Whiplash and SPECT imaging - exciting new research

[Guest guest]

Hi all,

The abstract below has just been accepted in a peer-reviewed forum for

presentation at the Cervical Spine Research Society meeting in Monterey this

December. I have been sitting on the abstract for months, and now instead of

15 patients we have over 40 in the study. The idea that people with chronic

pain following whiplash may have bony injury including occult fracture would

turn the med-legal aspect of these so-called " soft tissue " cases upside

down, since the (incorrectly) assumed transient nature of soft tissue

injuries is a frequent line of defense.

Although our data is preliminary, this may end up being an important

discovery in the search for reasons why whiplash pain persists so

frequently, and we are quite excited about the prospects for future research

and the potential of various types of treatments that have not been

previously tried.

D Freeman PhD DC MPH

Forensic Trauma Epidemiologist

Department of Public Health and Preventive Medicine

Oregon Health Sciences University School of Medicine

Mailing address: 2480 Liberty Street NE Suite 180

Salem, Oregon 97303

phone 503 763-3528

fax 503 763-3530

pager 888 501-7328

Whiplash injury and occult vertebral fracture; a case series of bone scan

and SPECT imaging of patients with severe pain following a motor vehicle

crash.

Freeman PhD DC MPH

Dan Sapir MD

Boutselis MD

Gorup MD

Glen Tuckman MD

Arthur Croft DC MPH MS

Centeno MD

Arnie MD

Introduction

The pathology of chronic whiplash injury continues to be a controversial

subject in the literature, with some authors claiming that long term pain

following whiplash is a factitious disorder. These claims are made despite a

growing canon of research demonstrating the cervical zygapophysis as a

primary source of pain in approximately half of all chronic whiplash cases.

Other research suggests that the intervertebral disc may be a source of

continuing pain, associated with so-called rim lesions and other disc

injuries.

The pathomechanics of whiplash resulting from a rear impact collision

include both segmental hyperextension in the lower cervical spine during the

initial rearward movement of the head as well as flexion following the

rebound of the head off of the head restraint, suggesting forceful loading

of both posterior and anterior elements of the cervical spine. Recent

cadaver testing of simulated whiplash has resulted in findings of injuries

including fracture of both the vertebral body and elements of the neural

arch, leading to the supposition that bony injury can occur with both the

extension and flexion phases of whiplash trauma.

While plain x-ray with lateral flexion and extension views is the generally

recognized standard for evaluating bony injury and instability following

whiplash, it is not particularly sensitive for the presence of incomplete

cortical disruption such as endplate fractures and subchondral fractures of

the facet.

In the current investigation, we undertook bone scan and SPECT evaluation of

consecutive patients who were referred for significant refractory pain

following whiplash trauma based on the hypothesis that there may be a

subpopulation of these patients who have continued symptoms resulting from

unhealed occult fracture.

Methods

Following Institutional Review Board approval of the study protocol, 15

consecutive patients who were referred for orthopedic evaluation of spine

pain secondary to a motor vehicle crash (MVC), with symptoms that were

un-responsive to conservative means of treatment such as physical therapy,

chiropractic, and rehabilitation exercises, were subsequently referred for

bone scan and SPECT imaging of their cervical and thoracic spine. The bone

scans and SPECT images were read by two radiologists, blinded with regard to

each other's findings as well as to the patients' symptom patterns. The

results of the bone scan and SPECT imaging were compared to the patients'

prior imaging studies (including plain x-ray and MRI) as well as their

symptom pattern. Other details regarding patient demographics and the

specifics of the MVC were tabulated.

Results

Of the 15 referrals, one could not obtain insurance coverage for the study

and thus did not undergo the diagnostic imaging. Of the remaining 14

subjects who were studied, ten had positive findings on bone scan and/or

SPECT (71%). Nine of the ten positive studies closely corresponded with the

patient-reported symptoms. The most frequent finding was vertebral endplate

fracture, found in six cervical (60%) and three thoracic (30%) vertebrae.

