Neck conditions/Headaches

Question 1

List possible structures damages in whiplash?

Answer 1

joints: zygapophyseal joints, Atlanto-axial joint, Atlanto-occipital joint
intervertebral discs and cartilaginous endplates
muscles
ligaments: Alar ligament, Anterior atlanto-axial ligament, Anterior atlanto-occipital ligament, Apical ligament, Anterior longitudinal ligament, Transverse ligament of the atlas
bones: Atlas, Axis, vertebrae (C3-C7)
nervous systems structures: nerve roots, spinal cord, brain, sympathetic nervous system
the vascular system structures: internal carotid and vertebral artery
adjacent joints: Temporomandibular joint, thoracic spine, ribs, shoulder complex
the peripheral vestibular system

Question 2

Damaged caused from whiplash movements? IE> Hyperextension/flexion

Answer 2

Hyperextension and distraction of the neck may rupture the anterior longitudinal ligament and also some discs. A ruptured disc can lead to backward displacement of the vertebra lying above it (the upper facets then slide downwards on the lower) with damage to the spinal cord as a result. Spinal cord injuries after motor vehicle accidents occur most often in young car users in the 15–24 year age group.

Pure hyperextension may also lead to compression of the spinal cord in those cases where retrolisthesis or spinal stenosis already existed. Compression fractures of the posterior elements may occur in other cases.

Hyperflexion injury may lead disruption of posterior ligaments and occasionally facet joint luxation and/or to fractures of the vertebral body (most fractures of the atlas and of the axis are the result of motor vehicle accidents).

Less likely, lesions of veins, arteries, neural structures, oesophagus and retropharyngeal tissues may occur.[6]

Question 3

Less severe legions

Answer 3

Less severe lesions which may involves the intervertebral discs, the zygapophyseal joints, the cervical ligaments and muscles are much more frequent. These lesions may occur in isolation but are more often combined and therefore are sometimes difficult to recognize. The common complaint is neck pain

Facet Joint Problems
Whiplash may also lead to problems at the level of the zygapophyseal joint capsules.[9] Lord et al undertook a placebo-controlled prevalence study after whiplash and found that chronic cervical facet joint pain was common.[10]

Pain which is usually localized is felt unilaterally. A convergent or divergent motion pattern may occur, although any asymmetrical pattern is compatible.

Question 4

Disc injury in whiplash what happens?

Answer 4

As the result of the hyperextension element during the trauma the disc may have fissured. The subsequent flexion or hyperflexion element causes displacement of disc material in a posterior direction. Davis et al describe a number of posterolateral disc lesions with radicular symptoms as the result of a hyperextension whiplash trauma. These herniations seemed to develop only after the acute phase and it took a few weeks for the radicular symptoms to manifest. In postmortem studies, Taylor et al describe the intervertebral disc as the most frequently damaged structure.[7] Jónsson et al[8] also confirmed the large number of disc lesions after whiplash, and during surgery were able to confirm the findings from magnetic resonance imaging (MRI).

Posterocentral protrusions lead to central, bilateral or unilateral pain in a multisegmental distribution: pain in the neck, upper scapular area and trapezius. On examination, a symmetrical (mimicking a full articular pattern) or asymmetrical pattern of limitation is evident. In acute cases the picture may be torticollis-like.[6]

Question 5

Whiplash presentation: motor

Answer 5

Motor Dysfunction:
One of the most common clinical characteristics is a restricted range of motion of the cervical spine. This finding may reflect underlying disturbances in motor function due to the initial peripheral nociceptive input caused by injured anatomical cervical structures. Further research of such potential mechanisms in WAD is necessary[3][21].
Another characteristic is altered patterns of muscle recruitment in both the cervical spine and shoulder girdle regions. This is clearly shown to be a feature of chronic WAD[21][25][26][27].
Mechanical cervical spine instability[24]

Question 6

Whiplash presentation: Sensorimotor Dysfunction

Answer 6

Loss of balance
Disturbed neck influenced eye movement control[24]
Sensorimotor dysfunction is greater in patients who also report dizziness due to the neck pain[21][28][29].

