Whiplash Injury, Cervical Kyphosis, and Cervical Spine Arthritis


Soccer’s World Cup, 2010, has just finished. Having watched many of the games, I constantly observed players “head” the ball, and often the ball had traveled more than half the length of the playing field prior to contacting the head while “on the fly.”


In 2004, researchers from Cankaya University, Ankara, Turkey, published an article in the European Spine Journal, titled (1):


Soccer causes degenerative changes in the cervical spine


In this study, the authors assessed the incidence of degenerative changes of the cervical spine joints in active amateur and veteran soccer players. They designed a cross-sectional descriptive study using biomechanical, radiological, and magnetic resonance assessments. The study subjects were active (<30 years; n=15) and veteran (>30 years; n=15) male amateur soccer players, and their age-matched controls (n=13 and n=15).


The authors found that degenerative changes were prominent in veteran players, and the sagittal diameter of their spinal canal at C2 to C6 was lower when compared to controls. Narrowing of the sagittal spinal canal diameter suggests advancing degenerative spondylotic changes, predisposing these individuals to spinal cord myelopathy. Consequently, magnetic resonance findings of degeneration were more prominent in soccer players when compared to their age-matched controls. These authors note:


“Severe muscle spasms, spinal cord injuries, disc herniation and fracture dislocations are documented among the acute injuries to the cervical spine in soccer.”


In soccer, “scoring, defending and passing the ball with the head is an integral part of this game; so chronic degenerative changes should be common in the cervical spine.”


“High- and/or low-impact recurrent trauma mainly due to heading the ball may initiate degenerative changes at the cervical spine.”


“The cervical spine absorbs a significant amount of the force generated due to heading the ball. This type of repetitive force during competition or training may increase the risk of degeneration at the intervertebral joints, intervertebral discs or the spinal cord.”


“Continuous micro- and macro-trauma to the cervical spine due to heading the ball in soccer may cause early degenerative changes.”


“Cervical disc bulging, osteophytes in the cervical canal, disc protrusion, loss of cervical lordosis, spinal cord compression, and cord compression in hyperflexion were the most common MR findings.”


The “degenerative changes of the cervical spine in soccer are not only limited to the skeletal tissues but may also extend to the soft tissues, including the intervertebral disc and the spinal cord.”


“Biomechanical, radiological, and MR findings present a tendency towards early degenerative changes of the cervical spine most probably due to heading the ball in soccer.”


“A tendency towards early degenerative changes exists in soccer players most probably due to high- and/or low-impact recurrent trauma to the cervical spine caused by heading the ball.”


“The onset of such [spinal degenerative] changes was 10–20 years earlier than that of the normal population.”


•••••


There is an important difference between soccer cervical spine trauma and whiplash injury cervical spine trauma. Clearly, “heading” the soccer ball is primarily a repeated microtraumatic event; an event that occurs hundreds or thousands of times over years or decades. In contrast, whiplash injury is usually a single macrotraumatic event. These questions are explored in this work:


1) Do whiplash injury single macrotraumatic events lead to the acceleration of cervical spine degeneration and arthritis (spondylosis)?


2) What is the relationship between whiplash trauma and reversal of the normal cervical lordotic curve, or cervical spine kyphosis?


3) Does cervical spine kyphosis accelerate cervical spine spondylosis and cervical spinal cord dysfunction (myelopathy)?


4) Is there any evidence that cervical spine kyphotic deformity can be improved or corrected with chiropractic management?


I will explore these questions one at a time.


1


Do whiplash injury single macrotraumatic events lead to the acceleration of cervical spine degeneration and arthritis (spondylosis)?


In 1964, whiplash injury expert and pioneer, Ruth Jackson, MD, from Baylor University Medical School, published an article in the American Journal of Orthopedics titled (2):


“The Positive Findings In Neck Injuries”


Dr. Jackson’s conclusions in this article were based on her evaluation of 5,000 injured patients. She notes:


“An adequate radiographic examination of the cervical spine is essential for diagnosis.”


“Any injury of the disc causes a disturbance in the dynamics of the motor unit of which the disc is a part. This leads to degeneration of the disc and the proximate joints.”



The 1989 reference text produced by the Cervical Spine Research Society titled (3):


The Cervical Spine Research Society


addresses the question of whiplash trauma and acceleration of degenerative disc disease. The text notes that in one study, x-rays taken an average of 7 years after whiplash injury showed neck disc arthritis was present in 39% of the patients. The control group only showed a neck disc arthritis incidence of 6%. The authors concluded:


“Thus, it appeared that the injury had started the slow process of disc degeneration.”



In 1993, Dr. Hamer and colleagues published a study pertaining to whiplash injury and surgical cervical disc pathology. The study was published in the journal Injury and titled (4):


Whiplash injury and surgically treated cervical disc disease


In this study, the authors reviewed the incidence of a previous whiplash injury in 215 patients who underwent an anterior cervical discectomy and fusion. The rate of this disc surgery was found to be twice that of a control population of 800 general orthopaedic outpatients. The mean age at which the whiplash injury occurred in the surgical group was 37 years and in the control group 36 years. The mean age at operation of those patients with a previous whiplash injury (45 +/- 12 years) was significantly less than those patients without a previous whiplash injury (55 +/- 14 years). These authors concluded:


“This study provides further evidence that whiplash injury causes structural changes predisposing to premature degenerative disc disease.”



