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Whiplash is a lay term combining all the complications of a cervical sprain or distortion associated with an extension. It may lead to cervical or back pain, but patients may also complain about functional visual impairment. These visual complaints: fixation disparity, heterophoria or convergence insufficiency, are frequently neglected and difficult to quantitate and treat. Establishing the relationship between the indirect cervical trauma and the visual signs may be challenging for the medical-legal expert and must include consideration of the previous oculomotor status of the patient.

Objective.To compare health status, effect on family, occupational consequences, and quality of life (QOL) 1 year after an accident between patients with whiplash versus other mild injuries, and to explore the relationship between initial injury (whiplash vs other) and QOL.Methods.This was a prospective cohort study. The study used data from the ESPARR cohort (a representative cohort of road accident victims) and included 173 individuals with “pure” whiplash and 207 with other mild injuries. QOL at 1-year followup was assessed on the World Health Organization Quality of Life questionnaire. Correlations between explanatory variables and QOL were explored by Poisson regression to provide adjusted relative risks, with ANOVA for the various QOL scores explored.Results.One year post-accident, more patients who had whiplash than other casualties complained of nonrecovery of health status (56% vs 43%) and of the occupational effect of pain (31% vs 23%). QOL and posttraumatic stress disorder (PTSD) were similar in the 2 groups. Impaired QOL did not correlate with whiplash when models were adjusted on sociodemographic variables and history of psychological distress. Whatever the initial lesion, PTSD was a determining factor for poorer QOL.Conclusion.Sociodemographic factors, preaccident psychological history prior to the accident, and PTSD were the main factors influencing QOL, rather than whether the injury was whiplash. PTSD may also be related to pain.

The authors report a case of Dropped Head Syndrome with an unusually rapid onset after an accident in a patient with a history of Hodgkin's lymphoma cured by chemotherapy and mantle field radiotherapy and compare this case to the rare published cases of chronic Dropped Head Syndrome occurring after this type of treatment. A 56-year-old man was treated at the age 36 years for supra-diaphragmatic Hodgkin's lymphoma by chemotherapy and mantle field radiotherapy according to a standard technique and standard doses (40Gy, 20 fractions, 27 days). Seventeen years after the end of treatment, he experienced a violent whiplash injury, rapidly followed by a Dropped Head Syndrome, similar to the cases of chronic Dropped Head Syndrome already described in the context of Hodgkin's lymphoma (permanent flexion of the head, only reduced in the supine position). Physical and neurophysiological examination, electromyogram, and magnetic resonance imaging confirmed the diagnosis of Dropped Head Syndrome. Very few treatment options are available for the major disability related to Dropped Head Syndrome. This type of subacute onset of Dropped Head Syndrome has not been previously described. The good results of radiation therapy after chemotherapy allow a dose reduction to 30Gy in the involved regions. This, together with recent progress in treatment planning, should allow eradication of these complications.

In this paper, the imaging features of traumatic injuries of the spine in an emergency department will be reviewed. Three themes are discussed. 1) Review of current indications for additional imaging work-up. Conventional radiographs are not always mandatory, especially at the cervical level since validated criteria are available from the literature. The low sensitivity of conventional radiographs often requires additional imaging by CT (bone lesions) or MRI (disk and ligamentous lesions). The degree of urgency in scheduling these different examinations will be defined by the clinical setting and risk level (low/intermediate/high) of the injury. 2) Review of imaging features associated with stable and unstable lesions. The analysis of conventional radiographs is based on biomechanical concepts. The features of the main lesions will be illustrated by clinical cases and diagrams. 3) Review of key points that must urgently be transmitted to clinicians. The preliminary radiology report is an essential document for the management of patients with traumatic injury to the spine. It will have an impact on the type of immediate management (medical, orthopedic or surgical). A final report validating the initial interpretation should, of course, soon follow.

The Whiplash Associated Disorders (WAD) are mostly chronic cervical and cephalic pain syndromes. They are often associated with general disorders and with sensorial difficulties. The neurologist evaluates this trouble according to neurochemical and neurophysiological models, hypothesizing a "central hypersensitivity" after a localised peripheral lesion (such as cervical distortion). Other epistemological points of view are certainly legitimate, for example "biopsychosocial" models. From a therapeutic point of view, it seems worth while to try to prevent the development of WAD. When chronic pain is accompanied by difficult life situation, the solution is not simply medical but also social. Faced with a persistent WAD, the therapeutic attitude should be individualised and multidisciplinary, seeking the autonomy of the patient.

