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Home , Strain (injury), Whiplash (medicine)

Management of chronic cervical and due to mechanism

ARNOLD GERBER, D.O., M.Sc. (Orth.,) rear as a result of a rear-end collision. The opposite F.A.C.O.S.,° and LAWRENCE E. MILLER, B.S., can also occur (Fig. 2), with the sudden stop af- D.O.,t Philadelphia, Pennsylvania fecting the body and the forward movement being continued in the head and , as when accelerat- In reviewing the literature published in major ing a car at high speed and stopping very suddenly, journals in the past 10 years, the term "whiplash" or merely slipping on the pavement or ice. The has been seen more and more often as describing degree of naturally is dependent on the a common injury; however, little or no definitive speed of acceleration. therapy has been outlined. The purpose of this Sprain and strain result from this injury, because paper is to describe a treatment and the results of the acute spontaneous flexion or extension force obtained in cervical lesions caused by this type as well as the reverse movement of recoil function, of injury. depending on which motion of the cervical area is In our series, there were 16 patients who were initiated. A majority of opinion indicates that the admitted for what we call chronic cervical sprain primary problem is usually the result of the recoil and strain, post-traumatic, due to whiplash mech- rather than the first thrust or motion. anism. In each case, the trauma was caused by an The force which is exerted on the head is tre- automobile accident. There were no gross osseous mendous. The neck is a rotating, extending, flexing, abnormalities on x-ray except for variable degrees and side-bending which is therefore extremely of spondylosis. mobile, supporting the average head which weighs approximately 8 to 9 pounds, with the base of the Pathogenesis neck, the fulcrum, and the forehead being used as the lever. It is possible, as has been reported in The mechanism involved in a majority of cases connection with airplane accidents, for the head reviewed here is a sudden forward motion of the of the victim to be found a hundred yards or more body caused by a force from the rear (rear-end away from the body, which is still in the wrecked collision with the patient's vehicle at standstill), plane. This, however, occurs only at extremely with a momentary posterior lag of the head and high speeds. In the more routine auto accident in- neck. Actually, the head and neck are at a stand- juries, the great flexibility of the cervical spine still as the body moves rapidly forward. There is fortunately gives protection against fractures and a sudden forceful extension of the neck, which is dislocations, even though the strain and sprain are quickly followed by flexion of the cervical spine as produced. The greater the acceleration, the greater the head is whipped forward from its posterior or the snap of the neck. There is no support at this backward position. The degree of movement in ex- time, because the muscles of the neck are relaxed. tension and flexion is evaluated as showing that Damage is done by both the hyperflexion and the the extension is less forceful than the flexion. hyperextension; however, hyperflexion is a compen- Figure 1 describes the altering force from the sation to overcome hyperextension. Were it not for the compensatory mechanism, even greater damage °Head of the Department of Surgery, and Chairman of the Ortho- pedic Division, Metropolitan Hospital. would occur. tSecond-year resident in ortheopedic surgery, Metropolitan Hospital. Regardless of the initiating force, if the car is

212 difficult at times to evaluate. If the violence of the injury is severe enough, this eliminates use of the terms "chronic cervical sprain and strain, post- traumatic, due to whiplash," and puts the injury B C into the category of acute hyperflexion syndrome, or fracture, dislocation, or even herniated disk. Fig. A is a representation of the normal sitting position in an automobile. B shows the acute hyperextension which is the Bony complications include fractures of the spinous first result of a rear-end collision, while C shows the acute hy- process and pedicle, and also forceful compression perflexion which follows as a recoil motion. fractures of the vertebral bodies, accompanied by acute hyperflexion. Although the vertebral bodies are strong enough to withstand much trauma, the acuteness of the situation, plus the extensive hyper- flexion and extension, will cause a maximum of damage. The pathology of cervical sprain and strain is entirely . There is a A C B stretching of the cervical muscles, ligamentous and Fig. 2. As in Figure I, A represents the normal sitting position capsular tearing, fascia' plane tearing, and even in an automobile. B shows the acute hyperflexion which first rupture of the smaller blood vessels. follows a sudden stop after rather high acceleration, and C shows the recoil function, acute hyperextension. It is our opinion that lesioning occurs in the arthrodials. This becomes more evident with the chronicity of the problem, and it is the basis of our present treatment. The entire ligamentous standing still and is struck from behind, or is going structure can be sprained; possible cartilaginous forward and strikes an object, varying pathologic damage with minimal or even hernia- changes will result. In the former, the strain and tion of an intervertebral disk may occur. This last sprain are common, and frequently are called also takes the injury out of the "sprain and strain" "whiplash" ; in the latter, the degree of force classification. may exceed the strength of the ligamentous and osseous structures, and the severe hyperflexion in- A post-traumatic neurosis or hysteria may also be present. Especially when litigation is one of the jury would result, with fracture and cord disrup- complicating factors, a patient's recovery is very tion. slow. However, it seems that he gets well excep- The pathologic changes that may evolve from tionally fast and has no more symptoms as soon as hyperflexion and hyperextension are multiple and there has been a settlement of the case. Symptoms The examination findings from a cervical strain and sprain, post-traumatic, due to whiplash injury, are very complex. The first thing is to take a very adequate history. It is important to remember that symptoms which can disable a patient may crop up years after the trauma. Naturally, it is necessary to know if all the positive findings are caused by the recent accident or stem back to before that time. The most pertinent findings usually include in the neck on either one or both sides, with radia- tion to the suboccipital area or down the spine into the . The pain may be constant or inter- mittent. There is restriction of motion of the cervi- cal spine on flexion, extension, side-bending, or rotation to either side, with palpatory tenderness over the middle and lower cervical musculature. The patient may have experienced a dazed or be- wildered sensation, which followed the accident immediately or even up to 24 hours later. Neu- rologically, the patients are negative. After a complete history is taken, the physical examination may be evaluated thoroughly. Again, this should be just as complete, both for helping to evaluate the patient and from the litigation stand- point. All neurologic tests should be performed, Fig. 3. A view of the normal cervical arch, as shown in view along with other examinations. A in Figures I and 2. The history and physical examination, along

