Cervical whiplash syndrome (CWS), or whiplash syndrome, is a much-debated concept because there is still no consensus on its definition—the symptoms are often severe, but the underlying cause of the pain is often uncertain. Clinical investigation and detailed radiology rarely identify specific pathology. Therefore, soft tissue injury is often considered the most likely explanation for symptoms, although it is difficult to confirm even by MRI. We describe the clinical case of a physical education teacher who had an accident in one of her classes. She was evaluated in the emergency room the next day, and after cervical spine radiology, she was diagnosed with a straight cervical spine (kyphoscoliosis). Seven days later, due to persistent pain, she was placed under observation again without changing the indications for rest and medication. Afterwards, her neck and arm pain progressively worsened, limiting active movement of her left shoulder and causing associated muscle wasting (in addition to burnout syndrome). A few years later, she was deemed totally and permanently disabled. Finally, the authors suggest that CWS should be approached according to post-traumatic physical injury assessment methods and propose some interventions.
introduce
Cervical whiplash syndrome (CWS) or whiplash syndrome is a traumatic injury that occurs due to hyperextension-hyperflexion of the cervical spine affecting the soft tissue structures surrounding the cervical spine [1]. Clinical investigation or detailed radiology rarely identifies specific pathology.Brachial plexus involvement has been demonstrated in some patients with chronic whiplash [2] But the actual incidence of symptoms associated with chronic disability is unknown [3-4]. Symptoms may take hours or even days to appear. Neck pain (88%-100%) and headache (54%-66%) were most common, but lumbago and/or other back pain, fatigue, dizziness, paresthesias, nausea, and jaw pain may also occur.Many patients also report anxiety, depression, and poor concentration [5-6]. The prognosis of CWS is generally good [3], but there is wide variation in the frequency, severity, and duration of disability.This difference depends in part on each country’s traditions in litigation and compensation [7], but this cannot explain all the differences, especially within the same population.Two systematic reviews [3-4] Little consistency was found in factors affecting the results, such as age, pre-existing psychological problems and anxiety. However, they did identify pain severity, headache, and functional limitations as major prognostic factors.
Case presentation
A 45-year-old female patient, a physical education teacher, was hit in the neck while helping her student do a handstand, and was hit by the student’s leg and left shoulder. Immediately, she felt that her neck was severely broken, a sharp pain ran through her entire thoracic spine, and she temporarily lost her vision and hearing. She underestimated the incident; since her muscles were still warm, she thought it was normal in her profession. As symptoms worsened, she went to the emergency department (ED) the next day and was diagnosed with cervical spine surgery based on cervical spine x-rays. She was discharged on medication (diclofenac 75 mg/3 mL IM + paracetamol 500 mg/thiocolchicoside 4 mg/2 mL IM for 6 days) and had no work restrictions. As her condition continued to worsen (barely getting out of bed in pain), she went to the ER 7 days later and was diagnosed with a cervical sprain, rhomboid rupture, and various muscle contractures. She was out of work for 10 months because she underwent several physical therapy sessions, mesotherapy, acupuncture, exercise therapy, heat therapy, psychotherapy, pain counseling, psychiatry (diagnosed as posttraumatic stress with somatization anxiety and depression), and different combinations of medications to minimize pain, weakness, and sleep disturbances. Despite all efforts, the accumulation of fatigue eventually leads to burnout (emotional, physical and mental exhaustion). During this time, the patient was referred to multiple medical boards to assess her ability to work and to legally define the incident as a work accident.In the absence of clinical improvement, she underwent cervical spine MRI, which described incipient foraminal asymmetry at intervertebral levels C4-C5 (Fig. 1), it is repeated in C5-C6, and the expression on the left is less (Fig. 2); no stenotic features (Fig. 3). She had an electromyogram (EMG) showing moderate neurogenic changes in the muscles dependent on the left bilateral C5 and C6 sarcomeres, which was assessed as some degree of cervical radicular pain. She repeated a cervical spine x-ray maintaining the diagnosis of cervical spine correction and performed a cervical spine CT describing signs of physiologic cervical lordotic correction at the examination site. Ultrasound of the left shoulder ruled out rotator cuff tendinopathy; it was performed due to left neck arm pain radiating to the third and fourth digits of the hand with associated paresthesias, suspected left shoulder tendinopathy and ipsilateral thoracic pain.
Currently, she exhibits functional limitations (Table 1), with disabling sequelae of recurrence of mixed left cervicobrachial pain (musculoskeletal and neuropathic) in the context of structured analgesic vicious postures that cause cervical, scapular, dorsal, and left Development of upper extremity muscle atrophy and proprioceptive deficits. Current treatment: sertraline 50 mg 1 id + amitriptyline 25 mg, 1/2 id + trazodone 150 mg 1/3 id + diazepam 5 mg, 1 id + flupirtine 100 mg id. Known drug allergy: ranitidine and tramadol. Declared her total and permanent inability to perform her job in the Labor Tribunal.
discuss
Most whiplash injuries progress positively, with only a few cases becoming chronic due to poor response to treatment. The variety and intensity of the complaints was unexpected at first, but became clear after a few hours. With proper rest, physical and medical support, people can expect resolution within days or months. However, there are also a small number of cases that are chronic, poor response to treatment, low or no imaging examination visibility, but severe functional impairment. This reported case is an example—vertebral trauma in flexion and forced lateralization involving stretching of ligamentous structures and the left cervical root. The intensity of the pain exacerbated by the physical activity of daily activities, combined with the functional limitations, made it a decision to declare physical education impossible to teach at all.
In addition to this, assessment of physical impairments in the context of CWS can serve as a key data set to identify the defining core of syndromes and their subdivisions, as cross-sectional information and miscellaneous data are collected for all patients. The authors propose that CWS should be managed according to posttraumatic physical injury assessment methods, recommending the following interventions: (a) Periodic assessment of pain with concurrent studies of its character, intensity, irradiation, analgesic and aggravating maneuvers, periodicity, and pain correlation. relation to daily activities and repetitive movements, effects of pharmacological and non-pharmacological treatments, etc.; (b) regular assessment of mobility, while studying the cervical spine, back-lumbar spine, upper extremities, and relating them to the characteristics mentioned in the previous paragraph; (c) Periodic assessment of muscle strength, study of the cervical spine, dorsal lumbar spine and upper extremities, and correlating them with other features; (d) assessment of structures around the cervix, by imaging, in terms of function, by combining pain points, mobility deficits, functional tests, Response to treatment, physical or pharmacological, response to stimuli, combine all these and other data with other suggested characteristics.
in conclusion
Following an accident, whether at work or of any other nature (e.g., traffic), the assessment of the CWS as a repairable bodily injury is a very useful tool in the study of this clinical entity, as it separates most people from discomfort A small number of lesions become chronic in clinical cases where it is discontinued for a short period of time. In addition, it provides medical relevance to a small number of clinical cases that are currently overlooked because they have nonspecific and/or fragile imaging most of the time. The follow-up of clinical cases and the study of CWS require multidisciplinary diagnostic and/or therapeutic interventions because CWS combines subjective impairments, such as pain and paresthesias, and objective impairments, such as functional deficits and muscle strength. It combines direct injuries (more attributed to cervical spine injuries) and indirect, more general injuries with more distant cervical causes, such as burnout, loss of capacity for work or activities of daily living, personality disorders, or psychiatric disorders.
