrate The G-7 quently
injury
is superimposed however,
of the neck on the relatively
fixed
stress at the levels of great mobility.
levels show the earliest development
(Fig. 5). Discograms,
arthritis with fibrous ankylosis of
on pre-existing
of degenerative
but sometimes
so often demonstrate
disrupted
not been involved in acute trauma that a pathological
changes and not infre-
asymptomatic
pathology
discs in necks that have
cervical discogram as an isolated
item in diagnosis cannot be accepted as proof of fresh disc injury. Combined with localized pressure pain and stiffness
and, perhaps, accurate
reproduction
of the pain com-
plained of, it may be taken as justifying a diagnosis at least of aggravation of the preexisting disc pathology. Previous discogenic neck pathology may predispose to the localization of injury at that site. A proportion of cases qualify for anterior fusion to combat disc pathology aggravated or accelerated by a single traumatic episode. In practice these cases are rare. Injury to the vertebral artery, the brain stem or the brain itself may, of course, occur in survivors. The assumption that headache is often the consequence of neck injury may, however, have other explanations. Pain behind the eyes, associated with a neck injury, has been explained on the basis of a hypothetical nervous connection between the occipital nerves, their cord origins and the trigeminal spinal tract (Fig. 6)4. Headache in the occipital region, the vertex and the forehead is often explained on the basis of tension, anxiety, fatigue and the vicious circle of muscle spasm. The greater and lesser occipital nerves are,
8
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r
L. Fig. 6. Hypothetical ganglionic synapses.
I
-. connexion
between the origin of the occipital nerve roots and the trigeminal
Preg
Fig. 7. Greater and lesser occipital nerves and pain reference. The level of preganglionic section of the posterior nerve roots is indicated by the solid vertical lines.
9
POST-TRAUMATICPAINFULNECK allegedly, implicated
(Fig. 7) and some surgeons perform preganglionic
this reason, although
no pathology
the mechanism
section of C2 for
in the nerve has ever been reported in such a case and
of injury has not been elucidated.
This operation
has not found approval
and acceptance by neurosurgeons. One cannot
dismiss the majority
exaggerated by litigation
of soft-tissue
injuries
of the neck as minor and as
neurosis or anxiety. In many cases of multiple injury the patient
has borne the discomforts
and agonies of limb injuries with equanimity,
admit that the neck is any better. Humbugs intent on magnifying
but refuses to
their claims for damages
would probably not readily admit regression of pain in some parts and not in others. The occasional brilliant cure of a neck-ache by a single manipulation, a solitary injection or a simple one-level
fusion
must surely prove that the cause may be organic if it can be
localized with precision.
A. Discography Reputable
observers such as Simmons’
pain in a particular anaesthesia
of Toronto
find that precise reproduction
of
disc level coupled with precise referred pain and relieved by local
in the same disc will localize the lesion satisfactorily.
The need for precise
technique is stressed. On the other hand, Klafter and Colli@ report that the diagnostic localizing accuracy of the cervical discogram is controversial and the significance of the pain response is particularly indeterminate. This point of view is also supported by Holt7, who states that
there are errors of technique
apparent situation is that techniques described.
as well as errors in interpretation.
cervical discs do not lend themselves
to evaluation
The by the
B. Fusion Fusion
of narrow
cogenic degenerations
disc spaces with osteophytes are asymptomatic.
may also be unreliable.