JOURNAL A.O.A., VOL. 60, NOV. 1960 213 in the left side of the neck, radiating into the suboc- cipital area from the first thoracic vertebra. This first came on, to a mild degree, after an accident 111 which the other automobile hit the patient's auto broadside. This was 3 months prior to admis- sion. The pain was intensified after another acci- dent 6 weeks prior to admission when his auto was struck from behind. The pain was constant and aching in nature. On physical examination there was no pain, paracsthesia, or weakness in the or . The patient's posture was good, although there ap- peared to be a loss of cervical . tie was an extremely well-developed male. There was good, active motion of the cervical spine. Pain was noted in the left paracervical area on side-bending to the left or right, and there was a very positive response to Spurling's test on the left side. Sharp pain was induced at the extremes of all passive motions. All reflexes were equal and active. There was palpatory tenderness of the first thoracic and fourth cervical vertebrae on the left. No superclavicular abnormal- ities were noted, and shoulders were negative for Fig. 4. The cervical arch as it appears when the head is in pathologic change. There was no muscle atrophy extreme hyperflesion, showing the maximum compression force or sensory aberration, and the radial pulse was taking ploce at the fifth and sixth cervical levels. normal on elevation. Roentgenograms taken of the cervical area are reproduced in Figure 6. with the x-ray findings in this particular type of Treatment consisted of manipulation of the cer- case, will help to diagnose this injury. vical spine under general anesthesia, followed by 4 days of traction. The patient has had excellent Case reports results since the manipulation; there is no suboccip- ital pain and no cervical restriction or pain. The following are hvo typical cases: Case 2 • This patient, a man 32 years of age, was admitted with pain in the neck with minimal spread A 38-year-old man was admitted with pain Case 1 • into the right . Constant suboccipital pain had been present since an automobile accident with a whiplash type of injury. He had been treated with a Thomas collar, diathermy, and injections. Six months after the accident, the patient had pain on active and passive motion of the cervical spine. There was minimal palpatory tenderness over the middle and lower cervical musculature. X-rays (Fig. 7) indicated minimal degenerative arthritic changes. Treatment consisted of manipulation of the cervical spine under anesthesia, followed by cervical traction for 4 days. The patient had an ex- cellent result for 2 months, then a minimal recur- rence of occasional pain in the left scapular area, There was no suboccipital pain and no cervical restriction or pain. Treatment Immediately after the accident has occurred the therapy is rest. The patient is placed in cervical traction for up to 1 week, followed by soft-tissue manipulation, physical therapy which includes dia- thermy and ultrasound, and a Thomas collar. The main objective is to decrease the edema in the cervical region and bring about maximum healing Fig. 5. The cervical arch as it appears when the head is in extreme hyperextension. showing the maximum compression force of the tearing and stretching. at the fifth and sixth cervical levels. Unfortunately, most patients are first seen in the

2I4 such as a true subluxation, fracture, or dislocation. Here at Metropolitan Hospital, we have had 25 patients with cervical disorders who were treated by manipulation under anesthesia. Of these, only 12 were true cases of sprain and strain, post-tr.11- matic, due to whiplash. However, in discussion of our project with others, 4 more cases of cervical strains and were added, making a total of 16 cases which we can report. The stud y covers the past 3 years, with complete follow-up so far by either the authors or the other ph ysicians involved. Of the 16 cases, 14 patients are completely symp- tom-free at this writin g,. They were completely free of pain within 4 days after the procedure and have remained so thus far. As for the other two patients. one has a suit pending and is still complaining of his same symp- toms, but to a lesser degree. The last patient in- volved was treated b y another physician. His first manipulation had excellent results as the patient stated she had no pain at all. However, cervical traction was then applied incorrectl y by a nurse a few hours after the procedure was accomplished. and the patient ryas twisted into an awkward posi- tion. The next morning she had her oid pain back.