In 1997, Drs. Gargan and Bannister published a long-term follow-up comparison study of whiplash-injured patients to a group of matched controls. This study appeared in the Journal of Orthopedic Medicine, titled (5):


The Comparative Effects of Whiplash Injuries


This study is a cross-sectional age and sex-matched comparison of the clinical signs and radiographic features of 41 patients 10 years after whiplash injury, with 80 clinical and 100 radiographic controls. Specifically, the symptoms and signs of 41 patients who had sustained a whiplash injury 10 years previously were compared with 80 age-matched controls and their radiographs with 100 age-matched controls. Importantly, the x-rays showed that radiographic degenerative changes in the cervical spine appeared 10 years earlier in the whiplash group than in the control group, leading Gargan and Bannister to conclude:


“The prevalence of degenerative changes in the younger cervical spine [of the whiplash group] suggests that the condition has an organic basis.”


“After soft tissue neck trauma, degenerative change presented over 4 times as frequently in those aged between 31 and 40 and twice as often between 41 and 50.”


“Degenerative change and its association with neck stiffness support an organic basis for the symptoms that follow soft tissue injuries of the neck.”



These studies indicate that whiplash trauma does in fact initiate and


accelerate degenerative changes of the cervical spine, spondylosis.


2


What is the relationship between whiplash trauma and reversal of the normal cervical lordotic curve, or cervical spine kyphosis?


The greatest achievement of Dr. Ruth Jackson’s remarkable life is the publication of her book The Cervical Syndrome (6). The fourth and final edition of this book was published in 1978. The text is 399 pages in length and contains 158 figures. The majority of these figures involve sequential series of x-rays showing the acceleration of degenerative joint disease as a consequence of time after sustaining a cervical spine trauma. A common denominator in these series includes kyphotic angulation of the cervical spine following whiplash injury; when these kyphotic angulations are radiographically followed over a period of years, there is a predictable pattern of acceleration of cervical spondylosis observed. Dr. Jackson states:


“A loss of the forward curve which can be noted in the lateral view made with the patient looking straight ahead is indicative of some disorder of the cervical spine.”


“Loss of the forward curve occurs in 78% of all cases of cervical involvement and a reversal of the forward curve [kyphosis], which is localized usually to 3 or 4 segments, will be found in 20% of these cases. The apex of the reversed curve indicates usually the site of maximum involvement.”


“The reversed curve may present a sharp angulation at one specific level. This indicates a tearing of the posterior ligamentous structures or a rupture of the intervertebral disc anteriorly at that level. Subluxation of the posterior joints upward and forward with widening of the posterior joint spaces and separation of the corresponding spinous processes may be responsible, also, for the posterior angulation.”


Dr. Jackson discourages sleeping on the back with a regular pillow because it places the cervical spine in a position of kyphosis. She advocates the use of a “Cervical Contour Pillow” which maintains a normal cervical lordosis. Her text has photographs of radiographs of patients with both a normal pillow and the contour pillow to support her point.



Radiologist Lee Hadley, MD, in his 1979 text Anatomico-Roentgenographic Studies of the Spine, also shows several long-term case studies of cervical kyphosis progression to cervical spondylosis (7). On page 135 of his text, he states that cervical kyphotic angulation “should be considered a permanent injury.”



In 1995, radiologist Dr. Harry Griffiths and colleagues from the Department of Radiology, University of Minnesota Hospital, published an article in the journal Skeletal Radiology, titled (8):


Hyperextension strain or “whiplash” injuries to the cervical spine


In this study, the authors evaluated a full cervical spine radiographic series in 40 patients with clinically proven whiplash injuries and compared them to the radiographs of 105 normal controls. They found that patients with cervical kyphosis of greater than 10 degrees occurred in the whiplash-injured group 80%. They suggested that this finding was indicative of a more severe ligamentous injury at the segmental level below the kyphotic angulation.



In 2002, the journal Emergency Radiology published a study titled (9):


The use of flexion and extension MR in the evaluation


of cervical spine trauma: initial experience in 100 trauma patients compared with 100 normal subjects


In this study, the authors evaluated the cervical spines of 100 consecutive uninjured normal asymptomatic adults and 100 adult accident victims following rear-end low-impact motor vehicle accidents using rapid T2-weighted MRI. The injured subjects were evaluated during the subacute period, at 12 to 14 weeks after injury, following clinically resolved muscle spasm.


In the control, population, loss of normal cervical lordosis was observed in 4% of the subjects. In the subacute whiplash-injured patient population, loss of cervical lordosis was observed in 98% of the group. The authors were unable to ascribe this finding to muscle spasm.



These studies clearly indicate that cervical spine kyphosis certainly can occur as a consequence of whiplash trauma. They also indicate that cervical kyphosis is significantly more likely to be found in a whiplash patient population than in controls. Additionally, these cervical spine kyphotic deformities in whiplash-injured patients are unlikely to be caused by muscle spasm; rather they are much more likely to be the result of more significant ligamentous injury.


3


Does cervical spine kyphosis accelerate cervical spine spondylosis and cervical spinal cord dysfunction (myelopathy)?


In 2001, researchers from the Department of Orthopaedic Surgery, Shiga University of Medical Science, Otsu, Japan, published a study in the European Spine Journal titled (10):


Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels


In this study, 42 patients who underwent anterior interbody fusion surgery for cervical spondylosis and disc herniation were followed for an average of 9.8 years. The authors found degenerative change in adjacent intervertebral levels was observed in 77% of the fused segment when there was kyphotic angulation, which was statistically significant. They stated: