The Multitude of Problems Occurring after Whiplash Injury. Instability of the Upper Cervical Joints - Booklet - Head-neck-joints instability conditions
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The Multitude of Problems Occurring after Whiplash Injury. Instability of the Upper Cervical Joints - Booklet

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The Multitude of Problems Occurring after Whiplash Injury

Symptoms, Diagnosis and Therapy

Surgical Treatment of Instability of Upper Cervical Joint

Contents

Worldwide Problem

  • About 400.000 accidents in Germany with neck injury every year
  • 10 % need medical treatment afterwards
  • Very different symptoms often cause physicians to suspect psychlogical problems or the patients trying to get money from insurances
  • Most physicians do not have any knowledge about instability in upper cervical joint and cervico-encephal symptoms
  • In non-functional x-ray or MRI there are no traumatic signs visible

Indication for surgical treatment

Prior to indication for surgery (or non surgical treatment) it is necessary to make an accurate diagnosis

Symptoms

motor failures , coordination disorders

  • Simple weakness
  • Paresis (weakness or spastic)
  • Fine motor failures or inability to walk
  • Stumbling
  • Losing the sense for body feeling

Pain and dizziness

  • Headache beginning from the neck
  • Neck and shoulder pain
  • Body and low back pain
  • Dizziness (various intensity)
  • Combination of pain and dizziness

Visual disorders

  • Weakness
  • Disturbance in focusing
  • Change of color seeing
  • Worse nocturnal vision

Hearing problems with tinnitus

  • Change in hearing quality
  • Loss of hearing
  • Phonophobia
  • Tinnitus (mostly high whistle tone)
  • Feeling pressure behind the ear
  • Normal hearing is impeded

Disturbance of the sense of balance

  • Losing the sense for body feeling
  • Different feelings for left and right part of body
  • Feeling the position of body in room only with open eyes
  • Need for crutches

Sensory losses

Vigilance disorders

  • Disorders of the awakeness, consciousness, and self-perception

Patho Physiological Hypothesis

  • Compression and/or elongation of functional nerve tissue
  • Compression of arteries (basilar artery and/or vertebral arteries)
  • Brainstem function is disturbed : disturbance of ability for cognition, senses, motoric, coordination and balance


Diagnosis

An Acurate Diagnosis Necessitates The Following Evaluations:

Exact anamnesis

  • Anamnesis about the time before injury
  • Accident anamnesis
  • Early symptoms after accident
  • Type of treatment
  • Worse symptoms now
  • Growing symptoms during the years after the accident

Clilnical examination

  • Examination of head movements
  • Dizziness and nausea by head movements? (Not in all cases!)
  • Muscle tension of the neck, arms and legs (Not in all cases!)
  • The sense of body feeling (Not in all cases!)
  • Coordination tests

Neuro-otological special examination

not really neccessary, because, often without any findings

  • Checking of the senses
  • Seeing, perimetry
  • Hearing, audiometry
  • Smelling
  • Balance Equilibriometry
  • Craniocorpography

Special radiological processes

The most important part of diagnosis is:

  • Functional x-ray (tilting the head with 2 hands)


  • conventional x-ray of C1/C2
  • Functional CT and
  • Functional MRI(depiction of alar ligament)


Alar ligaments in MRI


Facet-joints in MRI

Dens Axis Fracture and Ligamentous Reaction

Complete fracture without ligament rupture

COMPLETE DISLOCATION OF C1 with massive elongation of transverse ligament

Very rare incidence the complete rupture of the transverse ligament


Ligament Rupture between C0and C1 (Functional X-Ray!!)

Ligament Rupture between C1and C2 (Functional X-Ray!!)

Dens axis fracture Image two showing the result.


Luxation by dens fracture and x-ray after operation.


Traumatic Luxation C6/C7

Posttraumatic injuries First you can see posttraumatic disc herniation, to the right, there is myelomalacia.


  • Functional analysis shown by fluoroscopy

Infiltration test of C0,C1, and C2 under fluoroscopy (C-arm)


  • Optional halo fixation for one week
  • External stabilization by using halo fixation
  • Checking the change of symptoms during one week

Note: Halo fixation is not really effective. Because stability of the head-neck-joint is almost not to work

Treatment

  • Surgical
  • Stabilization operation of upper cervical joint
  • Non-Surgical
  • Physiotherapy??
  • Radiofrequency therapy
  • Magnet-wave therapy

Surgical Treatment

Surgical Technique

Aim of The Operation: Stabilization between C0/C1/C2 - stopping the vascular or mechanical brainstem damages

Technique of the operation

  • Positioning
  • Incision line
  • Operation approach


  • Pathological movement C0-C2

See the video Overview:Video Capture of Surgical Stabilization Technique. Please read warning (in index) of Categories -> Movies right before.

  • X-ray control after operation


Outcome

Intervals of examination, care and support after the operation

  • One night intensive care unit.
  • The patients are mobilized on the first or second day after the operation.
  • Surgical adjustment of the geometry cause new tension of neck muscles.
  • Lymph drainages and the prescription of chewing gum are helpful.
  • Infiltration paravertebral with scandicain.

Clinical outcome and Result

Only Patients with Instability of Upper Cervical Joints:

  • Operated patients with follow up
  • 1999 to 2003 operated on 262 patients
  • 114 of the patients were male, 148 female
  • The age range was from 17 to 68 years
  • 44% car accident (half were not self fault)
  • 27% sports accident
  • 25% other accidents
  • 4% had no remembrance of the trauma
  • Different resultes from different

Operation Methods

  • Iliacrest bone graft wire fixation between Co/C1/C2 (65% of bone graft osteolysis)
  • Bone graft in combination with a thin titanium plate (16% morbidity after bone harvesting)
  • Stabilization from C0 to C3,transarticular C2/C1screwing and using thick plate
  • Best Result By Using Titanium 3mm Plates Between C0-C3 in Combination With Transarticular C1/C2 Screwing
  • Reversible operation
  • No bone graft (less problems after surgery)
  • No back out of screws or braking the thick plates
  • Best Outcome
  • Stabilisation with thick Titanium plates
  • Using 45 mm screws for transarticular fixation between C1/C2
  • Cranial fixation on occiput, distal on C3 facet Joint
  • Results

Because of vast diversity of symptoms it is not possible to come to a single analysis of surgical outcome

  • Before Surgery
  • permanent headache78%
  • Permanent analgesics 98%
  • Inability to work 100%
  • After Surgery
  • Permanent headache22%
  • Permanent analgesics 24%
  • Inability to work 61%

Summary for upper joints stabilization

  • 85% of patients stated that surgery hat significantly improved their quality of life
  • 92% of the patients would agree again for the same operation
  • 15% of patients stated that surgery had not fulfilled their expectations


The instability of upper cervical joint can often be detected by special processes of examining If a conservative therapy fails, better results can very often be reached by an operative therapy. A significant reduction of head mobility must be accepted.


Complications

  • Loose screws at occiput 16%
  • Breaking of (thin) titanium plates 13%
  • One case of bending of C1/C2 screws due to physiotherapy
  • One case of subarachnoidal hemorrhage in the fossa posterior
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