MRI and Whiplash: What Have We Been Missing?
ABSTRACT & COMMENTARY
Source: Borchgrevink G, et al. MRI of cerebrum and cervical columna within two days after whiplash neck sprain injury. Injury 1997;28:331-335.
In a study from norway, borchgrevink and colleagues sought to answer the question of whether patients with whiplash symptoms have structural abnormalities that would be missed by plain film or physical examination. Borchgrevink et al examined 46 patients with neck sprain injury after car crash by performing magnetic resonance imaging (MRI) of the brain and neck within two days of the crash. They also studied a group of volunteers by MRI with no neck injury as a control group. MRI examinations were performed with state-of-the-art imaging equipment and were blindly evaluated by two observers. These observers recorded the presence or absence of any intracerebral lesions, widening of cerebral sulci, increased amounts of cerebral spinal fluid, large ventricles, or enlarged perivascular spaces. Neck findings were classified as positive or negative for postural abnormalities (loss of cervical lordosis), disk pathology, hematomas, spinal canal or foraminal stenosis, spinal cord lesions, ligamentous lesions, vertebral lesions, pre-existing spondylosis, neck muscle bleeding, edema, or other soft tissue injuries.
Plain film radiographs were also performed at the time of the first visit and six months later. Physical examination, including neurological exam, was performed within two days of the crash, and again at two weeks, six weeks, three months, and six months after the crash. Patients were questioned about the presence of whiplash symptoms at these visits and again at one year via questionnaire.
There were no differences in the MRIs of the brain between the crash patients and the control group. Likewise, in the neck, there were no soft tissue changes to indicate bleeding or edema in any of the cervical images of any of the crash patients. Of all possible pathologic findings, there were no differences between the group of crash patients and the normal volunteers with respect to posture abnormalities, disk pathology, or pre-existing spondylosis. All patients found to have ligamentous lesions, neural foraminal stenosis, or spinal stenosis also had both disk pathology and pre-existing spondylosis.
In spite of the absence of new structural pathology on MRI, a high percentage of patients had subjective symptoms at six months and one year, including headache, neck pain, and, most commonly, neck stiffness. Those patients with disk pathology and spondylosis had more subjective symptoms than those patients with no structural pathology.
In summary, there were no significant differences in MRI exam or the neck or brain between patients in motor vehicle crash with whiplash and the uninjured volunteers. Also, MRI findings could not predict development of whiplash syndrome during the one year following motor vehicle crash. There was no MRI evidence of bleeding or edema in the soft tissues of the neck or in the brain.
Comment by Jeffrey W. Runge, MD, FACEP
Motor vehicle crash is the most frequent etiology of injury seen in emergency departments in the United States. The most common diagnosis of patients in rear-end crashes is cervical muscle strain, also commonly known as "whiplash." Whiplash syndrome results in many lost workdays and high medical and legal liability costs. The paucity of physical and plain radiography findings seems to belie the frequency and severity of subjective symptoms of the patients. One wonders if we have been missing something that more sensitive imaging techniques could detect.
This study suggests that the lack of objective physical examination and radiographic findings in whiplash has been correct. In this study, careful MR imaging techniques have failed to detect structural abnormalities, such as muscle bleeding and edema that may be missed clinically and by x-ray. It also confirms earlier tenets of treating neck strain and sprain: Patients with pre-existing neck pathology are at higher risk for subjective symptoms after a whiplash injury. Because of the lack of objective findings, we are left with only the patient’s subjective complaints to define the degree of functional pathology present. In more lenient employment cultures, such as in Europe, patients frequently miss many weeks and sometimes months of work for common whiplash syndrome. This is the type of evidence needed to be certain that we are unlikely to harm patients by sending them back to normal activity sooner than their subjective symptoms may dictate.
For patients without previous disk or cerebral pathology, functional recovery should be expected without complication. It seems that the time-tested strategy of ice, ibuprofen, and short-term rest has merit after all.
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