aThis month it’s time for us to discuss the remarkably common nature of cervical spine degenerative joint disease in the general population. In a book titled Painful Cervical Trauma, John Hopkins University School of Medicine neurosurgeon John Aryanpur, MD, states:
“Degenerative spondylosis, or osteoarthritis, of the cervical spine is common in all individuals over 50 years of age.”
Cervical spine degenerative joint disease is also frequently found in individuals younger than age 50 years. As a rule, cervical spine degenerative joint disease is asymptomatic, with the exception of the possibility of stiffness and reduced range of cervical motion. Cervical spine degenerative joint disease is usually considered to be a part of the normal aging process, and this process can be accelerated by single macrotraumatic event or from repeated microtraumatic events. For example, in 1997, physicians Martin Gargan and Gordon Bannister published a study in which 41 patients who had sustained a whiplash injury 10 years previously were radiographically compared with 100 age-matched control subjects. They found that:
“Radiographic degenerative changes in the cervical spine appeared 10 years earlier in the whiplash group.”
This indicates that a single macrotraumatic event, a whiplash injury in this study, accelerates degenerative changes of the cervical spine.
In another example, in 2004, Alparslan Kartal and colleagues assessed the development of radiological and MRI changes and degeneration of the cervical spine in soccer players as compared to matched control subjects. The authors specifically looked at the association between repeated “heading” of the soccer ball and cervical spine degenerative changes. These authors noted:
In soccer, “scoring, defending and passing the ball with the head is an integral part of this game; so chronic degenerative changes should be common in the cervical spine.”
“The cervical spine absorbs a significant amount of the force generated due to heading the ball. This type of repetitive force during competition or training may increase the risk of degeneration at the intervertebral joints, intervertebral discs or the spinal cord.”
“Continuous micro- and macro-trauma to the cervical spine due to heading the ball in soccer may cause early degenerative changes.”
“The onset of such [degenerative] changes was 10–20 years earlier [in the soccer players] than that of the normal population.”
“Magnetic resonance findings of degeneration were more prominent in soccer players when compared to their age-matched controls.”
“Low-impact recurrent trauma mainly due to heading the ball may initiate degenerative changes at the cervical spine.”
“In conclusion, biomechanical, radiological, and MR findings present a tendency towards early degenerative changes of the cervical spine most probably due to heading the ball in soccer.”
Repeated heading of the soccer ball is an example of a repeated microtraumatic event. This study confirms that such repeated microtraumatic events accelerate the development of cervical spine degenerative changes.
When it comes to whiplash trauma, if the radiographs exposed shortly after the injury show cervical spine degenerative joint disease, these arthritic changes are certainly not attributable to the accident. Rather, these degenerative changes were pre-existing. Often, the patient’s post-injury symptomatology is attributed to the pre-injury degenerative joint disease, even in cases where the patient was completely asymptomatic prior to injury. This is clearly not logical and not fair to the injured patient.
In dealing with the whiplash-injured patient, an important question is:
What is the Influence of Pre-Accident Degenerative Joint Disease?
Over the past four and a half decades, a number of books and articles have addressed this question. The comments and research found in these publications are remarkably consistent, and summarized below.
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In 1964, whiplash injury expert and pioneer, Ruth Jackson, MD, published an article titled “The Positive Findings In Neck Injuries” in the American Journal of Orthopedics. Dr. Jackson’s conclusions in this article were based on her evaluation of 5,000 injured patients. She notes:
“An adequate radiographic examination of the cervical spine is essential for diagnosis.”
Pre-existing pathological conditions of the cervical spine, when injured, “result in more damage than would be anticipated in a so-called ‘normal’ cervical spine.”
“Any injury of the disc causes a disturbance in the dynamics of the motor unit of which the disc is a part. This leads to degeneration of the disc and the proximate joints.”
“All radiographs should be repeated periodically. Subsequent findings may be very revealing.”
