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Whiplash Injuries Evaluation and treatment

Whiplash Injuries Evaluation and treatment. Vikram B. Patel, MD FIPP DABIPP Medical Director] ACMI Pain Care Algonquin, Illinois. Disclaimer. No financial relationships with any manufacturing companies or pharmaceutical companies Some indications may not be FDA approved

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Whiplash Injuries Evaluation and treatment

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  1. Whiplash InjuriesEvaluation and treatment Vikram B. Patel, MD FIPP DABIPP Medical Director] ACMI Pain Care Algonquin, Illinois

  2. Disclaimer • No financial relationships with any manufacturing companies or pharmaceutical companies • Some indications may not be FDA approved • Mention of any trade names is purely for the sake of clarification and simplicity • Personal disclaimer (!)

  3. Whiplash Injuries • Injury due to trauma to the cervical spine •  The term "whiplash" was first used in 1928. • Mechanism of injury • Flexion • Extension • Vertical compression • Direct trauma • Mixed mechanisms • Trivial to fatal severity

  4. Cervical Spine Anatomy

  5. Cervical Spine Anatomy

  6. Cervical Spine Anatomy Atlanto-Axial Joint

  7. Cervical Spine Anatomy

  8. Cervical Spine Injuries • Trauma • 10-15% of E.R. visits • Most injuries at C6 C 7 level (~50%) • 1/3rd injuries at C2 level • Hanging • Hangman’s fracture (C2) • Direct trauma • Verticle fall (Jefferson fracture – C1) • Object hitting from top or horizontally

  9. Flexion Injuries • Head-on collision • Falling face forward • Forcible forward flexion • Structures primarily injured • Disc • Nerve root • Vertebral body • Compression • Subluxation

  10. Extension injury • Rear ended collision • Falling backwards • Forcible extension of the neck • Structures injured • Facet joints • Muscles • Vertebral artery

  11. Mixed Injuries • Flexion-rotation • Extension-rotation • Vertical compression • Structures injured • Multiple structures • Muscles and ligaments

  12. Clinical Presentation • Neck pain • Upper back pain • Headaches • Radiating pain to the occiput, shoulders, arms • Neurological symptoms • Numbness, weakness • Remote signs and symptoms • Leg weakness and numbness • Bowel or bladder symptoms

  13. Evaluation • History • Mechanism of injury (Flexion, extension or mixed) • Aggravating and relieving factors • Additional symptoms and complains • Bowel or bladder symptoms

  14. Evaluation • Physical examination • Muscolo-skeletal exam • Range of motion (cervical spine and shoulders + arms) • Palpation • Neurological exam • Sensory and motor examination • Reflexes • Gait • Always assume spinal cord trauma unless proven otherwise

  15. MRI Cervical Spine

  16. Management • Based on injured structures • Immobilization • Investigations • Plain x-ray • MRI • MRA • EMG/NCV • Multi-modal approach • Interventions • Physical therapy • Pharmaceuticals

  17. Flexion injuries • Disc injury • Surgical approach • Percutaneous decompression • Nerve root • Steroid injections • Cervical epidural • Transforaminal approach vs. interlaminar approach

  18. Interlaminar Epidural Injection

  19. Transforaminal Epidural Injection

  20. Selective Nerve Root Block

  21. Extension Injuries • Subluxations • Surgical approach • Facet joint injury • Direct joint injection • Neuro-ablative techniques • Muscular injury • Physical therapy (with or without TPI) • Pharmaceuticals

  22. Facet Joint Anatomy

  23. Cervical Facet Syndrome • Symptoms Neck pain Headache Shoulder pain Suprascapular pain Scapular pain Upper arm pain • Signs Decreased range of motion of then neck Pain on neck extension, rotation Decreased discomfort with forward flexion Tenderness over the affected joint (lateral palpation)

  24. Distribution of Symptoms • C2-C3: occiput and cervical spine • C3-C4: Neck • C4-C5: Lateral aspect of the name and shoulder • C5-C6: Arm • C6-C7: Shoulder, and into back, as far down as scapula

  25. Cervical Facet Syndrome Raj et al. Practical Management of Pain

  26. Selective Joint Injections

  27. Cervical Medial Branch Block

  28. Cervical Medial Branch Block

  29. Cervical Radio-Frequency

  30. Cervical Radio-Frequency

  31. Summary • Whipash injuries are very common in MVAs • Very high mortality rate with upper cervical spine injuries • High morbidity with lower cervical spine injuries • MRI is the best modality for evaluation • Surgical interventions should be considered earlier due to risk of spiral cord trauma • Neurological assessment is a must (upper and lower extremities) • Effective management includes multimodal approach

  32. Thank You • Questions??

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