There were occult fractures identified in the lateral mass/lamina region of

two cervical (20%) and two thoracic (20%) vertebra. A spinous process

fracture was identified in the thoracic spine of one (10%) subject.

There were ten females and four males in the study, with an average age of

33.3 (SD 9.0). The bone scan and SPECT imaging was performed an average of

18.9 months post-crash (SD 13.5, range 2-47). Pain levels were uniformly

high, with average VAS scores of 7.8 (SD 1.1).

Seven of the crashes were rear impact (50%), four were side impacts (29%),

and three were front end impacts (21%). Nine of the occupants were drivers

(64%) and ten were wearing seatbelts (71%). It did not appear that any of

the fractures were a result of direct contact with the vehicle interior.

None of the subjects had fractures that were detectable on plain film, even

after reviewing the SPECT images and re-reading the radiographs. Ten of the

subjects had MRI testing prior to the bone scan/SPECT protocol, and of

these, six had signs of disc bulging in the cervical spine, four had disc

bulges in the thoracic spine, and one had a frank thoracic herniation. One

subject had undergone prior cervical discectomy and fusion, but had uptake

activity in an area other than the healed fusion.

Discussion/Conclusion

Our results, even though of a limited sample of patients, suggest a possible

pathological mechanism at work in chronic whiplash that has not been

previously described. While other authors have reported vertebral fractures

resulting from whiplash trauma, none that we are aware of have suggested

unhealed fractures as a potential source of chronic pain. Lack of

specificity of bone scan and SPECT imaging for fracture may be a factor in

our series, however, the high correlation of symptoms to findings suggests a

traumatic rather than degenerative etiology. Greater subject numbers are

needed in order to perform meaningful subgroup analyses relating to gender,

age, and injury and crash details as risk factors for occult spinal fracture

following whiplash. Our findings may point to more effective methods of

dealing with chronic spine pain resulting from motor vehicle crashes. A

larger scale investigation of the routine use of bone scans with bone SPECT

in whiplash cases with persisting pain is warranted.

[Guest guest]

Sorry, Don. SPECT stands for Single Photon Emission Computed Tomography, and

it is to a bone scan what a CT is to a plain x-ray.

D Freeman

Mailing address: 2480 Liberty Street NE Suite 180

Salem, Oregon 97303

phone 503 763-3528

fax 503 763-3530

pager 888 501-7328

Whiplash and SPECT imaging - exciting new research

>

>

> > Hi all,

> > The abstract below has just been accepted in a peer-reviewed forum for

> > presentation at the Cervical Spine Research Society meeting in Monterey

> this

> > December. I have been sitting on the abstract for months, and now

instead

> of

> > 15 patients we have over 40 in the study. The idea that people with

> chronic

> > pain following whiplash may have bony injury including occult fracture

> would

> > turn the med-legal aspect of these so-called " soft tissue " cases upside

> > down, since the (incorrectly) assumed transient nature of soft tissue

> > injuries is a frequent line of defense.

> > Although our data is preliminary, this may end up being an important

> > discovery in the search for reasons why whiplash pain persists so

> > frequently, and we are quite excited about the prospects for future

> research

> > and the potential of various types of treatments that have not been

> > previously tried.

> >

> > D Freeman PhD DC MPH

> > Forensic Trauma Epidemiologist

> > Department of Public Health and Preventive Medicine

> > Oregon Health Sciences University School of Medicine

> > Mailing address: 2480 Liberty Street NE Suite 180

> > Salem, Oregon 97303

> > phone 503 763-3528

> > fax 503 763-3530

> > pager 888 501-7328

> >

> > Whiplash injury and occult vertebral fracture; a case series of bone

scan

> > and SPECT imaging of patients with severe pain following a motor vehicle

> > crash.