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In 1977, Samuel Turek, MD, clinical professor from the Department of Orthopedics and Rehabilitation at the University of Miami School of Medicine, and author of the reference text, Orthopaedic Principles and their Applications, states:
“The injury may be compounded by the presence of degenerative disease of the spine.”
“With advancing age, especially in the presence of degenerative disease, the tissues become inelastic and are easily torn.”
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In 1981, Rene Cailliet, MD, professor and rehabilitation specialist from the University of Southern California, and author of the book Neck and Arm Pain, states:
“The pre-existence of degeneration may have been quiescent in that no symptoms were noted, but now minor trauma may ‘decompensate’ the safety margin and symptoms occur.”
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In 1983, Norris and Watt followed 61 whiplash-injured patients for a minimum of six months in order to establish factors that were prognostic for recovery. They published their findings in the prestigious British Journal Of Bone And Joint Surgery, titled “The Prognosis Of Neck Injuries Resulting From Rear-End Vehicle Collisions.” Their conclusions include:
“Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, [loss of cervical lordosis], and pre-existing degenerative spondylosis.”
Entirely normal radiographs were found in 30% of patients with no objective findings and in 13% of patients with reduced cervical range of motion; all radiographs in patients with neurological loss were abnormal [showing degenerative changes].
Degenerative spondylosis was detected in 26% of patients with no objective findings, 33% of patients with reduced cervical range of motion, and 40% of patients with neurological loss, indicating that cervical spine degenerative changes are associated with greater injury and worse prognosis for recovery.
This “study suggests that prognosis is predictable on the basis of the initial presentation of the patient.” “Two features on plain radiographs seem relevant.”
1) “Pre-existing degenerative changes in the cervical spine, no matter how slight, do appear to affect the prognosis adversely.”
2) Abnormal curves in the cervical spine “are more common in patients with a poor outcome.”
“The prognosis may be modified by the presence or absence of degenerative changes, by an abnormality [degeneration] of the cervical spine on the initial radiograph, or by both.”
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In 1985, Webb in his article titled “Mechanisms and Patterns of Tissue Injury” notes:
“Degenerative joint disease is recognized as a major influence on subsequent tissue damage both in severity and pattern.”
“In any individual where changes consistent with degenerative joint disease are present, one can expect the injury to be more severe or a very minor injury to produce severe symptoms requiring prolonged treatment.”
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In 1986, Arthur Ameis, MD, who practices physical medicine and rehabilitation, and is on the Faculty of Medicine at the University of Toronto, notes:
“For the elderly, neck injury can be very serious. The degenerative spine is biomechanically ‘stiffer’, behaving more like a single long bone than like a set of articulating structures. Deforming forces are less evenly dissipated, and more damage is done.”
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In 1987, physicians Edward Dunn and Steven Blazar authored “Soft-Tissue Injuries of the Lower Cervical Spine” for the American Academy of Orthopedic Surgeons. In this publication they note:
“If present, degenerative changes should be duly noted as they may affect the prognosis.”
“...pre-existing degenerative changes adversely affected the outcome."
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In 1988, Mairmaris and colleagues published a study titled “Whiplash Injuries of the Neck.” They reviewed 102 whiplash-injured patients 2 years after injury. They concluded:
“The analysis of the radiological results showed that pre-existing degenerative changes in the cervical spine are strongly indicative of a poor prognosis.”
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In October of 1988, physician Hirsch and colleagues published a paper titled “Whiplash Syndrome, Fact or Fiction?” in Orthopedic Clinics of North America.
These authors note:
Pre-existing structural changes and degenerative changes are “frequently associated with a more difficult, more prolonged, and less complete recovery.”
“The films should be inspected especially for evidence of pre-existing structural changes or for alteration, which are frequently associated with a more difficult, more prolonged, and less complete recovery.”
“These changes may include the presence of osteophytes, foraminal encroachment on the oblique projections, and the presence of intervertebral disc space narrowing.”
“When hyperextension injury occurs in the presence of pre-existing osteophyte formation, there is further narrowing of the spinal canal, which increases the potential for injury to the nerve roots or cord.”
