10 Injury (1987) 18, 10-12 Printedin GreatBritain

Neck sprain-a major cause of disability following car accidents

G. T. Deans, J. N. Magalliard, Malcolm Kerr* and W. H. Rutherford

The Accident and Emergency Department, Royal Victoria Hospital, Belfast

Summary One hundred and thirty-seven patients attending hospital following road traffic accidents were contacted regarding pain in the neck between 1 and 2 years later. Eighty-five (62 per cent) stated that they had suffered pain in the neck at some time following their accident compared with 42 (30.6 per cent) who were noted to have pain in the neck when ex- amined soon after the accident. Thirty-one patients (22.6 per cent) still felt occasional pain 1 year after the accident and 5 had continuous pain at 1 year. Pain in the neck occurred irrespective of the direction of impact but was dispro- portionately common in rear impact accidents. Patients wear- irig seat belts experienced pain more frequently than unbelted patients.

INTRODUCTION A RECENT multicentre survey reported that sprains of the neck occurred in 18.5 per cent of patients attending hospital following road traffic accidents (Rutherford et al., 1985). The incidence was noted to rise following the compulsory wearing of seat belts in the United King- dom on 1 January 1983. Most patients had their injuries documented within a few hours of the accident. It was realized that this might underestimate the extent of the condition since patients with multiple injuries might not mention pain in the neck while in hospital, yet might later experience considerable disability. Similarly, pa- tients with minor injuries may develop pain only after leaving hospital. It was therefore decided to study patients from one of the participating hospitals to see if the true incidence of pain in the neck might be higher than that originally reported.

METHOD The study was performed on car occupants already included in the multicentre study (Rutherford et al., 1985), who attended the Royal Victoria Hospital, Bel- fast, following road traffic accidents during a 6-month period in 1982 and 1983. Patients were contacted by questionnaire between 1 and 2 years after their acci- dent. The questionnaire asked the direction of impact; whether the car had been moving; the presence of previous pain in the neck and if such pain occurred after the accident, its time of onset and duration. The resultant coded information was added to data already collected in the multicentre study. After 39 per cent of the patients had been contacted, it was realized that there might be a suggestion of pain in the neck in the

* Belfast Monica Project.

questionnaire. From then on patients were contacted by telephone or personal visit, care being taken to avoid any suggestion of pain in the neck. Only if the patient volunteered the presence of pain in the neck was the remaining information on the questionnaire sought.

Controls were obtained from a random subsample of the World Health Organization’s Monica Project on cardiovascular diseases in Belfast. They were asked about pain of at least 1 week’s duration anywhere around the body, from which the incidence of pain in the neck in the local community was determined.

PATIENTS Between 1 February and 31 July in both 1982 and 1983, respectively 108 and 67 car occupants attended the hospital following car accidents. Thirty-eight proved untraceable, leaving 137 patients in the study. Seventy- four were men (54 per cent) and 63 women (46 per cent), the minimum age being 12 years. No patient sustained cervical fractures or dislocations.

FINDINGS Eighty-five patients (62 per cent) complained of pain in the neck following their accident. In 36 (26.3 per cent) the pain lasted more than 1 year, 31 (22.6 per cent) experiencing occasional pain and 5 (3.7 per cent) severe continuous pain. Ten patients (7.3 per cent) had suf- fered pain in the neck before their accident. The acci- dent was caused by a rear impact in 31 patients, in 14 of which the patient’s car was moving at the moment of impact. Table I shows the distribution of patients according to the time of onset of pain and Table II the duration of the pain. Table III shows the association of pain in the neck with the various other factors that were sought. Of the five patients who experienced con- tinuous pain at 1 year, two had front impact, two side impact and one a rear impact collision. Their ages

Table 1. Distribution of 85 patients with pain in the neck by onset of pain

Time of onset of pain No. of patients

<I2 hours 66 (778%) 12-23 hours 11 (13%) 2447 hours 2 (2.4%) >48 hours 6 (7%)

Deans et al.: Neck sprain following RTAs 11

Table //. Distribution of 85 patients with pain in the neck by duration of pain

cent), implying that patients answered our questions honestly.

Duration of pain

1 week 1 week-l month l-3 months 4-6 months 7-12 months 12 months occasional 12 months constant

No. of parienrs

15 (18%) 15 (18%) 11 (13%) 7 (8%) 1 (1%)

31 (36%) 5 (6%)

There was no significant difference in the incidence of pain between those to whom the questionnaire was posted and those contacted personally. It was possibly a mistake in the original study design to use a question- naire which might have suggested pain in the neck to patients, but in the event this did not seem to distort the results.

ranged from 14 to 59 years, with two having a previous history of pain in the neck.

The incidence of pain in the neck among the controls was 7.2 per cent.

DISCUSSION A primary aim of our study was to see if the original examination identified all those who suffered pain in the neck as a result of the accident. The original hospital examined noted 30.6 per cent of patients to have sprains of the neck which is higher than the 1.5 per cent reported in a similar questionnaire study (Larder et al., 1985). However, at follow-up 62 per cent claimed to have suffered pain in the neck. Thus if a person in a car accident sustains an injury of sufficient severity to make him attend hospital, he has a 62 per cent chance of suffering pain in the neck.