> >

> > Freeman PhD DC MPH

> > Dan Sapir MD

> > Boutselis MD

> > Gorup MD

> > Glen Tuckman MD

> > Arthur Croft DC MPH MS

> > Centeno MD

> > Arnie MD

> >

> > Introduction

> > The pathology of chronic whiplash injury continues to be a controversial

> > subject in the literature, with some authors claiming that long term

pain

> > following whiplash is a factitious disorder. These claims are made

despite

> a

> > growing canon of research demonstrating the cervical zygapophysis as a

> > primary source of pain in approximately half of all chronic whiplash

> cases.

> > Other research suggests that the intervertebral disc may be a source of

> > continuing pain, associated with so-called rim lesions and other disc

> > injuries.

> > The pathomechanics of whiplash resulting from a rear impact collision

> > include both segmental hyperextension in the lower cervical spine during

> the

> > initial rearward movement of the head as well as flexion following the

> > rebound of the head off of the head restraint, suggesting forceful

loading

> > of both posterior and anterior elements of the cervical spine. Recent

> > cadaver testing of simulated whiplash has resulted in findings of

injuries

> > including fracture of both the vertebral body and elements of the neural

> > arch, leading to the supposition that bony injury can occur with both

the

> > extension and flexion phases of whiplash trauma.

> > While plain x-ray with lateral flexion and extension views is the

> generally

> > recognized standard for evaluating bony injury and instability following

> > whiplash, it is not particularly sensitive for the presence of

incomplete

> > cortical disruption such as endplate fractures and subchondral fractures

> of

> > the facet.

> > In the current investigation, we undertook bone scan and SPECT

evaluation

> of

> > consecutive patients who were referred for significant refractory pain

> > following whiplash trauma based on the hypothesis that there may be a

> > subpopulation of these patients who have continued symptoms resulting

from

> > unhealed occult fracture.

> >

> > Methods

> > Following Institutional Review Board approval of the study protocol, 15

> > consecutive patients who were referred for orthopedic evaluation of

spine

> > pain secondary to a motor vehicle crash (MVC), with symptoms that were

> > un-responsive to conservative means of treatment such as physical

therapy,

> > chiropractic, and rehabilitation exercises, were subsequently referred

for

> > bone scan and SPECT imaging of their cervical and thoracic spine. The

bone

> > scans and SPECT images were read by two radiologists, blinded with

regard

> to

> > each other's findings as well as to the patients' symptom patterns. The

> > results of the bone scan and SPECT imaging were compared to the

patients'

> > prior imaging studies (including plain x-ray and MRI) as well as their

> > symptom pattern. Other details regarding patient demographics and the

> > specifics of the MVC were tabulated.

> >

> > Results

> > Of the 15 referrals, one could not obtain insurance coverage for the

study

> > and thus did not undergo the diagnostic imaging. Of the remaining 14

> > subjects who were studied, ten had positive findings on bone scan and/or

> > SPECT (71%). Nine of the ten positive studies closely corresponded with

> the

> > patient-reported symptoms. The most frequent finding was vertebral

> endplate

> > fracture, found in six cervical (60%) and three thoracic (30%)

vertebrae.

> > There were occult fractures identified in the lateral mass/lamina region

> of

> > two cervical (20%) and two thoracic (20%) vertebra. A spinous process

> > fracture was identified in the thoracic spine of one (10%) subject.

> > There were ten females and four males in the study, with an average age

of

> > 33.3 (SD 9.0). The bone scan and SPECT imaging was performed an average

of

> > 18.9 months post-crash (SD 13.5, range 2-47). Pain levels were uniformly

> > high, with average VAS scores of 7.8 (SD 1.1).

> > Seven of the crashes were rear impact (50%), four were side impacts

(29%),

> > and three were front end impacts (21%). Nine of the occupants were

drivers

>

> > (64%) and ten were wearing seatbelts (71%). It did not appear that any

of

> > the fractures were a result of direct contact with the vehicle interior.

> > None of the subjects had fractures that were detectable on plain film,

> even

> > after reviewing the SPECT images and re-reading the radiographs. Ten of

> the

> > subjects had MRI testing prior to the bone scan/SPECT protocol, and of

> > these, six had signs of disc bulging in the cervical spine, four had

disc

> > bulges in the thoracic spine, and one had a frank thoracic herniation.

