Actu Radiologicu 36: (1995) 425-428 Printed in Denmark . All rights reserved
Copyrighr 0 Acru Rudidogicu I Y Y 5
ACTA R A D I O L O G I CA ISSN 0248-1851
MR IMAGING AND RADIOGRAPHY OF PATIENTS WITH CERVICAL HYPEREXTENSION-FLEXION INJURIES AFTER CAR ACCIDENTS
GRETHE E. BORCHGREVINK, OLAUG SMEVIK~, ASBJON NORDBY3, PETER A. RINCK2, T. c. STILES4 and I. LEREIM
I Abstract Fifty-two patients underwent MR imaging and conventional radiography
of the neck within 4 days after a hyperextension-flexion injury. The patients also had follow-up investigations during the first 2 years. The images did not reveal any serious lesions in any of them. Based on the main MR and radio- graphical findings the patients were divided into 4 groups; no findings, posture abnormalities, spondylosis and disc pathology (from MR images) or reduced intervertebral space (from the radiographs). The outcomes of the different groups were compared with reference to neck stiffness, neck pain and headache during a 2-year follow-up period. The patient groups did not correspond com- pletely when diagnosed from MR imaging and radiography. However, pa- tients with pre-existing spondylosis had more symptoms when examined by both modalities. Based on the radiographs, the group with posture abnormali- ties had significant fewer symptoms than the other groups.
Cervical hyperextension-flexion injuries are usually caused by car collisions and the mechanism of the injury is often referred to as whiplash. A characteristic of hyperextension-flexion injury is the occurrence of considerable pain and prolonged disability in spite of failure to observe objective signs of pathology by traditional investigations. The most common symptoms are neck pain and neck stiffness. In hyperextension-flexion injury ex- periments in monkeys MACNAB (7) found tearing of the anterior longitudinal ligament, separation of the disc from the vertebrae, retropharyngeal haematomas in the muscle layer of the oesophagus and muscle injuries affecting the sternocleidomas-
Grethe E. Borchgrevink, Olaug Smevik2, Asbjon Nordby3, Peter A. Rinck2. T. C. Stiles4 and I. Lereim The Emergency Clinic, 2MR-Centre Medical Section, 3Department of Radiology, Trondheim University Hospital; and 4Department of Psychiatry and Behavioural Medicine, University of Trondheim, Trondheim, Norway.
Key words: Neck injuries; MR imaging; radiography.
Correspondence: Grethe Borchgrevink, Emergency Clinic, University Hospital, N-7006 Trondheim, Norway. FAX *47-73-99 73 43.
Accepted for publication 7 November 1994.
toideus and longus colli muscles. OMMAYA et al. (12) found superficial haemorrhages of subdural nature in the cerebrum, in the brain stem, and in the cervical cord, although there were haemor- rhages only in monkeys that were concussed.
The aim of the present study was 3-fold: 1) to use the acute MR findings to reveal pathology of clin- ical significance; 2) to examine the relation between the acute MR findings with subjective symptoms during a 2-year follow-up period; and 3) to consider the benefit of MR imaging in relation to conven- tional radiography. The study was prospective and included 52 whiplash patients who underwent cervi- cal MR imaging within 4 days after the injury.
G . E. BORCHGREVINK ET AL.
Material and Methods
Fifty-two patients with hyperextension-flexion in- jury were examined at our Emergency Clinic. They were living in or near the city of Trondheim and were examined within 4 days following a car colli- sion. Patients with radiographically disclosed frac- ture of vertebrae or clinical signs of nerve root compression were excluded (5, 6, 13). There were 30 women (58%) and 22 men (42%) and their ages varied from 18 to 66 years (mean 34.5212.3).
All patients underwent clinical investigation by the same doctor. Previous neck pain and other symptoms were recorded at the first consultation. The clinical investigation was repeated after 2 weeks, 6 weeks, 3 months, and 6 months. After 1 and 2 years the patients were contacted by tele- phone. At the 3-month examination, 2 women were missing due to hospitalisation for other ill- nesses. At the 6-month examination 1 man and 1 woman were missing and after 1 year yet another woman.
At the first consultation previous episodes and present intensity of symptoms were rated by the interviewer (G. E. B.) on a scale graded no, moder- ate or severe symptoms. At each of the follow-up assessment points symptom discomfort was rated by the same interviewer as frequency of symptoms on a scale graded never, sometimes, every day and constant. The primary symptoms assessed were neck pain, neck stiffness and headache. Other symptoms measured were shoulder stiffness, pain in the back or chest, difficulties with memory or concentration, buzzing in the ears, dizziness, nausea, diminished vision, insomnia, consumption of analgesics, depression and anxiety.
