Göran Toolanen

Outcome after soft-tissue injury of the cervical spine: A prospective study of 93 car-accident victims

Ninety-three cases with a car-accident soft-tissue injury of the cervical spine were studied prospectively. Neck pain and stiffness were the main initial symptoms, while 4 cases had abnormal neurologic signs. At follow-up, on an average 2 years after the accident, 42 percent had recovered completely, 15 percent had minor discomfort, and 43 percent had discomfort sufficient to interfere with their capacity for work. The statistical analysis of 17 factors, including acute symptoms and physical findings, as well as the forces and directions of impact, head rests, radiographs, length, and sex, did not reveal any factor of prognostic importance.

The incidence of whiplash trauma and the effects of different factors on recovery

We performed a prospective study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery. A total of 356 patients were enrolled in the study. All the patients received a comprehensive questionnaire after the injury, and 296 cases responded to the follow-up protocol more than 1 year after the accident. Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors. The annual incidence of acute whiplash trauma in the catchment area was 4.2 per 1,000 inhabitants and 3.2 per 1,000 for whiplash-associated disorder grades 1–3. Thirty-two percent reported persisting disability at follow-up. The following factors were significantly associated with a poor prognosis: pretraumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2–3.

Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation.

STUDY DESIGN This study was used to evaluate the relationship between magnetic resonance imaging findings and clinical findings after whiplash injury. OBJECTIVES To identify initial soft-tissue damage after whiplash injury, the development of disc pathology, and the relationship of disc pathology to clinical findings. SUMMARY OF BACKGROUND DATA Although a few studies have reported pathological magnetic resonance imaging findings after whiplash injuries, there is no prospective study published to our knowledge. METHODS Thirty-nine patients, 20 women and 19 men with a mean age of 32 years, were treated for whiplash injury. Magnetic resonance imaging and clinical examination were performed in a blinded manner at a mean of 11 days after trauma. The procedure was repeated at a 2-year follow-up visit. Two patients could not be examined with the second magnetic resonance imaging because of claustrophobia and pregnancy, respectively. RESULTS The authors found 13 patients (33%) with disc herniations with medullary (six cases) or dura (seven cases) impingement over the 2-year follow-up period. At the follow-up examination all patients with medullary impingement had persistent or increased symptoms, and three of 27 patients (11%) with no or slight changes on magnetic resonance imaging had persistent symptoms. No ligament injuries were diagnosed. CONCLUSION Although disc pathology seems to be one contributing factor in the development of chronic symptoms after whiplash injury, it may be unnecessary to examine these patients in the acute phase with magnetic resonance imaging; correlating initial symptoms and signs to magnetic resonance imaging findings is difficult because of the relatively high proportion of false-positive results. Magnetic resonance imaging is indicated later in the course of treatment in patients with persistent arm pain, neurologic deficits or clinical signs of nerve root compression to diagnose disc herniations requiring surgery.

Early complications after anterior dislocation of the shoulder in patients over 40 years : an ultrasonographic and electromyographic study

The rate of complications after anterior dislocation of the shoulder was evaluated in 65 patients aged over 40 years. 36 of 55 cases had electromyographically verified axillary nerve or brachial plexus injury. Rotator-cuff lesion was seen in 24 of the 63 sonographically examined cases. At follow-up in a telephone interview on average 3 years after the injury, 27 of the 57 cases had complaints from their shoulder. The incidence of initial nerve and/or cuff lesions was higher in those with persisting symptoms at follow-up.

MRI and neurology in acute whiplash trauma: No correlation in prospective examination of 39 cases

39 consecutive cases of whiplash injury of the neck were examined clinically and with MRI at a mean of 11 days after trauma. 26 of these showed changes on MRI with disc lesions in 25, 10 of which were classified as disc herniations, and a muscle lesion in 1 case. All had neck pain or headache. 29 cases had neurological deficits, mostly sensibility disturbances. 22 of the 26 cases with pathologic MRI findings had neurological signs, as had 7 of the 10 cases with disc herniation. The relationship between the MRI findings and the clinical symptoms and signs was poor.

Oculomotor problems after cervical spine injury

Oculomotor function was investigated in 39 patients with a previous soft-tissue injury of the cervical spine. The velocity, the accuracy, and the pattern of the eye movements were disturbed in 20 patients with chronic and disabling symptoms. Oculomotor function in the 19 asymptomatic patients did not differ from a control group. The oculomotor function seems to be impaired, possibly by brain stem lesions, in patients with chronic symptoms of whiplash injury of the cervical spine.

Familial insensitivity to pain (HSAN V) and a mutation in the NGFB gene. A neurophysiological and pathological study.

