Predicting Prognosis in Soft Tissue Injuries of the Cervical Spine

Abstract

Soft tissue injuries of the cervical spine, as a result of acceleration-deceleration automobile collisions, make up a considerable part of the patient load of many chiropractic practices. The ability to predict which patients may have poor prognosis, based upon the patient's history, radiographic, and physical findings is presented.

Introduction

As our society becomes more mobile, hyperextension and hyperflexion injuries of the cervical spine occur with increasing regularity. As a result, the chiropractic practitioner will become called upon more frequently to render an opinion of the permanency of the patient's condition following treatment. The following article is intended to give the chiropractic practitioner a basic understanding of how this outcome may be predicted, based upon the patient's history, radiographic findings, and physical examination findings. This article in no way intended to give a complete review of the subject, but shall serve as a starting point for further investigation by the interested party.

Clinical Factors and Poor Prognosis

The history, radiographic, and physical examinations of the patient involved in an acceleration-deceleration collision, may reveal a wide variety of findings. However, a few authors have attempted to determine which of these findings could provide an insight into the prognosis of these patients.

M. Hohl1 has described six factors associated with poor prognosis following soft tissue injuries of the cervical spine: numbness and/or pain in an upper extremity; a reversal of the cervical lordosis; restriction of mobility at one interspace, as viewed on flexion-extension cervical radiographs; the necessity for the patient to utilize a cervical collar for more than 12 weeks; the need of home cervical traction; or the resumption of physical therapy more than once, due to exacerbation of symptoms.

Another factor described by Hohl1, which is likely to result in a poor prognosis, is loss of consciousness. Hohl found that those patients who lost consciousness, as a result of their injury, were much more likely to suffer from degenerative changes of the cervical spine later in life. Hohl's 1974 study demonstrated that 57 of the 146 patients studied (39%) developed degenerative arthritis within 7 years of their accident. This compared to an average incidence of 6% occurrence of degenerative changes in a similar population, without injury of this type. However, 64% of patients who lost consciousness during injury developed degenerative changes, but the number of patients involved was too small to test the statistical significance of this finding.

In addition, medical researchers S.H. Norris and I. Watt2 performed a study in which a series of 61 patients suffering neck injuries, as a result of rear-end vehicle collisions, were classified into categories based upon presenting symptoms and physical examination findings. Group 1 was comprised of patients complaining of symptoms relating to their injuries, but with no abnormal physical examination findings. Group 2 was comprised of patients complaining of symptoms relating to their injuries, and a reduced range of motion of the cervical spine. Finally, Group 3 was comprised of patients with symptoms, reduced range of cervical movement, and evidence of objective neurological loss (diminished upper extremity reflexes, sensory abnormalities, and/or muscle weakness in an upper extremity).

Their study found a significant relationship between the presence of residual neck pain following treatment, and the category in which they were classified. Forty-four percent of Group 1 patients, 81 percent of Group 2 patients, and 90 percent of Group 3 patients still suffered with residual neck pain after approximately 24 months had elapsed, from the time of their release from active treatment.

Other factors described in the medical literature that are indicators of possible poor prognosis: include relative or absolute neural canal stenosis,3,4,5 and preexisting degenerative changes.2 These additional factors have been studied due to their possible long-term involvement in neurological complications.

In light of this information, it should be recognized that if pain is present in an upper extremity, or there are other objective neurological signs, this patient's prognosis is most likely to be poor, due to probable neurological involvement from the injury. However, this is not to say that the other factors presented are not important; they too have been associated with less than the best prognosis.

Foreman and Croft's Prognosis Scale

Chiropractic researchers Foreman and Croft6 have developed a numerical scale to predict prognosis, based primarily on the previously presented information. Their system begins by classifying patients into categories, based upon the findings of Norris and Watt2. Patients having only symptomatic complaints, but no abnormal physical examination findings (Category 1), are assigned a point value of 10. Patients with symptomatic complaints and a loss of cervical spine motion (Category 2) are assigned a point value of 50. And, finally, those patients with symptoms, loss of range of motion, and objective neurological loss (Category 3) are assigned a point value of 100 points (see Table 1).

To these initial classifications, additional points are accumulated based upon applicable "modifiers" (Table 2). The patient is then placed into one of five categories which describes their predicted prognosis (see Table 3).

The benefit of this system is four-fold:

  1. "The physician can predict, with some accuracy, the approximate length of treatment and the probability of future.

  2. The attorney can monitor the patient's progress, knowing in advance the approximate degree of probable improvement.

  3. The insurance carrier can establish accurate settlement reserves and decrease the number of litigated cases.

  4. The patient can better understand what future problems may results from the injury."6

Conclusion

Several factors are associated with poor prognosis following soft tissue injuries of the cervical spine. The most significant, pain in an upper extremity due to neurological involvement, seems to be the most reliable in making such predictions. In addition, the classification system of Foreman and Croft6 was presented. It allows an accurate prognosis to be predicted, based upon the patient's history, physical examination, and radiographic examination findings. It would behoove all practicing doctors of chiropractic to adopt this classification system. The system appears to be reproducible from one doctor to another, and is logically based upon the sound findings of the primary medical literature.

References

  1. Hohl, M. "Soft-tissue Injuries of the Neck in Automobile Accidents -- Factors Influencing Prognosis." J. Bone Joint Surg 1974; 56A:1675.

  2. Norris, S.H.; Watt, I. "Prognosis of Neck Injuries Resulting from Rear-end Vehicle Collisions." J. Bone Joint Surg 1983; 65B:608-611.

  3. Payne, E.E.; Spillane, J.D. "The Cervical Spine -- An Anatomical Radiological Study of 70 Specimens (Using a Specific Technique) with Particular Reference to the Problem of Cervical Spondylosis." Brain 1957; 80:571-596.

  4. Wolf, B.S.; Khilnani, M.; Malis, L. "The Sagittal Diameter of the Cervical Spinal Canal and its Significance in Cervical Spondylosis." J Mt Sinai Hosp 1956; 23:283-292.

  5. Verbiest, H. "Neurogenic Intermittent Claudication in Cases with Absolute and Relative Stenosis of the Lumbar Vertebral Canal (ASLS and RSLC) in Cases with Narrow Lumbar Intervertebral Foramina and in Cases with Both Entities." Clin Neurosug 1972; 20:204-214.

  6. Foreman, S.M.; Croft, A.C. Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome, Williams and Wilkins, Baltimore, 1988.

    Table 1. Point values assigned by history and physical examination findings.6

Category Findings Point Value

  1. Subjective symptoms only 10

  2. Symptoms and loss of range 50 of cervical motion

  3. Subjective symptoms, loss 100 of motion, objective neurological loss
Table 2. Modifiers and their assigned point values.6

Modifier Point Value

Canal Size 10-12mm 20

Canal Size 13-15mm 15

Kyphotic Curve 15

Fixated Segments 15

Loss of Consciousness 15

Military Neck 10

Preexisting Degeneration 10

Table 3. Prognosis categories and likely residual disabilities.6

Prognosis Category/Point Total          Prognosis/Residuals

Group 1 (10-30 points)                  Excellent -- mild muscle pain
and/or headaches

Group 2 (35-70 points)                  Good -- occasional mild to
moderate neck pain

Group 3 (75-100 points)                 Poor -- potential for future
neurological complications

Group 4 (105-125 points)                Guarded -- likely future or
persistent neurological
deficits

Group 5 (130-165 points)                Unstable -- no likely improve-
ment -- probable future
surgical intervention
Steve Troyanovich, D.C.
Bloomington, Illinois


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