Actu Radiologicu 36: (1995) 425-428 Printed in Denmark . All rights reserved

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ACTA R A D I O L O G I CA ISSN 0248-1851

MR IMAGING AND RADIOGRAPHY OF PATIENTS WITH CERVICAL HYPEREXTENSION-FLEXION INJURIES AFTER CAR ACCIDENTS

GRETHE E. BORCHGREVINK’, OLAUG SMEVIK~, ASBJON NORDBY3, PETER A. RINCK2, T. c. STILES4 and I. LEREIM’

I Abstract

Fifty-two patients underwent MR imaging and conventional radiography of the neck within 4 days after a hyperextension-flexion injury. The patients also had follow-up investigations during the first 2 years. The images did not reveal any serious lesions in any of them. Based on the main MR and radio- graphical findings the patients were divided into 4 groups; no findings, posture abnormalities, spondylosis and disc pathology (from MR images) or reduced intervertebral space (from the radiographs). The outcomes of the different groups were compared with reference to neck stiffness, neck pain and headache during a 2-year follow-up period. The patient groups did not correspond com- pletely when diagnosed from MR imaging and radiography. However, pa- tients with pre-existing spondylosis had more symptoms when examined by both modalities. Based on the radiographs, the group with posture abnormali- ties had significant fewer symptoms than the other groups.

Cervical hyperextension-flexion injuries are usually caused by car collisions and the mechanism of the injury is often referred to as “whiplash”. A characteristic of hyperextension-flexion injury is the occurrence of considerable pain and prolonged disability in spite of failure to observe objective signs of pathology by traditional investigations. The most common symptoms are neck pain and neck stiffness. In hyperextension-flexion injury ex- periments in monkeys MACNAB (7) found tearing of the anterior longitudinal ligament, separation of the disc from the vertebrae, retropharyngeal haematomas in the muscle layer of the oesophagus and muscle injuries affecting the sternocleidomas-

Grethe E. Borchgrevink‘, Olaug Smevik2, Asbjon Nordby3, Peter A. Rinck2. T. C. Stiles4 and I. Lereim’ ‘The Emergency Clinic, 2MR-Centre Medical Section, 3Department of Radiology, Trondheim University Hospital; and 4Department of Psychiatry and Behavioural Medicine, University of Trondheim, Trondheim, Norway.

Key words: Neck injuries; MR imaging; radiography.

Correspondence: Grethe Borchgrevink, Emergency Clinic, University Hospital, N-7006 Trondheim, Norway. FAX *47-73-99 73 43.

Accepted for publication 7 November 1994.

toideus and longus colli muscles. OMMAYA et al. (12) found superficial haemorrhages of subdural nature in the cerebrum, in the brain stem, and in the cervical cord, although there were haemor- rhages only in monkeys that were concussed.

The aim of the present study was 3-fold: 1) to use the acute MR findings to reveal pathology of clin- ical significance; 2) to examine the relation between the acute MR findings with subjective symptoms during a 2-year follow-up period; and 3) to consider the benefit of MR imaging in relation to conven- tional radiography. The study was prospective and included 52 whiplash patients who underwent cervi- cal MR imaging within 4 days after the injury.

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G . E. BORCHGREVINK ET AL.

Material and Methods

Fifty-two patients with hyperextension-flexion in- jury were examined at our Emergency Clinic. They were living in or near the city of Trondheim and were examined within 4 days following a car colli- sion. Patients with radiographically disclosed frac- ture of vertebrae or clinical signs of nerve root compression were excluded (5, 6, 13). There were 30 women (58%) and 22 men (42%) and their ages varied from 18 to 66 years (mean 34.5212.3).

All patients underwent clinical investigation by the same doctor. Previous neck pain and other symptoms were recorded at the first consultation. The clinical investigation was repeated after 2 weeks, 6 weeks, 3 months, and 6 months. After 1 and 2 years the patients were contacted by tele- phone. At the 3-month examination, 2 women were missing due to hospitalisation for other ill- nesses. At the 6-month examination 1 man and 1 woman were missing and after 1 year yet another woman.

At the first consultation previous episodes and present intensity of symptoms were rated by the interviewer (G. E. B.) on a scale graded no, moder- ate or severe symptoms. At each of the follow-up assessment points symptom discomfort was rated by the same interviewer as frequency of symptoms on a scale graded never, sometimes, every day and constant. The primary symptoms assessed were neck pain, neck stiffness and headache. Other symptoms measured were shoulder stiffness, pain in the back or chest, difficulties with memory or concentration, buzzing in the ears, dizziness, nausea, diminished vision, insomnia, consumption of analgesics, depression and anxiety.