There is a tremendous
difficulty
Many dis-
in choosing the
spaces to be bridged by bone graft and, not infrequently, the wrong levels are fused. In a personal case, a relatively normal level was fused and a grossly pathological disc with narrowing and gross osteophytes left untreated; yet the patient alleged that the operation had cured his post-traumatic painful neck. Careful immobilization, analgesic therapy, complete rest, sympathetic nursing and a happy tempo of rehabilitation may have played a part. In some cases, disc spaces to be bridged may be determined more readily. C Arteriography Despite quite severe bony damage the vertebral artery may escape injury. Where rotation or flexion of the neck has caused headache, giddiness and faintness, a vertebral arteriogram may show a kinking of the artery correlated with particular positions. Symp
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Fig. 8. Excision of Luschka (unto-vertebral)
facet and anterior decompression
of the vertebral vessels.
toms in such cases may be alleviated by external bracing, by fusion, or by decompression of the vessel (Fig. 8) as described by Jung’. D. Neurological signs
In an occasional case in which the positional sense of the patient has been lost and where the patient’s balance has been disturbed after trauma to the neck, it does happen that fusion of that level of the cervical spine has resulted in marked alleviation of symptoms. The whole syndrome of cervical discogenic myelopathy (Fig. 9) so ably analysed by Lord Brain7 can, of course, be aggravated by even mild injury. This is especially likely when old people fall down stairs. Not infrequently, progressive deterioration with widespread spinal cord involvement becomes inevitable. These are then desperate problems for the neurosurgeons and need hardly be included in a discussion of the post-traumatic painful neck.
THERAPY
The ultimate prognosis in neck injuries of the type being discussed is good, provided uninterrupted rest in bed is given until acute symptoms have subsided and provided adequate tranquillizers are given to keep the patient lying flat on his back with only one pillow most of the time. In some cases with severe, persistent physical discomfort, more localized therapy may be indicated, such as local anaesthetic blocking and treatment with ice packs. Scar tissue formation in the neck will probably not lead to prolonged or any serious degree of disability. Interspinous ligament injury and disc injury are probably part of an injury to the intervertebral complex. The main portion of this joint is the disc itself and, since it carries such important stresses in the neck, it is conceivable that it will
11
POST-TRAUMATIC PAINFUL NECK
Fig. 9. Cervical myelopathy verse osteophytes. occasionally
reasonable produce
be injured.
due to indentation
of the cord anteriorly by ridging produced by trans-
In cases where joint capsules are damaged and ligaments torn, it is
to believe that the disc has, at least, been subjected some damage, be it cracks in the endplates
discoverable
pathology
years later.
In a carefully
to enough trauma
to
or tears which may only produce
observed case the osteophytes
took
3 years to develop. When the patient first gets out of bed and lacks confidence is concerned, Commerell
an adequate
as far as posturing
the neck
cervical brace may well be used for a time. In South Africa the
brace is in common
use; it is a satisfactory,
adjustable
brace. Many of the
other supports on the market do not prevent flexion. Some cases of persistent pain in the neck with local tenderness may respond to local anaesthetics such as cortisone. If, after 3 or 4 injections, the response is not that of total relief, more drastic measures may be needed. It is recognized that certain traumatic neck-aches will respond to excision of the disc and fusion” ,il. The great difficulty is to choose the cases which are likely to benefit from such treatment, and some unnecessary fusions are possibly done. The essentials in successful operative surgery are, presumably, that the patient should be prepared to accept the operation as a cure, that the correct level should be fused, and that the operation be technically sound. In other words, there are many pitfalls even in this approach. It should be recognized that conservative therapy and adequate rehabilitation with isometric contractions of the neck muscles over a long period will result in
12
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marked
improvement
treatment
in most cases where operation
is reserved for a small minority,
is not clearly indicated.
Operative
possibly 5%, of injured necks.
FUSION
If the symptoms brought
and physical findings and local tenderness
are precise, and if the pain is
on by activity and by sudden jerks such as in coughing and sneezing, and if there
is improvement
after splintage,
traction
therapy
pain is likely and fusion will probably succeed. Definite localized tenderness in the midline
and rest, then a mechanical anteriorly
and posteriorly
basis for the is common
cases suitable for fusion. This is also usually the area in which X-rays show narrowing disc. Percussion
on the vertex of the head, reproducing
neck, must be regarded as confirmatory Occasionally
cases for operation.
