whiplash associated disorders (wad) - c.ymcdn.com · published in the 2001 proceedings of the...

Whiplash Associated

Disorders (WAD) Instability & Case Studies

Steven G. Yeomans, DC, FACO

404 Eureka Street

Ripon, WI 64971-0263

920-748-3644 (Ph)

920-748-3642 (Fax)

[email protected]

www.yeomansdc.com

RADIOLOGICAL Exam

RADIOLOGICAL Exam

Weight bearing: Pro – posture assessment; Con –

movement artifact / quality (esp. BMI >35)

Recumbent: Pro – quality best; Con – no

biomechanical assessment

Stress Views (C & L Spine primarily)

– Sagittal Plane: Flexion/Extension

– Frontal Plane: Lateral Flexion (Apical/Alar Ligs)

Special tests: MRI, CT, Bone Scan, fMRI, PET Scan,

DTI

SGY: In Handouts

2015 ACR LBP 12 pgs (in Handouts)

1999 / 2012 ACR Cervical Spine 23pgs (in Handouts)

Published in the 2001 proceedings of the

Cervical Spine Research Society Annual Meeting

Whiplash Injury and Occult Vertebral Fracture: A Case Series of

SPECT Imaging of Patients with Persisting Pain Following a

Motor Vehicle Crash

Michael Freeman, Ph.D., D.C., M.P.H, Dan Sapir, M.D., Alex

Boutselis, M.D., John Gorup, M.D., Glen Tuckman, M.D., Arthur

Croft, D.C., M.P.H., M.S., Chris Centeno, M.D., Arnie Phillips, M.D.

BONE SCAN – SPECT Scan

(See next 2

slides)

Whiplash Injury and Occult Vertebral Fracture: A Case Series of SPECT Imaging of

Patients with Persisting Pain Following a Motor Vehicle Crash

Michael Freeman, Ph.D., D.C., M.P.H, Dan Sapir, M.D., Alex Boutselis, M.D., John Gorup, M.D., Glen

Tuckman, M.D., Arthur Croft, D.C., M.P.H., M.S., Chris Centeno, M.D., Arnie Phillips, M.D.

Whiplash Injury and Occult Vertebral Fracture: A Case

Series of SPECT Imaging of Patients with Persisting Pain

Following a Motor Vehicle Crash

Michael Freeman, Ph.D., D.C., M.P.H, Dan Sapir, M.D., Alex Boutselis,

M.D., John Gorup, M.D., Glen Tuckman, M.D., Arthur Croft, D.C.,

M.P.H., M.S., Chris Centeno, M.D., Arnie Phillips, M.D.

Whiplash Injury and Occult Vertebral Fracture: A Case Series of

SPECT Imaging of Patients with Persisting Pain Following a Motor

Vehicle Crash

Michael Freeman, Ph.D., D.C., M.P.H, Dan Sapir, M.D., Alex Boutselis,

M.D., John Gorup, M.D., Glen Tuckman, M.D., Arthur Croft, D.C.,

M.P.H., M.S., Chris Centeno, M.D., Arnie Phillips, M.D.

MRI: Alar & Transverse Ligaments

STUDY:

Magnetic Resonance Imaging of the Alar and

Transverse Ligaments in Acute Whiplash-

Associated Disorders 1 and 2: A Cross-Sectional

Controlled Study.

– Spine Volume 36(6) pgs. 417-496,E373-E453 March

15, 2011; DOI: 10.1097/BRS.0b013e3181da21a9

– Vetti, Nils MD *,+; Krakenes, Jostein MD, PhD *,+; Damsgaard,

Eivind MD, ++; Rorvik, Jarle MD, PhD *,+; Gilhus, Nils Erik

MD, PhD [S],[P]; Espeland, Ansgar MD, PhD *,+ Miscellaneous

Article

MRI: Alar & Transverse Ligaments (Study)

AB Study Design.

– Cross-sectional.

Objective.

– To describe alar- and transverse-ligament magnetic resonance imaging

(MRI) high-signal changes in acute whiplash-associated disorders (WAD)

grades 1 and 2 in relation to the severity and mechanics of trauma, and to

compare them with controls.

Summary of Background Data.

– The alar and transverse ligaments are important stabilizers at the

craniovertebral junction. Acute injury of these ligaments should be

detected as high-signal changes on high-resolution MRI.


Methods.

– In the study, 114 consecutive acute WAD I-II patients and 157 non-

injured controls underwent upper-neck high-resolution MRI, using

proton-weighted sequences and Short Tau Inversion Recovery (STIR).

– Two blinded radiologists independently graded high-signal changes 0

to 3 on proton images and assessed ligament high-signal intensity on

STIR.

– Image quality was evaluated as good, reduced, or poor (not

interpretable).

– Multiple logistic regression was used for both within- and between-

groups analyses.