M R examinations. Fifty-one patients had an MR examination within 4 days (1 patient didn't manage to get through the investigation). The first 20 patients had a follow-up investigation after 6 weeks. The examinations were randomly per- formed at a 0.5 T (Gyroscan S 5, Philips) or 1.5 T (Gyroscan S 15, Philips) equipment employing sagittal images at a slice thickness of 5 mm and an FOV of 259. For T1-weighted images the following SE sequences were used: TR/TE 594/30 ms at 0.5 T and TR/TE 500/20 ms at 1.5 T. For T2-weighted images the following GRE sequences were used: TR/TE/flip angle 494/28 ms/18" (at 0.5 T) and TR/ TE/flip angle 371/16 ms/12" at 1.5 T. A head coil was used. In the MR images the following abnor- malities were looked for: Posture abnormalities (loss of cervical lordosis), disc pathology, bleeding in muscles and other soft tissue injuries, haema- tomas, spinal canal and root canal stenosis, spinal cord injuries, ligament tears and "sprain" injuries, vertebral pathology and pre-existing spondylosis.

The patients were grouped according to the main MR findings into 4 groups; no findings, only pos- ture abnormalities, pre-existing spondylosis and disc abnormalities (disc protrusion and reduced signal) without signs of spondylosis.

Cervical radiography. The patients also under- went cervical radiography at the first consultation, within 4 days after the accident. The radiographs were exposed in lateral, a.p. and oblique projec- tions, and the dens axis was imaged in an open- mouth position. Radiography was repeated after 6 months. The radiographs were checked for posture abnormalities, vertebral pathology, changes of in- tervertebral space and spondylosis. The radio- graphical findings were also arranged into 4 groups; no findings, posture abnormalities, re- duced intervertebral space and spondylosis.

Statistics. Separate overall analyses of variance were used to compare the various groups regarding age, while gender was tested by the Chi-square test. Significant 4-group ANOVAs were followed up with 2-group ANOVAs. Differences between the groups in symptom discomfort were assessed by the Kruskal-Wallis test followed by the Mann- Whitney U-test. The non-parametric tests were corrected for ties when appropriate (14). A p-value <0.05 was considered significant.

Results

Twenty-four of the 52 patients described the speed at the collision to be faster than 50 kdhour .

The most prominent symptoms were headache, neck pain and neck stiffness. Other symptoms did not give discomfort for most of the patients in the same way.

The M R imaging findings revealed no sign of pathology with blood or oedema in the soft tissues.

There were 14 patients (7 women, 7 men, mean age 30.5 years) without any findings. In this group, 2 had an MR follow-up after 6 weeks with the same negative result.

Eighteen patients had posture abnormalities (loss of lordotic curvature) as the only finding (10 women, 8 men, mean age 28.3 years). In this group, 8 had MR follow-up investigations. After 6 weeks

Table 1

Percentage of patients reporting severe episodes of symptoms prior to the accident and within 4 days following the accident

Neck Neck Headache, stiffness, pain, YO

% %

Previous episode of discomfort 10 10 17 Acute (within 4 days) 35 27 17

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CERVICAL HYPEREXTENSION-FLEXION INJURIES

Table 2 Percentages of patients reporting daily and constant discomfort

from symptoms during the follow-up period

Neck Neck Headache, stiffness, pain, %

% Yo

After 2 weeks 45 41 22 After 6 weeks 39 31 13 After 3 months 34 26 12 After 6 months 29 19 15 After 12 months 9 9 9 After 24 months 1 1 9 9

6 patients had improvement or normalisation of the neck posture abnormality.

Twelve patients had disc abnormalities without signs of spondylosis (9 women, 3 men, mean age 37.3 years). All these patients also had abnormal spinal posture in the neck. Three had disc abnor- malities at more than 1 level. The most frequent level with disc pathology was around C5-C6 (8 pa- tients). Ten of the patients had disc protrusions (anterior protrusion in 4 patients, posterior pro- trusion in 4 patients and both anterior and pos- terior' protrusion in 2 patients). Two patients had reduced signal of the disc and 1 had ligament ten- sion because of disc protrusion. In none of the cases did the disc abnormalities interfere with the spinal canal. Six of the patients in this group had a follow-up MR investigation after 6 weeks. The disc pathology had disappeared in 3 of the cases; 2 of these had normalisation of protrusion and 1 had normalisation of reduced disc signal. The con- comitant posture abnormalities had normalised or improved in 5 cases.

Seven patients (4 women, 3 men, mean age 52.4 years) had spondylosis which was supposed to be a pre-existing pathology. Five patients had osteo- phytes at 2 levels and 1 patient at 3 levels. Two had ligament strain because of osteophytes and disc protrusion. Four had spinal canal narrowing and 4 had disc pathology. In this group, 4 underwent follow-up investigations and there were no changes of the findings.

Radiographical $ndings. Fourteen patients (9 women, 5 men, mean age 32.6 years) had no radio- graphical findings. Of those, 8 had no findings on MR imaging. However, 5 patients were diagnosed as having posture abnormalities and 1 patient had disc protrusion on the MR images.

Twenty-two patients (1 1 woman, 1 1 men, mean age 27.8 years) had posture abnormalities as the only finding on the radiographical investigation. The MR diagnosis of 11 of these was posture ab- normalities, 5 had disc pathology, 1 spondylosis, and 5 had no pathological findings.