M R examinations. Fifty-one patients had an MR examination within 4 days (1 patient didn't manage to get through the investigation). The first 20 patients had a follow-up investigation after 6 weeks. The examinations were randomly per- formed at a 0.5 T (Gyroscan S 5, Philips) or 1.5 T (Gyroscan S 15, Philips) equipment employing sagittal images at a slice thickness of 5 mm and an FOV of 259. For T1-weighted images the following SE sequences were used: TR/TE 594/30 ms at 0.5 T and TR/TE 500/20 ms at 1.5 T. For T2-weighted images the following GRE sequences were used: TR/TE/flip angle 494/28 ms/18" (at 0.5 T) and TR/ TE/flip angle 371/16 ms/12" at 1.5 T. A head coil was used. In the MR images the following abnor- malities were looked for: Posture abnormalities (loss of cervical lordosis), disc pathology, bleeding in muscles and other soft tissue injuries, haema- tomas, spinal canal and root canal stenosis, spinal cord injuries, ligament tears and "sprain" injuries, vertebral pathology and pre-existing spondylosis.
The patients were grouped according to the main MR findings into 4 groups; no findings, only pos- ture abnormalities, pre-existing spondylosis and disc abnormalities (disc protrusion and reduced signal) without signs of spondylosis.
Cervical radiography. The patients also under- went cervical radiography at the first consultation, within 4 days after the accident. The radiographs were exposed in lateral, a.p. and oblique projec- tions, and the dens axis was imaged in an open- mouth position. Radiography was repeated after 6 months. The radiographs were checked for posture abnormalities, vertebral pathology, changes of in- tervertebral space and spondylosis. The radio- graphical findings were also arranged into 4 groups; no findings, posture abnormalities, re- duced intervertebral space and spondylosis.
Statistics. Separate overall analyses of variance were used to compare the various groups regarding age, while gender was tested by the Chi-square test. Significant 4-group ANOVAs were followed up with 2-group ANOVAs. Differences between the groups in symptom discomfort were assessed by the Kruskal-Wallis test followed by the Mann- Whitney U-test. The non-parametric tests were corrected for ties when appropriate (14). A p-value
CERVICAL HYPEREXTENSION-FLEXION INJURIES
Table 2 Percentages of patients reporting daily and constant discomfort
from symptoms during the follow-up period
Neck Neck Headache, stiffness, pain, %
After 2 weeks 45 41 22 After 6 weeks 39 31 13 After 3 months 34 26 12 After 6 months 29 19 15 After 12 months 9 9 9 After 24 months 1 1 9 9
6 patients had improvement or normalisation of the neck posture abnormality.
Twelve patients had disc abnormalities without signs of spondylosis (9 women, 3 men, mean age 37.3 years). All these patients also had abnormal spinal posture in the neck. Three had disc abnor- malities at more than 1 level. The most frequent level with disc pathology was around C5-C6 (8 pa- tients). Ten of the patients had disc protrusions (anterior protrusion in 4 patients, posterior pro- trusion in 4 patients and both anterior and pos- terior' protrusion in 2 patients). Two patients had reduced signal of the disc and 1 had ligament ten- sion because of disc protrusion. In none of the cases did the disc abnormalities interfere with the spinal canal. Six of the patients in this group had a follow-up MR investigation after 6 weeks. The disc pathology had disappeared in 3 of the cases; 2 of these had normalisation of protrusion and 1 had normalisation of reduced disc signal. The con- comitant posture abnormalities had normalised or improved in 5 cases.
Seven patients (4 women, 3 men, mean age 52.4 years) had spondylosis which was supposed to be a pre-existing pathology. Five patients had osteo- phytes at 2 levels and 1 patient at 3 levels. Two had ligament strain because of osteophytes and disc protrusion. Four had spinal canal narrowing and 4 had disc pathology. In this group, 4 underwent follow-up investigations and there were no changes of the findings.
Radiographical $ndings. Fourteen patients (9 women, 5 men, mean age 32.6 years) had no radio- graphical findings. Of those, 8 had no findings on MR imaging. However, 5 patients were diagnosed as having posture abnormalities and 1 patient had disc protrusion on the MR images.
Twenty-two patients (1 1 woman, 1 1 men, mean age 27.8 years) had posture abnormalities as the only finding on the radiographical investigation. The MR diagnosis of 11 of these was posture ab- normalities, 5 had disc pathology, 1 spondylosis, and 5 had no pathological findings.
At radiographical investigation 9 patients (7 women, 2 men, mean age 40.0 years) were diag- nosed as having reduced intervertebral space. Three of them had disc pathology on the MR im- ages, 3 posture abnormality only, 1 had spon- dylosis and 1 had no finding. One patient did not manage to complete the MR investigation.
The radiography group with spondylosis con- sisted of 7 patients (3 women, 4 men, mean age 49.2 years). After MR investigation 5 of them had the same diagnosis. Two had disc pathology ac- cording to MR imaging.
The radiographs taken 6 months after the acci- dent showed an improvement or normalisation in 50% of the patients (16 out of the 32 patients which had findings at the initial investigation).
Symptom development in various M R groups. The 4 MR groups differed significantly in age (p
G . E. BORCHGREVINK ET AL.
with pre-existing spondylosis had more headache than the groups with posture abnormalities and no findings at 3- and 6-month follow-ups (p