Question 7

Whiplash presentation - Sensory Dysfunction:

Answer 7

Sensory Hypersensitivity to a Variety of Stimuli
Psychological distress
Post traumatic stress[21]
Concentration and memory problems[28][29]
Sleep disturbances[30]
Anxiety[28]
Depression[28] is common in WAD patients. There are different types we can distinguish:
Initial depression: this can be associated with greater neck and low back pain severity, numbness/tingling in arms/hands, vision problems, dizziness, fracture[31]
Persistent depression: this can be associated with older age, greater initial neck and low back pain, post-crash dizziness, anxiety, numbness/tingling, vision and hearing problems[31]

Question 8

Degeneration Cervical Muscles =

Answer 8

Neck stiffness[28][29]
Fatty infiltrate may be present in the deep muscles in the suboccipital region and the multifidi may account for some of the functional impairments such as: Proprioceptive deficits, Balance loss, Disturbed motor control of the neck[

Question 9

Other Symptoms whiplash

Answer 9

The following symptoms may also occur[24][28]

Tinnitus
Malaise
Disequilibrium/Dizziness
Thoracic, temporomandibular, facial, and limb pain

Question 10

Rule out VBI

Answer 10

Dizziness is the most common complaint associated with vertebrobasilar insufficiency (VBI). VBI is an uncommon presenting condition but when dizziness is present before proceeding with physiotherapy management you must rule out VBI by assessing for the following symptoms. The presence of one of these symptoms is enough to warrant caution and further investigation.

Question 11

VBI - 5 Ds

Answer 11

Dizziness
Diplopia, blurred vision or transient hemianopia
Drop attacks (loss of power or consciousness)
Dysphagia (problems swallowing)
Dysarthria (problems speaking)

Question 12

VBI - 3 N’s

Answer 12

Nystagmus
Nausea or vomitting
Other neurological symptoms

Question 13

VBI - 5 others

Answer 13

Light headiness or fainting
Disorientation or anxiety
Disturbances in the ears - tinnitus
Pallor, tremors, sweating
Fascial paraesthesia or anaesthesia

Question 14

Key presenting features of CAD Early phase - Internal carotid artery disease

Answer 14

Acute onset of pain described as “unlike any other”.

Mid-upper cervical pain, pain around ear and jaw (carotidynia),

Head pain (fronto-temporo-parietal);

Ptosis;

Lower cranial nerve dysfunctions (VIII-XII);

Question 15

Key presenting features of CAD Early phase - Vertebrobasilar artery disease

Answer 15

Mid-upper cervical pain;
occipital headache;
Acute onset of pain described as “unlike any other”.

Question 16

Key presenting features of CAD Early phase - Temporal arteritis

Answer 16

Tenderness and sensitivity on the scalp

Jaw claudication (jaw pain when chewing)

Tongue claudication (tongue pain when chewing)

Question 17

Key presenting features of CAD Late phase - Internal carotid artery disease

Answer 17

Lower cranial nerve dysfunctions (VIII-XII);

Transient retinal dysfunction (scintillating scotoma, amaurosis fugax);
Transient ischaemic attack;
Cerebrovascular accident (ischaemic stroke).

Question 18

Key presenting features of CAD Late phase - Vertebrobasilar artery disease

Answer 18

Hindbrain transient ischaemic attack

(dizziness, diplopia, dysarthria,

dysphagia, drop attacks, nausea,

nystagmus, facial numbness)

Cranial nerve dysfunctions;

Ataxia, vomiting, hoarseness,

loss of short term memory, vagueness,

hypotonia/limb weakness [arm or leg],

anhidrosis [lack of facial sweating],

hearing disturbances, malaise, dysthaesia,

photophobia, papillary changes, clumsiness and agitation);

Hindbrain stroke (e.g. Wallenberg’s syndrome, locked-in syndrome)

Question 19

Key presenting features of CAD Late phase - Temporal arteritis

Answer 19

Reduced visual acuity (blurred vision)

Acute visual loss (sudden blindness)
Diplopia (double vision)

Acute tinnitus (ringing in the ears)
Polymyalgia rheumatica (in 50%)