Results.

– All proton and STIR images were interpretable.

– Interobserver agreement for grades 2 to 3 versus grades 0 to 1

changes was moderate to good ([kappa] = 0.71 alar; and 0.54

transverse).

– MRI showed grades 2 to 3 alar ligament changes in 40 (35.1%)

and grades 2 to 3 transverse ligament changes in 27 (23.7%) of

the patients.

– Such changes were related to contemporary head injury (P =

0.041 alar), neck pain (P = 0.042 transverse), and sex (P = 0.033

transverse) but did not differ between patients and controls (P =

0.433 alar; and 0.254 transverse).

– STIR ligament signal intensity, higher than bone marrow, was

found in only three patients and one control.


Conclusion.

– This first study on high-resolution MRI of craniovertebral

ligaments in acute WAD 1-2 indicates that such trauma

does not induce high-signal changes.

– Follow-up studies are needed to find out whether pre-

traumatic high-signal changes imply reduced ligament

strength and can predict chronic WAD.

SGY: Note the dif. betw recumb vs. upright in

trauma group only!

See Handouts!

What do you see?

What do you see?

RT LT

LT

What do you see?

Note the LT lateral

translation of C1 in

reference to C2 and

the increased signal

intensity (T2

weighted image)LT

What do you see?

The Occiput and C1-2 Relationship

http://www.ajronline

.org/content/175/3/6

61.long

Am. J. of

Roentgenology

AJR:175, Sept. 2000

SEE Handouts!

http://www.ajronline.org/content/175/3/661.long

Normal anatomy in 43-year-old woman

Benedetti P F et al. AJR 2000;175:661-665

©2000 by American Roentgen Ray Society

—Normal anatomy in 43-year-old

woman. Sagittal T2-weighted MR image

(TR/TE, 4500/117) obtained on 0.3-T

MR scanner shows:

1. Normal apical ligament

2. Anterior occipitoatlantal membrane

3. Anterior atlantoaxial membrane

4. Anterior longitudinal ligament

5. Tectorial membrane

6. Dural reflection

7. Posterior occipitoatlantal membrane

8. Posterior atlantoaxial membrane

9. Nuchal ligament

10. Flaval ligaments

11. Area of interspinous ligaments

12. Supraspinous ligament

http://www.ajronline.org/

content/175/3/661.long

Front Back

—Normal anatomy in 21-year-old man.

Benedetti P F et al. AJR 2000;175:661-665


—Normal anatomy in 21-

year-old man. Sagittal T1-

weighted MR image (TR/TE,

510/25) obtained on 0.3-T

scanner shows:

1. Normal apical ligament

2. Anterior atlantoaxial

membrane

http://www.ajronline.org/con

tent/175/3/661.long

SIDE VIEW

FRONT

C2C2

Back

—Normal anatomy in

a 38-year-old man.

Benedetti P F et al. AJR

2000;175:661-665

—Normal anatomy in 38-year-old man. Axial gradient echo or fast low-angle shot

MR image (TR/TE, 420/18; flip angle, 30°) obtained on 1.0-T MR scanner shows

1. Dens

2. Presumed anterior atlantodental ligaments

3. Alar ligaments

4. Transverse ligament

5. Lateral masses of C1

Coronal View

WHAT DO YOU SEE?


2000;175:661-665


C2

Coronal ViewLT

—Left alar ligament tear in 19-year-old woman with severe neck pain after fall on her

head while snowboarding.


2000;175:661-665


—Left alar ligament tear in 19-year-old woman with severe neck pain after fall on her head while

snowboarding. Fixed deviation of dens to right was seen on radiograph (not shown). C1-2 rotatory

subluxation was suspected. Axial T2-weighted MR image (TR/TE, 4000/90) obtained on 1.0-T MR

scanner shows isolated tear of left alar ligament (1) and deviation of dens (2) toward right with respect

to lateral masses of C2 (3). Transverse ligament (4) is intact. Sagittal images (not shown) depict normal

alignment of occipital condyles with C2, thus no rotatory subluxation is present. CT performed before

MR imaging was negative for fracture and fixed rotatory subluxation. These results allowed confident

symptomatic treatment that led to full recovery.

C2

Coronal ViewLT

11 yo M

WHAT DO YOU SEE?

11 yo M

11 yo M

WHAT DO YOU SEE?