Discography,
the pain in the exact spot in the
information.
there may be evidence
root at the same level. Myelography
in of a
of nerve root irritation
has not been particularly
an important
technique,
of one particular
nerve
helpful in deciding on the
is a very disputed
method
of
investigation. There are dogmatic and experienced opinions which condemn discography for determining the level of the patient’s complaints. On the other hand Simmons3 has found that if cervical discography
is precisely performed
so that the needle is accurately
placed in the nucleus and not in the annulus, then the injection of saline which raises the pressure in the disc will produce the constant pain pattern which the patient has complained
of, and this would be regarded as of diagnostic
significance.
If the injection
disappears into the soft tissues or spreads up and down in front of the posterior common ligament, then the localizing value of the discographic examination has been nullified. In Macnab’s analysis of 57.5 cases of extension-flexion injuries of the neck 2 years or more after settlement of all litigation, 45% still presented symptoms12. This indicates that one is indeed probably dealing with a condition which, although organic, is extremely difficult to pinpoint. There are cases of vascular complications
in neck injuries which can only be demon-
strated by arteriography. In one year we found 3 cases of obliteration of the vertebral artery and in one the obliteration was intermittent. In each case the block was at the level where there was demonstrable bony pathology. These cases had persistent headache and giddiness and, in the intermittent case, flexion produced fainting attacks which disappeared when a brace was worn habitually. Vascular damage has to be suspected before it can be diagnosed by arteriography. Some cases are missed as the investigation is avoided because of fear of discomfort or complications. Recently we have seen occasional cases of elderly patients (without radiological evidence of injury after falls) who developed severe neurological involvement of upper and lower motor power of arms and hands with escape of the lower extremities. There may be a central cord lesion with extensive damage arising from vascular pathology precipitated
by neck injury13.
POST-TRAUMATIC PAINFUL NECK
= Cervical T = Thoracic L = Lumbar S = Sacral
Gracilis Cuneatus /
Fig. 10. A cross-section of the cord to illustrate the various tracts.
Fig. 11. Central necrosis of the (After Hardy, ref. 13.)
cervical
cord affecting the upper limb with escape of the lower limbs.
14
G.T. du TOIT
Fig. 12. Section of the cervical cord showing central necrosis. (After Hardy, ref. 13.)
Fig. 10 illustrates
a cross-section
cord affects the upper extremities,
of the spinal cord. Central necrosis of the cervical while the lower escape (Fig. 11). Fig. 12 shows less
damage at a lower levelr3.
VENOUS PLEXUSES
In 1964 Trevor-Jones’4
described
neck. I have had two patients
the remarkably
who complained
extensive
venous plexuses
in the
of headache relieved by pressure on the
back of the neck. This is admittedly a very obscure and difficult problem. In each case an exploration of the neck with partial stripping of the paravertebral muscles, diathermy coagulation of numerous vessels in the area and closure of the wound resulted in complete cure of the neckache and the headache. This is an aspect of the functional anatomy of the neck requiring further investigation. Hirsch” has found cervical discography unreliable, but myelography of greater value as a diagnostic technique before cervical disc resection.
RADIOLOGICAL INVESTIGATION
The patient who walks into hospital with pain in the neck after a road accident should be X-rayed routinely and mobility tests should also be carried out.
POST-TRAUMATIC
15
PAINFUL NECK
Loss of the normal cervical lordosis should be regarded as due to an organic lesion and is often the consequence
of muscle spasm arising from nerve root irritation.
flexion lateral films may show undue
vertebra. This can only occur if the ligaments tially or totally. In a standard
case, the lipping
stabilizing
that joint have given way par-
and sclerosis developed
3 years after the only sign
following trauma was narrowing without reactive changes. Backward displacement of a vertebra with hyperextension to the anterior Abnormally
longitudinal
narrowed
ligament
intervertebral
years to develop in the ordinary
Forward-
forward shift of one vertebra on the next lower
which cannot
stretch
necessarily implies damage at all. It can only rupture.
disc spaces with marginal lipping and sclerosis take
course of life, and only after repeated trauma over long
periods. Such changes cannot be caused by a single, recent trauma. But with loss of disc substance, increased mobility allows localization of stress which may superimpose new pathology
on the old. A narrowed
sclerosis increases the likelihood
disc or a widened disc without
evidence of lipping or
that the lesion is recent.