Could a simple educational intervention modify beliefs about whiplash? A preliminary study among professionals working in a rehabilitation ward.Whiplash and its consequences remain an alarming clinical and social problem, and psychosocial factors could play a role. We aimed to translate and assess the effects on beliefs of an evidence-based educational booklet on whiplash-associated disorders among professionals who work in a rehabilitation ward.After translation/back-translation of the English version of The Whiplash Book, we undertook a before-and-after prospective study. The main outcome assessment was final score on the whiplash belief questionnaire (WBQ) involving nine questions assessing beliefs and attitudes about the consequences of whiplash rated on a 5-point Likert scale ranging from "completely agree" to "complete disagree." Final scores range from 9 to 45, low scores indicating positive beliefs. Demographic, educational and professional data, as well as personal medical history of neck pain, were recorded. Acceptability of the booklet was rated on a 10-point scale and by open questions.Among the 50 professionals included in the study, 48 completed the questionnaire. Whiplash beliefs tended to be positive at first assessment (WBQ score 23.37+/-6.45). Reading the whiplash booklet significantly improved beliefs (14.27+/-4.39; P0.05). Global evaluation of the booklet on a 10-point scale was good (8.13+/-1.05) as was acceptability (8.13+/-1.05).After reading a booklet about whiplash translated into French, beliefs about the consequences of whiplash were changed for the better in this sample of French-speaking healthy professionals working in a rehabilitation ward. This simple educational intervention translated into French could be used for education and for ameliorating beliefs about the consequences of whiplash among health care professionals and the public.

Attributing dysfunction of the temporomandibular joint (TMJ) to whiplash injury is a difficult problem to solve. TMJ disorders do not seem to be secondary to direct articular trauma but rather caused by a postural disorder of the cervical spine. Occlusal disorders and stress further complicate the picture. Four clinical cases illustrate a new hypothetical approach.

To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

After a short review of the non-traumatic, and rare, causes of vitreoretinal hemorrhages in infants, we analyze the 4 situations where a traumatic hemorrhage can be found: accidental head trauma, which has to be very severe and is then an unfrequent etiology, head trauma in child abuse or the so-called "shaken baby syndrome", which is the most frequent cause, and where we point out the key role of the ophthalmologist in the diagnosis and the prognostic evaluation, the perinatal trauma, which is a frequent, benign, and ephemeral cause, and finally, cardiopulmonary resuscitation, which is a controversial and unlikely cause.

SOFT TISSUE INJURY: Whiplash injuries of the cervical spine are common, usually after traffic accidents. Soft tissue injuries may involve the muscles, ligaments, disks, and facet joints (excluding severe cases of fracture or dislocation not discussed here).There are 2 cardinal signs: neck pain and headache. These signs may be associated or not with other symptoms.Most cases follow a benign course and resolve within a few weeks or months. Symptoms persist however in 20 to 40% of the cases. Evolutive organ injury, sensitization of the central nervous system, and secondary psychological reactions (including desire for financial compensation) all contribute to the development of a chronic situation.Excepting cases with over neurological complications, it is particularly difficult to assess the nature and seriousness of whiplash injuries with physical examination and imaging. This diagnostic difficulty explains the frequency of medicolegal procedures. It is particularly difficult to treat chronic forms. If a medicolegal procedure is in course, it is advisable that the expert reports and fair compensation be established as rapidly as possible.

The vertebral cervical syndrome is a clinical entity defined as a dysfunction of the cranio-cervical junction of traumatic or non traumatic cause. The authors report on asthenopic disorders occurring in such a syndrome. The fusion amplitude and the accommodation power were reduced in all patients and were a cause of delayed job recurrence. The treatment of fusion was long, painful and, in some cases, not successful. A depressive status associated with a prolonged job interruption were bad prognosis factors. A differential diagnosis has to be made with the so-called insurance neurotic reaction.

Common distortion of the cervical spine without evidence of neurological or osteoligamentary damage is a frequent consequence of indirect head and neck trauma. The mechanism of the injury (called "whiplash", "coup de lapin", or "Schleudertrauma") does not imply direct trauma to the head or neck. In the acute phase, common distortion of the cervical spine requires treatment. Rapid management may avoid or considerably reduce the chronic pain syndrome with the characteristic chronic tension-like headache. The chronic pain and the numerous associated functional disorders are not well understood: certain factors favour central and peripheral dysfunction and others emphasize the importance of extra-trauma phenomena. In our opinion, extra-trauma phenomena would explain the invalidating nature of pain in a small number of patients. Management of these chronic patients requires a multidisciplinary approach aimed at helping the patient overcome the inconveniences of this condition.

The aim of this study was to identify the characteristics of post-traumatic headache after whiplash injury in order to obtain some indications as to the pathogenesis of this particularly frequent clinical entity.A retrospective study of 63 patients who had suffered whiplash injury and who had persistent chronic pain was conducted.Forty-seven patients complained of headache and pain in the cervical spine and 16 of pain in the cervical spine alone. Among the patients with headache 74% complained of tension-like pain, while only about 10% had identifiable post-trauma migraine headache with or without aura. Current neurophysiological hypotheses of central dysfunction due to neurochemical disorders induced by the initial nociceptive stimuli, frequently found in the general population, would not explain the disabling characteristics observed in these patients with chronic pain.A multifactorial pathogenesis of post-traumatic chronic headache should be entertained, suggesting that not only trauma but also extra-trauma factors unrelated to whiplash would be involved.

