Multiplanar cervical spine injury due to head-turned rear impact

Which traumatic spinal injury creates which degree of instability? A systematic quantitative review

BACKGROUND CONTEXT

Traumatic spinal injuries often require surgical fixation. Specific three-dimensional degrees of instability after spinal injury, which represent criteria for optimum treatment concepts, however, are still not well investigated.

PURPOSE

The aim of this review therefore was to summarize and quantify multiplanar instability increases due to spinal injury from experimental studies.

STUDY DESIGN/SETTING

Systematic review.

METHODS

A systematic review of the literature was performed using keyword-based search on PubMed and Web of Science databases in order to detect all in vitro studies investigating the destabilizing effect of simulated and provoked traumatic injury in human spine specimens. Together with the experimental designs, the instability parameters range of motion, neutral zone and translation were extracted from the studies and evaluated regarding type and level of injury.

RESULTS

A total of 59 studies was included in this review, of which 43 studies investigated the effect of cervical spine injury. Range of motion increase, which was reported in 58 studies, was generally lower compared to the neutral zone increase, given in 37 studies, despite of injury type and level. Instability increases were highest in flexion/extension for most injury types, while axial rotation was predominantly affected after cervical unilateral dislocation injury and lateral bending solely after odontoid fracture. Whiplash injuries and wedge fractures were found to increase instability equally in all motion planes.

CONCLUSIONS

Specific traumatic spinal injuries produce characteristic but complex three-dimensional degrees of instability, which depend on the type, level, and morphology of the injury. Future studies should expand research on the cervicothoracic, thoracic, and lumbosacral spine and should additionally investigate the destabilizing effects of the injury morphology as well as concomitant rib cage injuries in case of thoracic spinal injuries. Moreover, neutral zone and translation should be measured in addition to the range of motion, while mechanical injury simulation should be preferred to resection or transection of structures to ensure high comparability with the clinical situation.

Effect of Active Head Restraint on Cervical Vertebrae Injuries Lessening

A three-dimensional multi-body model of the 50th percentile male human and discretized neck was built to evaluate the effect of active head restraint on cervical vertebrae injuries lessening in vehicle rear impact. The discretized neck includes of cervical spine vertebrae, intervertebral discs, ligaments, and muscles. The BioRID-II adult male dummy restrained using safety belt was seated on a sled, whose longitudinal velocity measured from rear impact FEM simulation was applied to simulate the relative motion of the head and neck. According to the interspinous ligament loads and the ligamenta flava loads of the cervical spine, an active head restraint and an impact absorber were designed to lessening the neck injuries in vehicle rear end collisions.

Effect of active head restraint on residual neck instability due to rear impact

STUDY DESIGN

An in vitro study of simulated whiplash using a hybrid cadaveric/surrogate model.

OBJECTIVE

The goal of the present study was to determine the effect of the active head restraint (AHR) on residual neck instability due to simulated rear impacts of a human model of the neck.

SUMMARY OF BACKGROUND DATA

Previous studies have indicated potential benefits of active injury prevention systems in reducing neck injuries during rear impacts.

METHODS

Six osteoligamentous whole cervical spine specimens (occiput-T1) were prepared with vertebral motion tracking flags. The model, consisting of the neck specimen mounted to the torso of BioRID II and carrying an anthropometric surrogate head, was rear impacted (7.1 and 11.1 g) with and without the AHR. Pre- and post-impact flexibility tests identified significant residual instability (P < 0.05) above physiologic values and among experimental conditions. Linear regression analyses were used to identify correlation between spinal rotation peaks measured during impact and the resulting flexibility parameter increases (R² > 0.35 and P < 0.001).

RESULTS

Our results indicated significant increases in the average flexibility parameters, up to 3.1°, at C2-C3, C3-C4, and C5-C6 due to 7.1 g rear impacts even in the presence of the AHR. Subsequently, increases in the flexibility parameters progressed and spread to head/C1 and to the inferior spinal levels following the 11.1 g impacts. Correlation was observed between the C7-T1 extension peaks measured during impact and the flexibility parameter increases measured following impact. The flexibility parameter increases were generally larger due to the impacts with no head restraint, as compared with the AHR.

CONCLUSION

Extrapolation of our results indicated that every 1° of extension beyond the physiologic limit during whiplash contributed approximately 0.5° of residual neck rotation following whiplash. The present data underscore the protective effect of the AHR in reducing residual neck instability due to whiplash.