One

> > subject had undergone prior cervical discectomy and fusion, but had

uptake

> > activity in an area other than the healed fusion.

> >

> > Discussion/Conclusion

> > Our results, even though of a limited sample of patients, suggest a

> possible

> > pathological mechanism at work in chronic whiplash that has not been

> > previously described. While other authors have reported vertebral

> fractures

> > resulting from whiplash trauma, none that we are aware of have suggested

> > unhealed fractures as a potential source of chronic pain. Lack of

> > specificity of bone scan and SPECT imaging for fracture may be a factor

in

> > our series, however, the high correlation of symptoms to findings

suggests

> a

> > traumatic rather than degenerative etiology. Greater subject numbers are

> > needed in order to perform meaningful subgroup analyses relating to

> gender,

> > age, and injury and crash details as risk factors for occult spinal

> fracture

> > following whiplash. Our findings may point to more effective methods of

> > dealing with chronic spine pain resulting from motor vehicle crashes. A

> > larger scale investigation of the routine use of bone scans with bone

> SPECT

> > in whiplash cases with persisting pain is warranted.

> >

> >

> >

> >

> >

> >

[Guest guest]

Thanks . Great piece of information. I have recently had a patient with similar complaints and the IME doc said that she simply had congenitally enlarged zygopophseal jts. I didn't know about SPECT imaging. She's a slightly built 21 yr old female. Her cervical and thoracic pain persist even 8 months after her MVA. Unfortunely her claims rep asked her to sign the claim off after giving her assurance that they would pay for medical needs for up to one year. All this was done before she even got to me for care. Prior to that she had very little care. Then after she signed, they told her she had to go to an IME. All further treatment was denied after that. I've given her the name of an attorney and hope something can be resolved. However, since she signed off further blame.....I don't know what else is possible. Any one out there have this happen before?

Minga Guerrero DC

[Guest guest]

This is exactly why we should have a "bad faith" law in this state.

Dr B

Re: Whiplash and SPECT imaging - exciting new research

Thanks . Great piece of information. I have recently had a patient with similar complaints and the IME doc said that she simply had congenitally enlarged zygopophseal jts. I didn't know about SPECT imaging. She's a slightly built 21 yr old female. Her cervical and thoracic pain persist even 8 months after her MVA. Unfortunely her claims rep asked her to sign the claim off after giving her assurance that they would pay for medical needs for up to one year. All this was done before she even got to me for care. Prior to that she had very little care. Then after she signed, they told her she had to go to an IME. All further treatment was denied after that. I've given her the name of an attorney and hope something can be resolved. However, since she signed off further blame.....I don't know what else is possible. Any one out there have this happen before? Minga Guerrero DC

[Guest guest]

Yeah--

I had one a year ago where the patient was hit by another car insured by STATE FARM as she was. Not knowing better she was told that it was policy when they were both insured by THE FARM to have them sign a release and they would have all medical bills covered for up to a year. She did it. I explained that they only agreed to do what they were already required to do and she had been duped. It was sad as it was a $50-60000 claim from what I have seen with some perm. damage. I gave her the name of a PI att. and they filed a complaint with the state AG and Ins. comm. but nothing came of it. This adjuster got away with one and probably was proud of what he did for his company. However I will not tx. a patient insured with the FARM since w/o them seeing a attorney to protect their rights even a simple injury case. So in the long run even with the few PI's I see it will cost them in the long run for now they have to pay the attorney's time in the each and every case to settle the case even if the injuries are minimal.

