Whiplash Injury

Spondylosis , Spondolysis and Spondylolisthesis

Dr. Kashif Abbas

Resident Orthopaedics
FFH Rawalpindi
WHIPLASH INJURIES
Definition
• as “bony or soft tissue injuries” resulting “from rear-end or side
impact, predominantly in motor vehicle accidents, and from other
mishaps”
• as a result of “an acceleration-deceleration mechanism of energy
transfer to the neck”
Classification of Whiplash Associated
Disorders

• Grade 0 ; No complaint about the neck. No physical sign(s)

• Grade I ; Neck complaints of only pain, stiffness or tenderness. No
physical sign(s)
• Grade II ; Neck complaints AND musculoskeletal sign(s) Musculoskeletal
signs include decreased range of motion and point tenderness
• Grade III ; Neck complaints AND neurological sign(s) Neurological signs
include decreased or absent tendon reflexes, weakness and sensory
deficits
• Grade IV ; Neck complaints AND fracture or dislocation.
Clinical Presentation
• Neck pain or stiffness
• Arm pain and paresthesias
• Temporomandibular dysfunction
• Headache
• Visual disturbances
• Memory and concentration problems
• Psychological distress
• Psychosocial Symptoms
• Depression
• Anger
• Fear
• Anxiety
Investigations
• Xrays
• Cervical Spine AP and Lateral Views
• Flexion and Extention views

• CT Scan

• MRI
Radiograph Findings
• Most Common X-Ray Findings
• Preexisting degenerative disease
• Slight loss of the normal lordotic curve of the cervical spine
s
MRI and CT-SCAN
• MRI and CT is not generally indicated at initial presentation due to
high false positive results
• CT and MRI are reserved for:
• Suspected disc or spinal cord injury
• Fracture
• Ligamentous injury
• Persistent arm pain
• Neurologic deficits or clinical signs of nerve root compression
Incidence
• Incidence Based on US population evaluation
• More than 300 persons per 100,000 population evaluated each year
Poor Prognostic Factors
Predictors of Poor Prognosis
• Increased symptom severity
• Neurological signs
• Feelings of helplessness in controlling pain
• Fear of movement
• Anxiety
• Low educational level
Treatment
• Active exercise including functional, range of motion, strengthening of
neck and scapular muscles and strengthening of deep neck flexors
• Advise ‘act as usual’, reassurance and education
• Short term NSAIDs and non-opioid analgesics
• Passive modalities: heat, massage, & U/S therapy.
• No collars
• Greater Occipital Nerve Blocks for occipital neuralgia.
Spondylolisthesis
• Defined as slippage of one vertebrae over an other vertebrae.
• Epidemiology
• Incidence
• Spondylolisthesis is seen in 4-6% of population.
•  Increased prevalence in sports that involve repetitive hyperextension (gymnasts,
weightlifters, football linemen).

• Location
• 82% occur at L5/S1
• 11% occurs  L4/5 (11%)
• due to forces in the lumbar spine being greatest at these levels and the facet being more
coronal.
Pathophysiology
• Foraminal stenosis

• Adult isthmic spondylolisthesis at L5/S1 often leads to radicular symptoms

caused by compression of the exiting L5 nerve root in the L5-S1 foramen.

• Compression can be caused by

• Hypertrophic fibrous repair tissue of the pars defect
• Uncinate spur formation of the posterior L5 body
• Bulging of the L5/S1 disc
• Lateral recess stenosis
• caused by facet arthrosis and hypertrophic ligamentum flavum.

• Central stenosis
• rare due to fact that these slips are usually only Grade I or II.
Progression of Slip
• Relatively few patients (5%) with spondylolysis with develop
spondylolisthesis.

• Slip progression more common in females.

• Slip progression usually occurs in adolescence and rare after skeletal

maturity.
Classification
•  Wiltse-Newman Classification
 
• Type I • Dysplastic: a congenital defect in pars 

• Type II  • Isthmic

•  Type III • Degenerative: facet instability without a pars fx 

•  Type IV • Traumatic: acute posterior arch fx other than pars 

•  Type V • Neoplastic: pathologic destruction of pars

Radiograph Based Classification
• Myerding Classification

•  Grade I • < 25%

•  Grade II • 25-50%
•  Grade III • 50-75% 
•  Grade IV • 75-100% 
•  Grade V • spondyloptosis
Clinical Presentation
• Symptoms
• Axial back pain
• Most common presentation
• Pain usually has a long history with periodic episodes that vary in intensity and duration
• Leg pain
• Usually a L5 radiculopathy usually caused by foraminal stenosis at the L5-S1 level
• Neurogenic claudication
• Caused by spinal stenosis
• Characterized by buttock and leg pain worse with walking
• Cauda equina syndrome
• Rare because these slips rarely progress beyond Grade II
• Physical exam
• L5 radiculopathy
• Ankle dorsiflexion and EHL weakness
Imaging
• Radiographs
• Recommended views
• Obtain AP, lateral, obliques, and flexion-extension views
• Findings
• AP
• Deformity in coronal plane
• Lateral
• Will see spondylolisthesis and pars defect
• Flexion-extension
• Instability defined as 4 mm of translation or 10° of angulation of motion compared to
adjacent motion segment
• MRI
• T2 parasagittal images are best study to evaluate for foraminal stenosis and
compression of neural elements
Treatment
• Nonoperative

