It is no surprise that the forces associated with a severe motor vehicle accident can result in multiple injuries. This is commonly seen in hospitalized patients. However, even less severe auto accidents or falls can present with multiple injuries. The less severe accidents are the type commonly associated with ambulatory, or non-hospitalized, patients. When these injuries result in symptoms lasting more than 12 weeks, the condition is deemed chronic and unlikely to resolve on its own.
Whiplash neck injury
Whiplash injury is very common in motor vehicle accidents and does not require high speeds. Whiplash injury can become chronic in a high proportion of patients. 20% of these patients suffer from disc herniation, while the other 80% suffer from cervical facet joints injury. MRI will distinguish the two. If there is chronic pain and the MRI does not show a disc herniation, there is about a 90% probability that a cervical facet joint injury is the cause. This is the joint between vertebra on either side of the disc. In a patient with a normal MRI and chronic neck pain, a physician skilled in cervical facet blocks can make an accurate diagnosis.
Cervical facet injury involves multiple joints in two thirds of cases. Commonly, this involves upper cervical joints and lower cervical joints.
Thoracic whiplash injury
Thoracic facet injuries are less common than cervical facet injuries and are seen in less than 20% of cases. The symptoms overlap with those of lower cervical facet injuries. Thoracic facet injuries are always seen in conjunction with cervical facet injuries. The diagnosis is suspected when there is residual upper thoracic pain after cervical facet injections.
Cervical radiculopathy and whiplash
Nerve injury resulting in pain or numbness of the hand and arm is common after a whiplash injury. This is called radiculopathy. Usually, there is no evidence of nerve compression on the MRI. The cause is felt to be a shear or stretching of the nerve during the whiplash motion of the neck. If there are bony spurs or if there is narrowing of the spaces of the spine, the nerve may also become contused during the whiplash motion. If there is a substantial disc herniation from the whiplash, there may be direct nerve compression.
When whiplash related nerve injury occurs, it is almost exclusively seen as a sensory deficit, like numbness. When it occurs, it is seen in more than one nerve distribution of the extremity nearly all the time.
Lumbar disc injury
Lumbar disc injuries are common after an accident. In some cases, the MRI will show an obvious disc herniation. In other cases, the MRI findings are subtler. A contained disc protrusion is more common than a full thickness herniation through the disc. These are often mistaken as disc bulges. Although contained disc protrusions can be small, they can still be quite painful. They can also still cause significant radiculopathy. To diagnose this entity, a knowledgeable physician schooled in the differences between a bulge and a contained disc protrusion is essential.
When lumbar disc injuries occur, they are multiple in over 50% of cases. These multiple injuries usually involve L5/S1 and L4/5. In rare cases, 3 discs or more may be injured.
Lumbar disc injury + whiplash injury
This is the most common combination of spinal injuries seen after automobile accidents, and sometimes falls. The combination of lumbar and cervical injuries occurs in two-thirds of cases.
Lumbar facet injury
Facet injuries of the lumbar spine can be an important cause of chronic pain and disability. In most cases, lumbar facet pain occurs because of a degenerative response to lumbar disc injury. In about 20% of cases, the facet injury is a primary injury, resulting from hyperflexion and extension.
L4/5 and L5/S1 lumbar facet injuries commonly occur together. In about 80% of cases lumbar facet injuries are bilateral.
Sacroiliac joint injury
Though far less common than other lumbar causes of pain after an automobile accident or fall, sacroiliac joint injury should be suspected when the patient’s pain is predominantly over the buttocks, hips or groin. These injuries are bilateral in two-thirds of cases.
Lumbar facet plus sacroiliac joint injury
When the primary lumbar injury is a lumbar facet injury, one should have a high index of suspicion for a concomitant sacroiliac joint injury. The sacroiliac joint and the lumbar facet joints are injured through a similar mechanism and transmission of forces across the spine. Successful treatment of lumbar facet pain may unmask the sacroiliac joint pain. Sacroiliac joint injuries are seen with lumbar facet injuries in about 20% of cases. To diagnose sacroiliac joint injury, one must perform a diagnostic block of the joint. Imaging cannot be relied upon.
Rare contributors to multiple spinal injuries
Vertebral compression fractures can occur after seemingly negligeable trauma in elderly patients or after significant force in younger patients.
Tailbone injuries can occur after both falls and automobile accidents. They are incredibly uncomfortable.
Though rare, these injuries can be seen with the vast array of possible spinal injuries.
Conclusion
Just because a patient is ambulatory does not mean that they did not sustain multiple spinal injuries. The presence of multiple injuries is quite common. Multiple injuries can occur in a single spinal segment or across multiple segments. The conscientious physician and plaintiff’s attorney will thoroughly catalogue and treat these injuries. In a patient with persistent complaints after initial treatment one should avoid the pitfall of thinking that the patient has failed the treatment; Save this shallow method for the defense. Instead, the patient should be evaluated and treated for the common presence of multiple spinal injuries.
John Quimper, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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