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In their 1988 reference text on whiplash injuries titled Whiplash Injuries, The Acceleration/Deceleration Syndrome, Steve Foreman and Arthur Croft note:
“...the presence of preexisting degenerative changes, no matter how slight, appears to alter the prognosis adversely.”
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In 1989, physician Porter published an article in the British Medical Journal titled “Neck Sprains After Car Accidents.” He noted:
“Pre-existing degenerative changes may worsen the prognosis.”
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In 1991, Watkinson, along with Gargan and Bannister, radiographically reviewed 35 whiplash-injured patients 10.8 years after injury. In this study, 87% of patients with spondylosis on initial radiographs reported continued symptoms, compared with only 20% of patients with normal initial radiographs. They concluded:
“Patients with degenerative change initially have more symptoms after 2 years than those with normal radiographs at the time of injury.”
“Degenerative changes occurred significantly more frequently in patients who had sustained soft tissue injuries than in a control population.”
Also in 1991, Lawrence Friedmann, MD (Chairman, Physiatrist-In-Chief at the New Youk Nassau County Medical Center, Edgar Marin, MD (Associate Chairman of the Department of Physical Medicine and Rehabilitation at the State University of New York), and Patricia Padula, DPM (Professor of Orthopedic Sciences at the New Youk College of Podiatric Medicine), wrote in the reference text Painful Cervical Trauma, Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries:
“The elasticity of tissues decreases with an increase in age. The range of motion in the cervical spine also decreases. In both cases, the potential for injury is increased because the neck is less resilient.”
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In 1995, physician Jerome Schofferman and colleague Dr. S. Wasserman published in Spine an article titled: “Successful treatment of low back pain and neck pain after a motor vehicle accident despite litigation.” In this study, the authors evaluated 39 consecutive patients with low back pain or neck pain that resulted from a motor vehicle accident who had litigation pending. The patients were treated until they became pain free, or until they reached maximum improvement. Maximum improvement was claimed after “mild-to-moderate pain remained stable for approximately 8 weeks.” These authors also noted:
“Pre-existing degenerative changes on initial x-rays, no matter how slight, had a worse prognosis.”
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In 1996, Squires, along once again with Drs. Martin Gargan and Gordon Bannister, published a 15.5-year follow-up evaluation of 40 patients who had been injured in a motor vehicle collision. They published their results once again in the prestigious British Journal of Bone and Joint Surgery, titled “Soft-tissue Injuries of the Cervical Spine. 15-year Follow-up.” In this article, these authors note:
“Symptoms had remained static in 54%, improved in 18% and deteriorated in 28%.”
“The patients who had deteriorated were on average five years older than the rest of the group.”
“80% of the patients who had deteriorated in the last five years had degenerative changes, compared with 67% of those whose symptoms had stayed the same and 50% of those who had improved.”
“Older patients were more likely to continue to experience symptoms, and only 5% of those who were aged over 40 years at the time of the accident were free from symptoms at follow-up.”
“100% of patients with severe ongoing problems had cervical degeneration at 11 years after injury.”
This study clearly shows that the older the patient at the time of injury, the greater the cervical spine degenerative disease, and the less likely that they would have recovered from their injuries more than 15 years later.
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In 1999, the reference text Whiplash and Related Headaches, by neurologist Bernard Swerdlow, MD, makes the following point:
Risk factors that may lead to chronicity include “pre-existing degenerative osteoarthritic changes.”
“Other conditions that may pre-exist the accident that may contribute to a chronic state following the accident are osteoarthritis, degeneration of vertebral body joints, disc degeneration and inflammatory processes.”
“Studies indicate that pre-existing osteoarthritic changes contributed to alter the prognosis adversely.”
“As we get older there is a degeneration of the intervertebral disc. This degeneration affects the height of the disc. When there is loss of disc height, then this may cause a decrease in motion of the posterior facets and lead to restriction of motion at that level. Therefore the biomechanical function of these vertebrae are affected.”
