The correct combination
Case 146
【Progress】
They continued to take rehabilitation training in our hospital.
【Discussion】
One of the important functions of the neck is to support the head. When traffic crash occurs, the supporting components of the neck are susceptible to the damage. Cervical spine includes cervical vertebrae, disk, ligament, membrane and spinal cord. The supporting components protect spinal cord as well. Car crash gives various damages to cervical spine dependent on its degree; fracture and/or dislocation of the vertebrae; tear and/or cutting of the ligament and membrane; edema, hemorrhage and cutting of spinal cord (1-3).
It is imperative to be familiar with anatomy of cervical ligaments not to overlook subtle spine damages after car crash (1-3). There exist specific ligaments at C1&C2 level; tectorial membrane, apical ligament, anterior occipito-atlantal membrane, anterior atlantoaxial membrane, anterior atlantodental ligament, alar ligament and transverse ligament. From C1 to C7, there exist strong supporting ligaments; anterior longitudinal ligament, posterior longitudinal ligament, flaval (yellow) ligament, interspinous ligament, supraspinous ligament and nuchal ligament.
The most common mechanism of spine injury by car crash is hyperflexion (1, 4-7). It causes various damages to cervical spine; hyperflexion sprain by the posterior ligaments (interspinous ligament, supraspinous ligament, nuchal ligament) rupture; simple wedge fracture of the upper endplate of the cervical vertebrae; unstable wedge fracture = posterior ligaments rupture + wedge fracture of vertebrae endplate; unilateral interfacet dislocation of the vertebral body + posterior ligaments fracture caused by flexion and rotation; bilateral interfacet dislocation of both vertebrae and spinous process + posterior ligaments fracture with a high incidence of cord injury; flexion tear drop fracture with a high incidence of cord injury.
The next most common mechanism of spine injury is hyperextension (1, 4-7). It causes rupture of the anterior longitudinal ligament, and hangman’s fracture of pars interarticularis or articular processes of C2 which is common in diving accidents. Hyperextension causes tear drop fracture which occurs at lower endplate of the cervical vertebrae. Odontoid or dens fracture often occurs after car crash with hyperextension
Fracture of the anterior and posterior arch of Atlas is caused by axial loading such as traffic accident and fall down accident. It is called Jefferson fracture (1).
The occult pathoanatomical lesions of whiplash injury are reported the cervical intervertebral discs, cartilage endplate and the facet joint (1, 8-10). Meanwhile, these lesions are also detectable on supine MRI for aged people without car crash. Although a prospective wide-ranged study should be warranted, it is believed that injury of the facet joint causes chronic pain of whiplash after car accident (1, 10). In the other word, subtle disk injury progresses facet joint degeneration, leading the chronic neck pain. In our case with whiplash symptoms of neck pain, MRI showed tears of anterior longitudinal ligament and posterior longitudinal ligament, bone marrow edema of cervical vertebrae, and cervical disk protrusion.
Spinal cord syndrome caused by spinal injury is categorized into central cord syndrome, anterior cord syndrome, posterior cord syndrome and Brown-Sequard syndrome (hemi-lateral injury)(1). In central spinal cord syndrome, upper extremity is more susceptible to damage than lower extremity, irrespective of motor tract and sensory tract. Injury to C1 to C4 is the most severe of the spinal injuries because the phrenic nerve is formed from C3 to C5 nerve fibers. Patients might not able to breath on her or his own.
【Summary】
We presented a couple of a husband and his wife who experienced a car crash from a rear side, becoming for both to suffer from the chronic neck pain. Cervical spine MRI showed tears of anterior longitudinal ligament and posterior longitudinal ligament, bone marrow edema of cervical vertebrae, and cervical disk protrusion. It is borne in mind that cervical spine injury varies from whiplash to spinal cord damages. The chronic pain of whiplash comes from facet joint disruption following injury of vertebrae endplate or disk. As hyperflexion injuries, it is listed from sprain by the rupture of interspinous ligament, supraspinous ligament, nuchal ligament to the wedge fracture of upper endplate of the vertebrae or tear drop fracture of the whole vertebrae, dislocation of the vertebrae. As hyperextension injuries, it is listed from rupture of the anterior longitudinal ligament to the hangman’s fracture of C2 (articular process or pars interarticularis), dens fracture of C2, and wedge or tear drop fracture of the lower endplate of the cervical vertebrae. As axial injuries, atlas fracture called Jefferson fracture is listed. As spinal cord injury, central spinal cord syndrome is listed that C1 to C4 is the most severe of the spinal injuries because the phrenic nerve is formed from C3 to C5 nerve fibers.
【References】
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