Narrowed intervertebral foramina due to osteophytic encroachment may pinch nerve roots or embarrass their segmental blood supply, especially in lateral bending strains of the neck. There are many neck lesions in which no evidence of new pathology
may be
reported. Too much value should not be attached to so-called negative X-rays. Mobility studies of the cervical spine are valuable both on still pictures and on cineradiographic study. In the latter, much is gained by being able to visualize the smooth rhythmic motion of the vertebra or the cog-wheel action of a deranged joint. However, much radiographic detail is necessarily lost in the smaller film.
CONCLUSIONS
It is apparent
that the available knowledge
on this difficult
subject has not yet been
crystallized completely. The manner in which the patient is handled makes a substantial difference to the end result. The psychological approach to the patient is important. The general run of post-traumatic neck pain cases may be classified thus: (a) A substantial number have minor injuries which get better in weeks or months; (b) Those with rather more soft-tissue injury require a few weeks of strict hospital bed-rest, some degree of splintage by positioning or light traction, together with analgesics and sedatives; (c) The third group includes those with more complicated pathology such as nerve root injuries, vertebral artery damage, spasm, sympathetic nervous system irritation or disc damage; and there may be headache, giddiness, noises in the ears, flushing of one side of the face, fainting and disturbances of vision. These cases are subjected to specific investigation by the ear, nose and throat, and eye specialists or neurosurgeons, and usually an organic basis for the main symptoms is discovered. In a few cases localized pressure pain anteriorly, discomfort on compression of the
16
@.T. du TOIT
cervical spine vertically, tenderness of a particular interspinous ligament and sometimes the exactly corresponding location of a radiologically abnormal disc space may indicate the need for a stabilization procedure. Anterior fusion over one or more intervertebral levels may bring about dramatic relief. Occasionally, the repeated kinking of a vertebral artery may be prevented by a permanent cervical brace if an elderly patient is unfit for surgery, or by decompression or fusion of the affected disc. Decompression of the vertebral artery with its venae comitantes has been much advocated by Jung’. The fact that cervical fusion has produced relief of pain in the traumatized neck has led to a rather indiscriminate fusion in cases of painful neck. Fusion may succeed with a variety of pathological entities; for example: 1. A simple recurrent subluxation of the neck sometimes results from inadequate primary post-accident immobilization. The patient persuades the medical practitioner against his better judgement to be allowed out of bed. The subluxation recurs and then becomes a recurrent subluxation, easily demonstrable with mobility studies. 2. The patient with some genuine cord injury, such as damage to the columns of Go11 and Burdach, will often admit improvement after fusion of that level. 3. The patient with a genuine disruption of the annulus or the posterior ligament with nerve root pressure, will admit relief from anterior removal of the whole disc and fusion by an anterior graft. Removal of an osteophyte arising from Luschka’s joint and irritating a nerve root may produce dramatic relief. 4. The patient with previously asymptomatic neck pathology precipitated into a crippled state by aggravation of the pre-existing pathology at one or several levels may feel even better after fusion than before the accident. This has led to an excess of enthusiasm for neck fusion in recent years. Surgeons are notoriously creatures of fashion. Few surgeons can continue to resist a mechanically ingenious operation - be it thoracic sympathectomy, vagotomy or acupuncture. We live in an age of substitution, with ersatz teeth, ersatz knee and hip joints, and even ersatz urinary bladders. Not surprisingly, patients may be fitted with metal ball-bearings, or silastic rubber intervertebral discs in attempts to relieve pain and yet retain some motion (Fig. 13). Out of experimental surgery, much surgical progress has been born. It behoves us to apply scientific criteria, to keep accurate records and to retain our objectivity in such work. The enthusiastic innovator readily plunges into a new field without enough forethought for the consequences. Thus new iatrogenic diseases have developed out of the pain in the neck. The following have been recorded: Ball-bearings escaped from disc spaces and migrating down into the mediastinum; ball-bearings countersunk into vertebral bodies and surrounded with solid bony fusion; dislocated silastic rubber bands woven round spinous processes in the neck, and bathed in secondary infection. There are indeed, some conditions appreciably less tolerable than the original pain in the neck. Such may be the consequences of misguided or unfortunate instrumentation. The value of discography is still controversial. Discography has been widely used and
POST-TRAUMATIC PAINFUL NECK
Fig. 13. Metallic intervertebral discs.