We have studied a large Swedish family with a mutation in the nerve growth factor beta (NGFB) gene causing insensitivity to deep pain without anhidrosis (hereditary sensory and autonomic neuropathy, type V; HSAN V). Painfree joint destruction and fractures were common. Peripheral nerve conduction was normal, but temperature thresholds were increased. Sural nerve biopsies showed a moderate loss of Aδ fibers and a severe reduction of C fibers. The three most severely affected cases were all born to consanguineous parents, and were homozygotes for the causal genetic mutation. Treatment of these patients is discussed. Muscle Nerve, 2004

High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study

Study Design. A prospective, randomized, double‐blind study comparing high‐dose methylprednisolone with placebo. Objectives. To evaluate the efficacy of high‐dose methylprednisolone when administered within 8 hours after whiplash injury. Summary of Background Data. Whiplash injury often results in chronic symptoms. The management of whiplash injuries is controversial, and pharmacologic therapy has received little evaluation. In recent reports, dysfunction of the central nervous system has been indicated in several cases. Methylprednisolone administered within 8 hours after the injury to patients with acute spinal cord injury has been demonstrated to improve the outcome. This procedure was also adopted in a randomized study of cases of whiplash injury in car accidents. Methods. Forty patients, 22 men and 18 women with a mean age of 35 years (range, 19‐65), were included in the study, 20 in each of two groups. They were treated for whiplash injury, which they had sustained in car accidents. The patients were enrolled if their diagnoses were complete and treatment had begun within 8 hours after injury. Disabling symptoms severe enough to prevent the patient from returning to work, number of sick days before and after injury, and sick‐leave profile after injury were used as parameters for the evaluation of the effects of the treatment. Baseline demographic data were controlled for when statistical analysis had been performed. Results. At the follow‐up examination 6 months after initial treatment, there was a significant difference in disabling symptoms between the actively treated patients and the placebo group (P = 0.047), total number of sick days (P = 0.01), and sick‐leave profile (P = 0.003). Conclusions. The results of this study indicate that acute treatment with high‐dose methylprednisolone may be beneficial in preventing extensive sick leave after whiplash injury. However, the number of patients studied was small, and therefore further prospective, controlled studies are needed.

Chronic compartment syndrome also affects nonathletic subjects: A prospective study of 63 cases with exercise-induced lower leg pain

Background Chronic exertional compartment syndrome is most often reported in young and physically active people. Patients and methods We studied 73 consecutive patients (mean age 39 (16–77) years, 45 women) with a history of exercise-induced pain and suspicion of chronic exertional compartment syndrome (CECS) of the lower leg—clinically, radiographically and with intramuscular pressure measurements. Results Intramuscular pressure increased with reproduction of symptoms and fulfilled the criteria for diagnosis of CECS in 36 patients (mean age 36 (16–65) years, 22 women), with engagement of 66 anterior, 2 lateral and 7 posterior muscle compartments in 72 legs. The patients with CECS of the lower leg were divided into 4 etiological groups: 18 with overuse, 10 with earlier trauma, 4 insulin-treated diabetics, and 4 others. Two-thirds of the patients had pain during walking. The outcome after fasciotomy was excellent or good in 41/57 of the legs. Interpretation CECS of the lower leg probably has a multifactorial etiology and is more common in sedentary individuals than has been recognized previously. Fasciotomy appears to be beneficial in these cases also.

Nervous Tissue Damage Markers in Cerebrospinal Fluid after Cervical Spine Injuries and Whiplash Trauma

Clinical examination is the only tool available to assess the extent of the nerve tissue damage after a spinal cord injury, and it is well known that the reliability of classification based on clinical examination is not satisfactory, especially in cases with incomplete motor injuries. There is a need to evaluate new methods in order to improve the possibilities of classifying and prognosticating spinal cord injuries. Methods for assessing central nervous system (CNS) damage using markers in cerebrospinal fluid (CSF) have recently been developed. Previous studies have reported glial fibrillary acidic protein (GFAp) and neurofilament protein (NFL) levels in non-traumatic diseases in the central nervous system. The present study is the first report of GFAp and NFL levels in CSF after trauma to the cervical spine. Six cases with cord damage and pronounced neurological deficit showed significantly increased concentrations of both GFAp and NFL in the CSF. Patients with tetrapareses showed higher values than those with incomplete injuries. Three of the 17 whiplash cases had increased levels of NFL, but normal GFAp. Assessment of nervous tissue markers in CSF will probably improve possibilities to classify and prognosticate spinal cord injuries and also to evaluate pharmacological intervention. The increased levels of NFL in three whiplash cases indicate neural damage in a proportion of the cases with neurological deficit. Neurological examinations are presently the only tools for grading and prognostication of spinal cord injuries. Assessment of nervous tissue markers in CSF makes it possible to quantify the degree of nerve cell damage after different types of cervical spine injury ranging from spinal cord lesions to whiplash injuries.