LT

11 yo M

LT

SAGITTAL PLANE STRESS XR

• Flexion / Extension Lateral Cervical

http://health-7.com/Handbook%20of%20Fractures/9%20-%20Cervical%20Spine

Ligaments, Capsules, Discs

and Muscles

http://health-7.com/Handbook of Fractures/9 - Cervical Spine

Sagittal C-Spine Instability Panjabi & White: Clinical Checklist of

Instability (discussed in):

http://emedicine.medscape.com/article/1264627-overview#showall

Cervical Spine Injuries in Sports

Author: Andrew A Sama, MD; Chief Editor:

Mary Ann E Keenan, MD more...

http://emedicine.medscape.com/article/1264627-overview

http://emedicine.medscape.com/article/1264627-

overview#showall

Andrew A Sama, MD Associate Professor of Clinical

Orthopedic Surgery, Weill Cornell Medical College; Associate

Attending Orthopedic Surgeon, Associate Director of Spine

Surgery Fellowship, Hospital for Special Surgery; Associate

Attending Orthopedic Surgeon, New York-Presbyterian Hospital

OTHERS:

Federico P Girardi, MD Associate Professor of Orthopaedic

Surgery, Weill Medical College of Cornell University; Associate

Attending Orthopaedic Surgeon, The Hospital for Special

Surgery; Director of Research, Spinal Surgical Service, The

Hospital for Special Surgery

Frank P Cammisa, MD Chief, Spine Service, Associate

Attending Orthopedic Surgeon, Assistant Scientist, Research

Division, Hospital for Special Surgery; Associate Professor,

Department of Surgery (Orthopedics), Weill Cornell Medical

College; Assistant Attending Surgeon, New York Hospital

Specialty Board:

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor,

University of Nebraska Medical Center College of Pharmacy;

Editor-in-Chief, Medscape Drug Reference

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest

Iowa Bone, Joint, and Sports Surgeons

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic

Surgery, New York University School of Medicine; Director of

Spine Service, Director of Spine Fellowship, Department of

Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU

Langone Medical Center

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor,

Department of Orthopedic Surgery, University of Texas Medical

School at Houston


A TOTAL of 5

or more =

UNSTABLE

http://emedicine.medscape.com/article/1264627-overview#showall

SGY: Note the

inconsistency with

the AMA Guides

(11° in flexion vs.

here 20° in flexion;

11° in neutral)


http://emedic

ine.medscap

e.com/article

/1264627-

overview#sh

owall

SGY: Note the high

“false-positive” rate

& the recommended

cord diameter / canal

size option


C-Instability/AOMSI:

1) > 20% translation

anterior OR posterior

on FL or Ext XR

2) > 11° on FL only XR

3) Fusion/disc

arthroplasty

pg578 In: 6th Edition:

AMA Guides to the

Evaluation of

Permanent

Impairment, 2008

6th Edition AMA

Guides, 2008

6th Edition AMA Guides, 2008

NOTE: L-spine is different! FL – EXT (vs. FL only XR in C-spine

Method 1


Method 2

Loss of

Motion

Segment

Integrity

DEFINITION:

A+B >3.5mm

translation in

FL + EXT =

C-Spine Instability

OR, >11° on FL XR

ONLY!


CASE STUDIES

CASE 1: Name: L A; DOB: 8/14/1986, Age: 27;Sex: Female; X-

ray #: 10356; Complaint: Mid-back, low back and neck pain of a

chronic history; XR taken 2-19-2014

C5: 14°

C6: 1°

Net: 13°

13° > 11°

(neutral XR)EXT

CASE 1: Name: L A; DOB:

8/14/1986, Age: 27;Sex: Female;

X-ray #: 10356; Complaint:

Mid-back, low back and neck

pain of a chronic history; XR

taken 2-19-2014

LOOK FOR:

1) SP widening

2) Angular rotation

3) Facet coverage

4) Translation FL

CASE 2: BB, DOB: 6/17/1987, Age: 26;Sex: Female; X-ray #:

10345; Complaint: Chronic low back, mid back, and neck pain

arising from a 3/17/10 motor vehicle collision. XR taken 1/21/2014

EXTNeutral

BB, DOB: 6/17/1987, Age: 26;Sex: Female; X-ray #: 10345;

Complaint: Chronic low back and mid back pain arising from a

3/17/10 motor vehicle collision.

C3/4= 12°

FL


10345; Complaint: Chronic low back and mid back pain arising

from a 3/17/10 motor vehicle collision.

EXT


10345; Complaint: Chronic low back and mid back pain arising

from a 3/17/10 motor vehicle collision.

Unstable

Definition

> 11° rotation

>20% transla

Spinal

Levels

Final Angle

Measured

Translation

(>20%)

C2/3 9° NA

C3/4 12° 11% / 2mm =

WNL

C4/5 3° NA

C5/6 8° NA

C6/7 10° NA

FRONTAL PLANE STRESS XR

• RT & LT Lateral Flexion APOM

The Alar Ligaments1. Alar Ligaments

2. Apical Ligament

Lateral Atlas-Dens

Interval (see article next

slide: LMI /LADI >4mm =

abnormal!)