bearings; a failed attempt at mechanical substitution
17
of intervertebral
often misinterpreted. So much is this the case that it has been proposed by Simmons3 that an independent radiologist be trained to carry out discography to avoid errors that may derive from the enthusiasm of the surgeon to find confirmation of the patient’s symptoms. This would avoid misinterpretations of the effects of extravasation in the soft tissues, and spread up and down under the common ligament. Meanwhile, it has not yet been determined whether the technique should be discarded. Perhaps, with greater precision, we are going to be able to sort out this rather difficult traumatic scrapheap of humanity suffering from soft-tissue injuries of the neck.
REFERENCES 1 M. Hohl, Normal motions in the upper portion of the cervical spine, J. Bone Joint Surg., 46A (1964) 1777-1779. 2 J.W. Fielding, Normal and skeletal abnormal motion of the cervical spine from the second cervical: to the seventh vertebra (cineradiography),J. Bone Joint Surg., 46A (1964) 1779 - 1781. 3 A.W.A. Goff and J.H. Aldes, Traumatic Cervical Syndrome and Whiplash, Lippincott, Philadelphia, 1967. 4 J.G. Love, The occipital nerves: A teaching drawing, Staff meetings of the Mayo Clinic, January 2nd, 1963, pp. 18-19. 5 E. Simmons, Localizing value of cervical discography, International Trauma Conference, Johannesburg, June, 1971. 6 L. Klafta and J.S. Collis, The diagnostic inaccuracy of the pain response in cervical discography, Clove. Clin. Q., 36 (1969) 35-39.
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G.T. du T&T
7 E.P. Holt, Jr, Following of cervical discography - report of 50 cases in normal subjects, J Am. Med. Assoc., 188 (1964) 799-801. 8 M.A. Jung, Resection de I’articulation unto-vertebrale et ouverture du trou de conjugaison par voie anterieure dans le traitement de la nevralgie cervico-brachiale, Mem. Acad. Chir., 88 (1963) 361-367. 9 R. Brain, Some unsolved prbblems of cervical spondylosis, Br. Med. J., (1963) 771-777.
10 R.B. Cloward, Cervical discography, technique, indications and use in diagnosis of ruptured cervical discs, Am. J. Roentgenol., 79 (1958) 563-574. 11 R.A. Robinson, and W.O. Southwick, Surgical approach to the cervical spine, Instructional Course Lectures, Vol. 17, American Academy of Orthopaedic Surgeons, St. Louis, 1960, pp. 299-330. 12 I. Macnab, Acceleration injuries of the cervical spine, J. Bone Joint Surg., 46A (1964) 1797-1799. 13 A.G. Hardy, Central cord lesions, International Trauma Conference, Johannesburg, 1971. 14 R. Trevor-Jones, Osteo-arthritis of the paravertebral joints of the second and third cervical vertebrae as a cause of occipital headaches, S. Afr. Med. J., 38 (1964) 392-394. IS C. Hirsch, Cervical disc resection, J. Bone Joint Surg., 46A (1964) 181 l-1 821.