At radiographical investigation 9 patients (7 women, 2 men, mean age 40.0 years) were diag- nosed as having reduced intervertebral space. Three of them had disc pathology on the MR im- ages, 3 posture abnormality only, 1 had spon- dylosis and 1 had no finding. One patient did not manage to complete the MR investigation.

The radiography group with spondylosis con- sisted of 7 patients (3 women, 4 men, mean age 49.2 years). After MR investigation 5 of them had the same diagnosis. Two had disc pathology ac- cording to MR imaging.

The radiographs taken 6 months after the acci- dent showed an improvement or normalisation in 50% of the patients (16 out of the 32 patients which had findings at the initial investigation).

Symptom development in various M R groups. The 4 MR groups differed significantly in age (p<O.Ol), but no sex differences were found. The group with pre-existing spondylosis was signifi- cantly older than all the other groups (p<O.Ol), while the group with disc pathology was signifi- cantly older than the group with posture abnor- malities (p<0.05).

The percentages of patients reporting severe neck stiffness, neck pain and headache prior to the accident and within 4 days following the accident are given in Table 1. There were no significant dif- ferences between the groups in reports of neck stiffness, neck pain and headache prior to the acci- dent or 4 days after the accident.

The percentages of patients reporting daily or constant discomfort during the follow-up period are displayed in Table 2. Group comparisons indi- cated that the patients with pre-existing spon- dylosis reported significantly more trouble with headache than all the other 3 groups at the 3- and 6-month follow-ups (p<0.05 and <0.01, respec- tively). In addition, they reported significantly more neck pain than the groups with posture ab- normalities and no findings (p<O.Ol), but similar to the group with disc abnormalities, at 3-month follow-up. However, at the 12- and 24-month fol- low-ups there were no significant differences be- tween the groups.

Symptom development in various radiographical groups. The 4 radiographical groups differed sig- nificantly in age (p<O.Ol), but not in gender. The group with pre-existing spondylosis was signifi- cantly older than the groups with no findings and posture abnormalities (p<O.Ol) and the group with reduced intervertebral space was significantly older than the group with posture abnormalities (p<O.Ol). The groups did not, however, differ in the report of neck stiffness, neck pain or headache prior to the accident or 4 days or 2 weeks after.

Group comparisons indicated again that patients

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with pre-existing spondylosis had more headache than the groups with posture abnormalities and no findings at 3- and 6-month follow-ups (p<0.05 and p<O.Ol, respectivly). Further, the group with pos- ture abnormalities had significantly less neck pain than all the other groups at the 3-month follow-up (p<O.Ol) and this group reported significantly fewer symptoms at the 6-week, 3-, 6- and 12-month fol- low-ups. Regarding neck stiffness the group with posture abnormalities was significantly less bother- ed than the group with no findings at the same fol- low-up periods (p<0.05), and for headache this group was significantly less bothered than the groups with spondylosis and reduced intervertebral space at 3 months, and less than the groups with spondylosis and no findings at the 6-month follow- up. There was no significant difference between the groups at the 24-month follow-up.

Discussion

Considering reports of relatively high intensity of neck pain and neck stiffness (Tables 1 and 2) we expected to find some sign of injury on the MR images. As the MR investigation was done within 4 days after the car accident it should be possible to detect .bleeding. However, none of the 51 MR examinations disclosed any sign of bleeding in the soft tissues or in the spinal canal. The projection used was sagittal only and transversal slices might be useful as a supplement for describing possible soft tissue changes. Four other MR studies after hyperextension-flexion injuries have been pub- lished, and none could identify any abnormal MR findings either; 2 studies of the neck (2, 9) and 2 studies of the brain (4, 17). However, there were several other findings on MR investigations in our study; among them disc pathology, ligament strain, spinal canal narrowing, spondylosis, and abnor- mal cervical posture, but such findings are also common in asymptomatic persons (1, 15, 16).

The most common finding on MR imaging and at radiography in our study was loss of the lordotic curvature. According to the findings from the con- ventional radiographs - but not the MR images - this group had less pain than the other groups from 6 weeks until 2 years after the accident. Nor- malisation and improvement of this MR and ra- diographical finding after the acute stage would suggest that pathology was caused by the acute pain after the hyperextension-flexion mechanism. The pain would give fixation and posture abnor- mality acutely, while decrease of pain would nor- malise the curvature. It is difficult to explain why the group with posture abnormalities had fewer symptoms than the other groups.

We found that the group with pre-existing spon-

dylosis had significantly more symptoms than the other groups. Previous radiographical studies have also shown that pre-existing degenerative changes give a prolongation of symptoms in patients after hyperextension-flexion injuries (3, 8, 10, 11).

In order to predict the patient’s prognosis, this study indicates that conventional radiography of the neck may give the best information and also that there is no additional benefit in using MR im- aging for common neck hyperextension-flexion in- juries.

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