Thirty-six patients (26.3 per cent) still experienced pain in the neck 1 year after their accident (22.6 per cent intermittently and 3.7 per cent continuously). The figure of 8 per cent with pain at 6 months reported by Larder et al. (1985) corresponds fairly well with our figure of severe continuous pain. However, figures for persistent pain of 75 per cent at 6 months (Schutt and Dohan, 1968) and 66 per cent at 2 years (Norris and Watt, 1983) are also reported. It is those with persistent symptoms who cause the greatest concern. Nygren (1984) reported permanent medical disability in 9.6 per cent of rear impact victims and 3.8 per cent of front or side impact victims. Juhl and Seerup (1981) found that 38 per cent of patients took sick leave or were unem- ployed due to cervical injury. Larder et al. (1985) reported that 59 per cent felt the injury interfered with their daily lives.

Pain in the neck would be under-recorded at hospital if it were not felt immediately after the accident. At follow-up, 22 per cent of patients felt their pain had started at least 12 hours after their accident, which is very similar to previous studies (Norris and Watt, 1983; Larder et al., 1985).

The incidence of pain in the neck (62 per cent) was nine times greater than that in the community (7.2 per cent). The rate for the community was similar to the incidence in patients before their accidents (7.3 per

Regarding the direction of impact, our series confirms previous reports (Skates et al., 1969; Wiggins, 1969; Hohl, 1975; Juhl and Seerup, 1981; Thomas et al., 1982; Nygren, 1984) showing that pain in the neck occurs after impact from any direction but is dispro- portionately common after rear impact accidents. Although our incidence of pain from rear impacts is higher than that in some reports (Hohl, 1975; Skates, 1975; Larder et al., 1985), our findings confirm that rear impacts cause pain in the neck almost twice as frequently as frontal collisions (Larder et al., 1985).

Earlier reports stated that pain in the neck following car accidents was more common in women (Schutt and Dohan, 1968; Skates et al., 1969; Thomas et al., 1982;

Table 111. Distribution of patients by method of approaching patient, seating position, belted or not, direction of impact and the presence or absence of pain in the first record

Pain ar any rime Pain >7 year No pain Total x2 P

Contacted by letter 34 (63%) 10 (19%) 20 (37%) 54 3.94 Contacted personally 51 (61%) 26 (31%) 32 (39%) 83 2 DF NS

Driver 46 (67%) 20 (29%) 23 (33%) 69 Front seat passenger 29 (62%) 11 (23%) 18(38%) 47 2.92 NS Rear seat passenger 10 (48%) 5 (24%) 11 (52%) 21 4DF

Belted 45 (73%) 21 (34%) 17 (27%) 62 6.07 0.05 Unbelted 40 (53%) 15 (20%) 35 (47%) 75 2 DF

Front or side impact 58 (56%) 25 (24%) 46 (44%) 104 8.22 Rear impact 26 (84%) 10 (32%) 5(16%) 31 2 DF 0.05 Not known 1 1 1 2

Pain in 1st record 38 (90%) 17 (40%) 4(10%) 42 21.33 No pain in 1st record 46 (49%) 19 (17%) 48 (51%) 94 2 DF 0.01 Not known 1 0 0 1

O-29 years 52 (67%) 19 (24%) 26 (33%) 78 30-49 years 17 (52%) 7 (21%) 16 (48%) 33 4.95 NS >50 years 15 (63%) 9 (38%) 9 (38%) 24 4DF Not known 1 1 1 2

The percentages relate to the totals of patients shown in the total column.

12

Larder et al., 1985). Our results, however, are similar to those of Hohl(l975) in that, although pain was more common in women, the difference was not statistically significant.

There were more sprains of the neck among the belted than the unbelted. This result could be because the number of sprains of the neck remained unchanged or decreased slightly while the total number of patients was reduced even more because of a greater effect on other organs and regions of the body. This explanation is unlikely, because Rutherford et al. (1985) have showed that in the year after the compulsory wearing of seat belts, there was an absolute increase of 198 pa- tients with sprained necks attending the 14 hospitals included in their study.

We do not know how many of our patients were involved in litigation. Macnab (1965) reported that 2 years after settlement, 45 per cent of patients still had symptoms. Gotten (1956) found that after settlement, 12 per cent of patients continued to suffer discomfort that was sufficiently severe to interfere with their work.

Soft-tissue injury of the neck appears to be a very common result of car accidents. The resulting pain may continue for a long time and seriously disrupt the working and social activities of patients. It occurs fre- quently in both front and back seat passengers. Head rests reduce the incidence in rear impact accidents by a mere 11-24 per cent (Hohl, 1975; Thomas et al., 1982; Larder et al., 1985). It is difficult to see a simple method of preventing this injury in front or side im- pacts except by a general reduction in speed.

Acknowledgements We are grateful to the Department of Health and Social Security for a research grant, to Dr Chris Patterson, Department of Medical Computing and Statistics, who helped with the statistical tests, and to Mrs Marie Loughran for typing the manuscript.

Injury: the British Journal of Accident Surgen/ (1987) Vol. 18/No. 1

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Paper accepted 21 April 1986.

Requestsfor reprints should be addressed to: Mr W. H. Rutherford, Accident and Emergency Department, Royal Victoria Hospital, Belfast BT12 6BA.