This presentation summarises the opinions concerning chronic pain after mild cervical trauma without neurological and radiological findings. Clinicians are often surprised by the disabling character of the pain, despite the lack of severe lesions. The initial lesions lead in some cases to chronic headache having different features associated with cervical pain, but in our opinion this pain does not have a disabling nature. When the disabling character is present, we postulated that it is associated with other psychological, social and professional factors. In fact, the pathogenesis of this chronic disorder is multifactorial. Its treatment doesn't lead to healing but to better management of patient life with chronic pain.

The biomechanical expert opinion on the injury mechanism is necessary in few cases only. However, the judgement of these cases is extremely compromised if mechanically wrong terms are introduced in the clinical report. Since the injury mechanism in the neck is very complex the clinical physician should concentrate on the clinical findings familiar to him; usually the clinician lacks technical case documentation and specific training in injury biomechanics. The relevant mechanisms of neck injuries are an indirect trauma induced by a) a head contact leading to compression, hyperflexion, hyperextension and/or hypertranslation and b) a non-head-contact mechanism (hyperflexion or hyperextension, hypertranslation, acceleration). A non-contact mechanism occurs e.g. during a rear end impact without head restraint (hyperextension) or a frontal collision of a belted occupant (hyperflexion) without head impact. The term "whiplash" is misleading and incorrect: It presumes a virtually non existing two phase movement back and forth (or vice versa) like during the development of the crack of the whip. Secondly, it mixes the physical criterion mechanism with the anatomical or morphological criterion injury e.g. distortion, sprain etc. A (head)-contact mechanism is due to a corresponding momentum exerted from the head on the neck. Again, the anatomical or morphological terms are equal, but the mechanism is different. During a contact mechanism as well as during a non-contact mechanism not only a hyperflexion or a hyperextension can occur; in the first phase of the impact also a shearing force between the upper vertebral bodies (CO-C2) may load the intervertebral structures by hypertranslation.

In four cases, the authors analyse the medical and legal factors which lead the expert to his conclusions in french law, concerning temporo-mandibular joint dysfunction after whiplash injury indemnification. An uncertain direct link between the injury and the damage together with the patient's dental prior state to the accident, lead to retain an incomplete legal imputability. The compensation awarded to the victim will consist of an overvalued extra-patrimonial damage which will eventually be able to balance a low physiological deficit price.

Purpose of this paper is to point out the interest in case of post-concussional syndroma following an head or whiplash injury to practice both: a posturographic examination objectiving the functioning of the different sensori-motor systems who maintain the body equilibrium giving an approach of the possibility of an organic etiology, psychiatric one giving the psychogenic aspect. Different therapeutics are proposed in regard of this double approach. Four cases illustrate this purpose.

The authors report 3 cases of infants presenting with cerebral lesions related to violent head shaking. They emphasize the diagnostic difficulties when the classical signs of the battered child (marks of blows, fractures) are lacking. The traumatism is rarely recognized: only the negativity of the usual medical causes of subdural hematoma, meningeal or retinal hemorrhage and a peculiar familial history lead to the possible diagnosis of shaken baby syndrome. The value of skull CT-scan is major, showing intracranial lesions which could not be found before. Because of the observed lesions, evolution is often severe.

The post-traumatic cervical syndrome (PTCS) is analysed in 61 cases. the symptomatology can be local (neck pain), cervicocephalic (traumatic vertebrobasilar insufficiency), cervicobrachialgic and also in some cases cervicomedullar. The PTCS is classified into the injuries of the cervical spine with vascular lesions: these injuries may induce severe or benign osteoarticular lesions on the one hand, sevre or reversible vascular lesions on the other hand. All these combinations are studied. The diagnosis of the PTCS is established by vertebral angiography. The surgical treatment according to the authors consists in freeing the vertebral artery or cervical nerve roots by uncusectomy or uncoforaminectomy. The results of these operations are analysed; they are very successful.

Short review of the different types of propulsion injuries of the cervical spine in acute and chronic cases. The basic principles of the therapy as well as the different techniques of physiotherapy, orthesis and surgical treatment and described.

The radiological study of the traumatic cervical spine must often be undertaken in two different ways depending on the time of examination. In patients severely involved, no manipulations can be undertaken during the acute state. Later on in these patients, as well as in those not so deeply involved, a thorough radiological investigation may be performed, e.g. in sitting position. The characteristics of both types are reviewed. Various syndromes are then considered following the different mechanisms of production.

A craniocervical injury has been carried out in rats (with head free to move) so that they get through a whiplash without any coma. Two days after the whiplash, comparable with a postcommotional syndrome, the acquisition of a labyrinth behavior is disturbed and, 7 days later, the retention is still disturbed. This disturbance of retention is not observed when the acquisition is performed before the whiplash. These data agree with the clinical observations, and we hypothesize a possible causal relation between the disturbance of learning behavior and the decrease of noradrenaline cerebral level induced by the whiplash. Treatment with imipramine (1 mg/kg) after the whiplash is able to remove these behavioral and biochemical disturbances.