Take care

Steve Kinne

Re: Whiplash and SPECT imaging - exciting new research

Thanks . Great piece of information. I have recently had a patient with similar complaints and the IME doc said that she simply had congenitally enlarged zygopophseal jts. I didn't know about SPECT imaging. She's a slightly built 21 yr old female. Her cervical and thoracic pain persist even 8 months after her MVA. Unfortunely her claims rep asked her to sign the claim off after giving her assurance that they would pay for medical needs for up to one year. All this was done before she even got to me for care. Prior to that she had very little care. Then after she signed, they told her she had to go to an IME. All further treatment was denied after that. I've given her the name of an attorney and hope something can be resolved. However, since she signed off further blame.....I don't know what else is possible. Any one out there have this happen before? Minga Guerrero DC

[Guest guest]

Minga, this happens to me all the time. I have adopted an add on to my

Report of Findings where I explain the threee aspects of a MVC:1, the

dents( other insurance pays) 2, Medical & Chiro treatment( your PIP pays) ,

and 3, settlement: when everybody agrees its over. You have to be

emphatic in telling your patient that the INs Co, both yours and theirs

will lie to you and do everything possible to chisel you out of a full

treatment schedule and righteous settlement. Get them understanding the

process early, and get them to an attorney early if somebody is dragging

their feet on their responsibilities. The other thing I do is send

copious narratives to the PIP carrier at no charge, and make sure I get a

second opinion if I'm not done with tx at 60 days. Ron Johansen

On Fri, 21 Sep 2001 11:12:15 EDT AboWoman@... writes:

> Thanks .

> Great piece of information. I have recently had a patient with

> similar

> complaints and the IME doc said that she simply had congenitally

> enlarged

> zygopophseal jts. I didn't know about SPECT imaging. She's a

> slightly built

> 21 yr old female. Her cervical and thoracic pain persist even 8

> months after

> her MVA. Unfortunely her claims rep asked her to sign the claim off

> after

> giving her assurance that they would pay for medical needs for up to

> one

> year. All this was done before she even got to me for care. Prior to

> that she

> had very little care. Then after she signed, they told her she had

> to go to

> an IME. All further treatment was denied after that. I've given her

> the name

> of an attorney and hope something can be resolved. However, since

> she signed

> off further blame.....I don't know what else is possible. Any one

> out there

> have this happen before?

> Minga Guerrero DC

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[Guest guest]

Ya, amen or how's about not making insurance companies exempt from Oregon's Unfair Trade Practices Act which they are, can ya believe it!

Vern Saboe

Re: Whiplash and SPECT imaging - exciting new research

Thanks . Great piece of information. I have recently had a patient with similar complaints and the IME doc said that she simply had congenitally enlarged zygopophseal jts. I didn't know about SPECT imaging. She's a slightly built 21 yr old female. Her cervical and thoracic pain persist even 8 months after her MVA. Unfortunely her claims rep asked her to sign the claim off after giving her assurance that they would pay for medical needs for up to one year. All this was done before she even got to me for care. Prior to that she had very little care. Then after she signed, they told her she had to go to an IME. All further treatment was denied after that. I've given her the name of an attorney and hope something can be resolved. However, since she signed off further blame.....I don't know what else is possible. Any one out there have this happen before? Minga Guerrero DC

[Guest guest]

Yes I can Verne, it just takes $ and a good lobbying effort. I recall when the AMA tried to maneuver such that they were exempt from the Antitrust Laws...like they wanted no accountability or something. Organizations like the Frame must have some accountability. Steve Lumsden

Re: Whiplash and SPECT imaging - exciting new research

Thanks . Great piece of information. I have recently had a patient with similar complaints and the IME doc said that she simply had congenitally enlarged zygopophseal jts. I didn't know about SPECT imaging. She's a slightly built 21 yr old female. Her cervical and thoracic pain persist even 8 months after her MVA. Unfortunely her claims rep asked her to sign the claim off after giving her assurance that they would pay for medical needs for up to one year. All this was done before she even got to me for care. Prior to that she had very little care. Then after she signed, they told her she had to go to an IME. All further treatment was denied after that. I've given her the name of an attorney and hope something can be resolved. However, since she signed off further blame.....I don't know what else is possible. Any one out there have this happen before? Minga Guerrero DC