Axial head rotation increases facet joint capsular ligament strains in automotive rear impact

Axial head rotation prior to low speed automotive rear impacts has been clinically identified to increase morbidity and symptom duration. The present study was conducted to determine the effect of axial head rotation on facet joint capsule strains during simulated rear impacts. The study was conducted using a validated intact head to first thoracic vertebra (T1) computational model. Parametric analysis was used to assess effects of increasing axial head rotation between 0 and 60° and increasing impact severity between 8 and 24 km/h on facet joint capsule strains. Rear impacts were simulated by horizontally accelerating the T1 vertebra. Characteristics of the acceleration pulse were based on the horizontal T1 acceleration pulse from a series of simulated rear impact experiments using full-body post mortem human subjects. Joint capsule strain magnitudes were greatest in ipsilateral facet joints for all simulations incorporating axial head rotation (i.e., head rotation to the left caused higher ligament strain at the left facet joint capsule). Strain magnitudes increased by 47-196% in simulations with 60° head rotation compared to forward facing simulations. These findings indicate that axial head rotation prior to rear impact increases the risk of facet joint injury.

Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients

Background

The cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine.

Methods

Measures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPT's) and cold pain thresholds (CPT's). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD.

Results

At baseline, PPT's were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPT's at all sites (p < 0.05), and significant decreases in CPT's at the cervical spine (p < 0.001).

Conclusions

The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.

Head-turned postures increase the risk of cervical facet capsule injury during whiplash

STUDY DESIGN

In vitro experiments using cadaveric cervical spine motion segments to quantify facet capsular ligament strain during whiplash-like loading.

OBJECTIVE

To quantify facet capsule strains during whiplash-like loading with an axial intervertebral prerotation simulating an initial head-turned posture and to then compare these strains to previously-published strains for partial failure and gross failure of the facet capsule for these specimens.

SUMMARY OF BACKGROUND DATA

Clinical data have shown that a head-turned posture at impact increases the severity and duration of whiplash-related symptoms.

METHODS

Thirteen motion segments were used from 7 women donors (50 +/- 10 years). Axial pretorques (+/-1.5 Nm), axial compressive preloads (45, 197, and 325 N), and quasi-static shear loads (posteriorly-directed horizontal forces from 0 to 135 N) were applied to the superior vertebral body to simulate whiplash kinematics with the head turned. Three-dimensional displacements of markers placed on the right facet capsular ligament were used to estimate the strain field in the ligament during loading. The effects of pretorque direction, compression, and posterior shear on motion segment motion and maximum principal strain in the capsule were examined using repeated-measures analyses of variance.

RESULTS

Axial pretorque affected peak capsule strains more than axial compression or posterior shear. Peak strains reached 34% +/- 18% and were higher for pretorques toward rather than away from the facet capsule (i.e.-, head rotation to the right caused higher strain in the right facet capsule).

CONCLUSION

Compared to previously-reported data for these specimens, peak capsule strains with a pretorque were double those without a pretorque (17% +/- 6%) and not significantly different from those at partial failure of the ligament (35% +/- 21%). Thus a head-turned posture increases facet capsular ligament strain compared to a neutral head posture-a finding consistent with the greater symptom severity and duration observed in whiplash patients who have their head turned at impact.

Whiplash causes increased laxity of cervical capsular ligament

BACKGROUND

Previous clinical studies have identified the cervical facet joint, including the capsular ligaments, as sources of pain in whiplash patients. The goal of this study was to determine whether whiplash caused increased capsular ligament laxity by applying quasi-static loading to whiplash-exposed and control capsular ligaments.

METHODS

A total of 66 capsular ligament specimens (C2/3 to C7/T1) were prepared from 12 cervical spines (6 whiplash-exposed and 6 control). The whiplash-exposed spines had been previously rear impacted at a maximum peak T1 horizontal acceleration of 8 g. Capsular ligaments were elongated at 1mm/s in increments of 0.05 mm until a tensile force of 5 N was achieved and subsequently returned to neutral position. Four pre-conditioning cycles were performed and data from the load phase of the fifth cycle were used for subsequent analyses. Ligament elongation was computed at tensile forces of 0, 0.25, 0.5, 0.75, 1.0, 2.5, and 5.0 N. Two factor, non-repeated measures ANOVA (P<0.05) was performed to determine significant differences in the average ligament elongation at tensile forces of 0 and 5 N between the whiplash-exposed and control groups and between spinal levels.

FINDINGS

Average elongation of the whiplash-exposed capsular ligaments was significantly greater than that of the control ligaments at tensile forces of 0 and 5 N. No significant differences between spinal levels were observed.

INTERPRETATION

Capsular ligament injuries, in the form of increased laxity, may be one component perpetuating chronic pain and clinical instability in whiplash patients.

Side impact causes multiplanar cervical spine injuries

BACKGROUND

Side impact may cause neck and upper extremity pain, paresthesias, and impaired neck motion. No studies have quantified the cervical spine mechanical instability and injury threshold acceleration due to side impact. The goals of the present study were to identify and quantify cervical spine soft tissue injury and the injury threshold acceleration for side impact, and to compare these results with previous findings.