Alar Ligament MRI Study (see Handout)

Peter G. Osmotherly et al. PHYS THER

2012;92:718-725

https://www.researchgate.net/publication/221768587_Construct_Validity_of_Clinical_Tests_for_Alar_Ligament_Integrity_An_Evaluation_Using_Magnetic_Resonance_Imaging

Alar Ligament MRI Study

ABSTRACT SUMMARY:

Peter G. Osmotherly et al. PHYS THER

2012;92:718-725


Alar Lig: Side-bending & Rotation Stress (n=16)

– Lat. Fl: 1.15 mm (mean from neutral distance)

– Rotation: 2.08 mm (mean from neutral distance)

Clinical texts state stress XR should be N, FL, Ext

This study supports LF & Rotation stress XR

Alar Ligament MRI Study (see Handout)Peter G. Osmotherly et al. PHYS THER

2012;92:718-725


Summary of Findings Following the Examination of

Alar Ligament Stress Testing.

Peter G. Osmotherly et al. PHYS THER 2012;92:718-725

© 2012 American Physical Therapy Association


Intraclass Correlation Coefficients (ICCs) for the Left-Right Difference in Alar Ligament Length

Measurements.

Peter G. Osmotherly et al. PHYS THER 2012;92:718-725

© 2012 American Physical Therapy Association

Frontal Plane C1/2 Left Lateral

Flexion Stress X-ray

**5mm LT and 3mm RT Lateral ADI (&

notice the C1 lateral mass translation)

CASE 3: CE

DOB: 12-10-91;DOI: 8-15-09 MVC

LLF

Frontal Plane C1/2 Right

Lateral Flexion Stress X-ray

**4mm LT and RT Lateral ADI

CASE 3: CE DOB: 12-10-91; DOI: 8-15-09 MVC

RLF

CE DOB: 12-10-91; DOI: 8-15-09 MVC

Frontal Plane C1/2 Left Lateral Flexion Stress X-ray

** 3mm of C1 overhang over C2

How many OCC injuries have

WE missed???

Ortho tests for the

Alar Ligament?

(see Handouts)

Osmotherly G, Rivett D, Rowe LJ. Toward understanding normal

craniocervical rotation occurring during the rotation stress test for

the alar ligaments. Phys Ther 2013;93:986-992

(SEE next 3 slides)

Ortho tests for the Alar Ligament? (see Handouts)

Osmotherly G, Rivett D, Rowe LJ. Toward understanding normal craniocervical rotation occurring

during the rotation stress test for the alar ligaments. Phys Ther 2013;93:986-992

Ortho tests for the Alar Ligament? (see Handouts)

Fig. above from: Osmotherly PG, Rivett

D, Rowe LJ. Toward understanding

normal craniocervical rotation occurring

during the rotation stress test for the alar

ligaments. Phys Ther 2013;93:986-992

Fig. above from: Osmotherly PG, Rivett DA, Rowe LJ.

Construct validity of clinical tests for alar ligament

integrity: An evaluation using magnetic resonance

imaging. Phys Ther 2012;92:718-725.

Many more Ortho tests for the Alar Lig:

See: “examination_of_the_cervical_spine” PDF in

Handouts (WAD 4)

This has MANY motion

palpation methods to assess

occipito-atlantal-axis

ligament integrity (see

pp135-! An EXELLENT

RESOURSE (not enough

time to cover in today’s

webinar.

SEE HANDOUTS!

Case 4: Michael L. 37yo M

WAD Injury

INITIAL EXAMINATION 2-25-13

(LAST VISIT)

Case 4:2-25-2013ML 37yoM

Case 4: 2-25-2013ML 37yoM

Case 4:2-25-2013ML 37yoM

Case 4: 2-25-2013ML 37yoM

2-25-2013 ML 37yoMSUMMARY

Significant past Hx: 12 MVC’s (all “quick” recoveries

– within 3 days); martial artist

NOT severe: Pain: 1-3/10; C-BQ: 20%; YFQ: 13%

(<45 = low risk of prolonged recovery)

Complicating factors: Significant

XR Findings: Significant

Treatment Outcome: RESOLVED (only 4 visits in <2

weeks)

UNUSUAL CASE!!!

Is MRI a sensitive tool for assessing clinical changes? Answer: NO

SIDE-BAR: 10-Yr Follow-up Study

SIDE BAR:

NEW STUDY re: NDI!

SIDE BAR: NEW NDI STUDY!

• NDI Score of 15-21% = recovered in WAD

• SGY correlate w/: Use Patient’s Global Impression of

Change to validate! (“Very Much Improved”): (See

Documentation Handouts / Next Slide)

PGIC

• Use at re-exams &

discharge

• Compare to scores

of other OATs

• Score of 1 or 2 =

50% & 30%

improvement,

respectively

NDI Score of 15-21% = recovered in WAD; SGY rec: Use PGIC to validate! (“Very Much Improved”): See

Documentation Handouts or “GOOGLE” for the 7-item PGIC

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