• Oral medications, lifestyle modifications, therapy 

• Indications
• Most patients can be treated nonoperatively
• Techniques
• Activity restriction
• NSAID
• Role of injections unclear
• Bracing may be beneficial especially in the acute phase
• Operative
• L5-S1 decompression and instrumented fusion +/- reduction
• Indications
• L5-S1 low-grade spondylolisthesis with persistent and incapacitating pain that has failed
6 months of nonoperative management (most common)
• Progressive neurologic deficit
• Slip progression
• Cauda equina syndrome
• Reduction
• improved sagittal balance with reduction
• risk of stretch injury to L5 nerve root with reduction 
Complications

• Psuedoarthrosis
• Dural Tear
Spondylolysis
• Spondylolysis term used to describe anatomic defect (radiolucent
gap) in pars interarticularis with adjacent bone sclerosis

• Epidemiology
• one of most common causes of back pain in children and adolescents
• defects are not present at birth and develop over time (seen in 4-6% if
population)
• Mechanism

• usually activity related and occurs from repetitive hyperextension

• prevalence as high as 47% in certain athletes (gymnasts, weightlifters, football
linemen)
Imaging

• Radiographs
• Lateral radiograph
• may show defect in pars in 80% 
• Oblique radiograph
• views may show sclerosis and elongation in pars interarticularis (scotty dog sign) 
• AP
• may see sclerosis of the stress reaction 
• Bone scan
• most sensitive (however lesion may be cold) 
• excellent screening tool for low back pain in children or adolescents
• CT 
• best study to diagnose and delineate anatomy of lesion 
• pars stress reaction will show up as sclerosis on xrays and CT scan

 
• Single photon emission computer tomography (SPECT)  
• best diagnostic adjunct when plain radiographs are negative
Treatment
• Nonoperative
• Observation with no activity limitations
• indications
• asymptomatic patients with low-grade spondylolisthesis or spondylolysis 
• may participate in contact sports 

• Physical therapy and activity restriction

• indications
• symptomatic isthmic spondylolysis
• symptomatic low grade spondylolisthesis
• technique
• physical therapy should be done for 6 months and include 
• hamstring stretching
• pelvic tilts
•  abdominal strengthening 
• TLSO bracing for 6 to 12 weeks

• Indications
• acute pars stress reaction spondylolysis
• isthmic spondylolysis that has failed to improve with physical therapy
• low grade spondylolisthesis that has failed to improve with physical therapy
• Outcomes
• brace immobilization is superior to activity restriction alone for acute stress reaction
 spondylolysis
Complications

• Neurologic deficits
• Pseudoarthrosis
• Progression of slippage
• Hardware failure 
Spondylosis
• Spondylosis is a natural aging process of the spine

• characterized by degeneration of the disc and the four joints of the

cervical motion segment which include
• two facet joints
• two uncovertebral joints
• Degenerative cycle includes
• Disc degeneration
• disc desiccation, loss of disc height, disc bulging, and possible disc herniation
• Joint degeneration
• uncinate spurring and facet arthrosis
• Ligamentous changes
• ligamentum flavum thickening and infolding secondary to loss of disc height
• Deformity
• kyphosis secondary to loss of disc height with resulting transfer of load to the facet and
uncovertebral joints, leading to further uncinate spurring and facet arthrosis
• Mechanism of Neurologic Compression
• Nerve root compression
• leads to the clinical condition of radiculopathy
• Central cord compression (central stenosis)

• leads to the clinical condition of myelopathy

• occurs with canal diameter is < 13mm (normal is 17mm)

• worse during neck extension where the central cord is pinched between
• degenerative disc (anterior)
• hypertrophic facets and infolded ligamentum (posterior)
Presentation
• Clinical Presentation
• Axial neck pain
• Cervical Radiculopathy 
• Cervical Myelopathy 
Imaging
• Imaging
• Radiographs
• common radiographic findings include
• degenerative changes of uncovertebral and facet joints
• osteophyte formation
• disc space narrowing
• endplate sclerosis
• decreased sagittal diameter (cord compression occurs with canal diameter is < 13mm)
• Lateral
• important to look for sagittal alignment and size of spinal canal

• Oblique
• important to look for foraminal stenosis which often caused by uncovertebral joint
arthrosis

• Flexion and extension views

• important to look for angular or translational instability
• look for compensatory subluxation above or below
• MRI
• axial imaging is the modality of choice and gives needed information on the
status of the soft tissues. It may show
• disc degeneration
• spinal cord changes (myelomalacia)
• preoperative planning
• CT myelography

• can give useful information on bony anatomy

• most useful when combined with intrathecal injection of contrast
(myelography) to see status of neural elements
• contrast is given via C1-C2 puncture and allowed to diffuse caudally or given
via a lumbar puncture and allowed to diffuse proximally by putting the patient
in Trendelenburg position.
• particularly useful in patients that can not have an MRI (pacemaker) or has
artifact from hardware
TREATMENT
• NSAIDS
• STERIODS
• MUSCLE RELAXANTS
• ANTIDEPRESSANTS
• ANTISEIZURE MEDICATIONS
THANK YOU