METHODS

Six human cervical spine specimens (C0-T1) underwent 3.5, 5, 6.5, and 8 g impacts. Pre- and postimpact flexibility tests were performed. Soft tissue injury was defined as a significant increase (p < 0.05) in the average intervertebral flexibility above the baseline 2 g impact. The injury threshold was the lowest T1 horizontal peak acceleration that caused the injury.

RESULTS

The injury threshold acceleration was 6.5 g, with injuries occurring at C4-C5 through C7-T1 in flexion, axial rotation, or left lateral bending. After 8 g, three-plane injury was observed at C4-C5 and C6-C7, whereas two-plane injury occurred at C3-C4 in flexion and left lateral bending and at C5-C6 and C7-T1 in axial rotation and left lateral bending.

CONCLUSIONS

Side impact caused multiplanar injuries at C3-C4 through C7-T1 and significantly greater injury at C6-C7, as compared with head-forward rear impact.

Predicting multiplanar cervical spine injury due to head-turned rear impacts using IV-NIC

OBJECTIVE

Intervertebral Neck Injury Criterion (IV-NIC) hypothesizes that dynamic three-dimensional intervertebral motion beyond physiological limit may cause multiplanar soft-tissue injury. Present goals, using biofidelic whole human cervical spine model with muscle force replication and surrogate head in head-turned rear impacts, were to: (1) correlate IV-NIC with multiplanar injury, (2) determine IV-NIC injury threshold at each intervertebral level, and (3) determine time and mode of dynamic intervertebral motion that caused injury.

METHODS

Impacts were simulated at 3.5, 5, 6.5, and 8 g horizontal accelerations of T1 vertebra (n = 6; average age: 80.2 years; four male, two female donors). IV-NIC was defined at each intervertebral level and in each motion plane as dynamic intervertebral rotation divided by physiological limit. Three-plane pre- and post-impact flexibility testing measured soft-tissue injury; that is significant increase in neutral zone (NZ) or range of motion (RoM) at any intervertebral level, above baseline. IV-NIC injury threshold was average IV-NIC peak at injury onset.

RESULTS

IV-NIC extension peaks correlated best with multiplanar injuries (P < 0.001): extension RoM (R = 0.55) and NZ (R = 0.42), total axial rotation RoM (R = 0.42) and NZ (R = 0.41), and total lateral bending NZ (R = 0.39). IV-NIC injury thresholds ranged between 1.1 at C0-C1 and C3-C4 to 2.9 at C7-T1. IV-NIC injury threshold times were attained between 83.4 and 150.1 ms following impact.

CONCLUSIONS

Correlation between IV-NIC and multiplanar injuries demonstrated that three-plane intervertebral instability was primarily caused by dynamic extension beyond the physiological limit during head-turned rear impacts.

Head-turned rear impact causing dynamic cervical intervertebral foramen narrowing: implications for ganglion and nerve root injury

OBJECT

A rotated head posture at the time of vehicular rear impact has been correlated with a higher incidence and greater severity of chronic radicular symptoms than accidents occurring with the occupant facing forward. No studies have been conducted to quantify the dynamic changes in foramen dimensions during head-turned rear-impact collisions. The objectives of this study were to quantify the changes in foraminal width, height, and area during head-turned rear-impact collisions and to determine if dynamic narrowing causes potential cervical nerve root or ganglion impingement.

METHODS

The authors subjected a whole cervical spine model with muscle force replication and a surrogate head to simulated head-turned rear impacts of 3.5, 5, 6.5, and 8 G following a noninjurious 2-G baseline acceleration. Continuous dynamic foraminal width, height, and area narrowing were recorded, and peaks were determined during each impact; these data were then statistically compared with those obtained at baseline. The authors observed significant increases (p < 0.05) in mean peak foraminal width narrowing values greater than baseline values, of up to 1.8 mm in the left C5-6 foramen at 8 G. At the right C2-3 foramen, the mean peak dynamic foraminal height was significantly narrower than baseline when subjected to rear-impacts of 5 and 6.5 G, but no significant increases in foraminal area were observed. Analysis of the results indicated that the greatest potential for cervical ganglion compression injury existed at C5-6 and C6-7. Greater potential for ganglion compression injury existed at C3-4 and C4-5 during head-turned rear impact than during head-forward rear impact.

CONCLUSIONS

Extrapolation of present results indicated potential ganglion compression in patients with a non-stenotic foramen at C5-6 and C6-7; in patients with a stenotic foramen the injury risk greatly increases and spreads to include the C3-4 through C6-7 as well as C4-5 through C6-7 nerve roots.