Fig. 6. A view of the cervical spine of the parIen n Case I. She was remanipulated 2 days later and now feels as good as before the accident. We are considering this a good result. Therefore, of the 16 cases in question, we have chronic phase, with a history of long disability and 93.75 per cent good results, and we think this can lack of results with the accepted form of treatment. be improved. It must be stated that no controls Because of this lack of previous response we started were run on this study. using manipulation of the cervical spine under anesthesia. The rationale for the procedure is that the whiplash mechanism induces a tear of the mus- cles and with hemorrhage. The hemor- rhage becomes fibrotic with organization, and ad- hesive formation occurs. There is also capsular arthrodial damage with mechanical derangement of the arthrodials, and secondary muscular spasm. The musculature is in part responsible for the derangement of the arthrodials. The patient is anesthetized with intravenous Pentothal sodium and curare is given for complete relaxation of the musculature. If the manipulation is attempted without complete relaxation, the en- tire procedure will be ineffective. Any individual with or without a strain and sprain, having a pain in the cervical region, will tend to tighten the musculature on palpation, and complete rotation of the neck is then almost impossible. When re- laxation has been obtained, with very gentle mo- tion the cervical spine is taken through its normal range with movement in all segments. The patient is then returned to his room and placed in cervical traction with sandbags on either side of the neck for 3 to 4 days. The only medication given is . The reason for traction and sandbags is to maintain the patient at complete rest until there is full recovery from manipulation. It should be remembered that treatment of this type can only Fig. 7. A view of the cervical spine of the por:en Case 2, be instituted if there are no other abnormalities, showing rn7nimal degenerative arthritic changes.

JOURNAL A.O.A., VOL. 60, NOV. 1960 215 Frankel, C. J.: Medical-legal aspects of injuries to neck. J. Am. Summary M. A. 169:216-223, Jan. 17, 1959. Gay, J. R., and Abbott, K. H.: Common whiplash injuries of Chronic cervical sprain and strain, post-trau- neck. J. Am. M. A. 152:1698-1704, Aug. 29, 1953. Gerber, A.: Cervical pain with associated brachial neuritis or matic, due to whiplash mechanism, has been mark- neuralgia. J. Am. Osteop. A. 51:225-231, Dec. 1951. edly benefited, in our hands, by manipulation under Gerber, A.: Problems of cervical spine. J. Am. Osteop. A. 56:172- 178, Nov. 1956. anesthesia with mobilization of all cervical seg- Gotten. N.: Survey of 100 cases of whip-lash injuries after settle- ments. This has proved an effective form of therapy ment of litigation. J. Am. M. A. 162:865-867, Oct. 1958. Vernon, S.: Whip-lash injury and liability. Am. J. Surg. 94:535- for this persistent and disabling problem. 536, Oct. 1957. Wright, J. M.: Whiplash injuries, management and complications. Cammack, K. V.: Whip-lash injuries to neck. Am. J. Surg. 93:683- J. Am. Osteop. A. 55:564-568, May 1958. 666, April 1957. Editorial: Injuries of cervical spine. Lancet 1:772, April 11, 1959.

Acute appendicitis in a premature infant associated with Pseudomonas septicemia and agranulocytosis

BERNARD KAY, D.O.,f and MYRON S. MAGEN, muscle tone was good with reflexes being reported D.0.1 Des Moines, Iowa as normal. The cardiac rate was 136 per minute, and the rhythm and intensity were normal. No respiratory distress was evident. While there has been a marked reduction in mor- The mother was a gravida I para 0, in apparent tality in acute appendicitis concomitant with rapid good health. The father was in the Armed Forces; advances in surgical and antibiotic therapy, this the mother had been under obstetric care since the does not hold true for those cases seen in infancy. fourth month of gestation in another state. The In addition, the presence of a coexisting disease exact length of the pregnancy was unknown, but renders the diagnosis of acute appendicitis more it was estimated that the patient was in the seventh difficult and increases the incidence of perforation. calendar month. The mother's blood type was A+. It is the purpose of this paper to present a case Labor had started 3 hours before delivery. of acute appendicitis with perforation in a pre- Routine nursery care was instituted with the ad- mature white male infant, complicated by Pseu- dition of chloramphenicol, 25 mg. intramuscularly domonas septicemia and agranulocytosis. every 12 hours, and penicillin, 150,000 units intra- muscularly every 12 hours. Feedings were withheld Case report for the first 24 hours. On the second hospital day (December 20), when the first weight was ob- A white male premature infant was delivered in tained, the infant weighed 3 pounds 11 ounces. a car in the parking lot of the hospital on December Feedings were started at 24 hours of age and the 18, 1958. He was admitted to the pediatric ward infant sucked well with all feedings being retained. and placed in an incubator for warmth. Initial Antibiotic therapy was discontinued on the fifth examination revealed an active premature infant, hospital day (December 23). The infant's condi- whose color was pink and cry was strong. The tion was apparently good until the eighth day when slight icterus was noted and sucking appeared to • Written in partial fulfillment of requirements for a pediatric resi- dency. tire the infant. At this time nasogastric tube feed- tResident in pediatrics, Still Osteopathic Hospital. ing was instituted. That evening the infant's rectal =Associate Professor, Pediatrics, College of Osteopathic and Surgery. temperature elevated to 100 F. Weight at this time

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