“If there is restricted motion and a cervical acceleration/deceleration accident takes place, an insult to the facet joint and disc is more probable and can lead to the chronicity of the pain.”
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In 2002, in their reference text titled Whiplash, Gerard Malanga, MD and Scott Nadler, DO, state:
“Radiographic spondylosis is not rare in any age groups typically affected by whiplash associated disorders.”
“Several researchers have associated poor clinical outcomes with spondylosis, reporting a higher prevalence of spondylosis in patients with continued symptoms.”
“It is certainly theoretically possible that symptoms from a previously asymptomatic cervical spondylosis are precipitated by trauma and are responsible for the continuing pain.”
“It is generally accepted, for example, that a previously asymptomatic hip or knee with long-standing radiographic degenerative changes can become painful after an apparently minor injury.”
“It seems reasonable to presume that a similar outcome can occur with so-called soft tissue strains to the cervical spine.”
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In 2005, physician Schenardi published a study titled “Whiplash injury, TOS and double crush syndrome, Forensic medical aspects.” In this article he addresses the issue of pre-injury cervical spine degeneration by stating:
A substantial percentage of people will have whiplash symptoms for more than a few months, “especially the elderly or those with pre-existing neck problems who may develop chronic long-term problems which may never resolve.”
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In his 2005 reference text titled Motor Vehicle Collision Injuries, Lawrence Nordhoff notes:
“Patients who have clinically significant pre-existing medical conditions may have more severe injuries, slower recoveries and poorer prognoses.”
Dr. Nordhoff clearly lists “spinal degeneration” as one such pre-existing medical factor.
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In conclusion, for more than 40 years, published studies, primary
research, and reference texts pertaining to whiplash trauma have evaluated the significance of pre-injury cervical spine degenerative joint disease. The consensus from these publications is that pre-existing degenerative joint disease renders such joints less capable of adequately handling and dispersing the forces of a new injury; therefore, injury to these articulations and the surrounding soft tissues is greater; the amount of treatment required for maximum improvement is greater; there are more long-term subjective, objective, and functional residuals. It appears that the traumatic event not only adversely affects the pre-injury degenerative joints, but places greater stresses on adjacent normal joints, altering their
neuro-biomechanics as well; this probably becomes an additional factor in post-whiplash chronic pain syndrome, requiring prolonged treatment to achieve maximum improvement. In 1989, Mason Hohl, MD, wrote “Soft-Tissue Neck Injuries,” in The Cervical Spine, The Cervical Spine Research Society, stating:
“In a follow-up study of patients with similar [whiplash] injuries but with preexisting degenerative changes in the neck, it was observed that after an average of 7 years 39% had residual symptoms, and roentgenographic evidence of new degenerative change at another level occurred in 55%.”
All injured patients, including the frail with pre-accident degenerative joint disease, are entitled to proper and adequate treatment. The take home message for clinicians treating these patients includes:
1) Degenerative joint disease of the cervical spine is common in the population, and nearly universal in those older than age 50.
2) When individuals with degenerative joint disease of the cervical spine are injured in a motor vehicle collision, their degenerative joints are less capable of adequately dealing with the traumatic forces.
3) Consequently, whiplash trauma to individuals with pre-accident degenerative joint disease increases the injury to these joints and to adjacent joints.
4) Whiplash trauma to individuals with pre-accident degenerative joint disease accelerates the degeneration of these joints and also accelerates the degeneration of adjacent joints that did not initially show signs of degeneration.
5) The greater injury and accelerated spinal degenerative disease in such patients is probably a contributing factor to chronic whiplash injury pain syndrome.
6) The greater injury and accelerated spinal degenerative disease in such patients creates a rational for the reason these patients often require longer treatment, more frequent treatment, and have a worse prognosis for complete recovery.
7) To ascribe whiplash injury symptomatology to pre-existing cervical spine degenerative changes is wrong, especially if those changes were quiescent prior to the accident.
Bibliography
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Gargan MF, Bannister GC; The comparative effects of whiplash injuries; Journal of Orthopaedic Medicine; 1997 Vol. 19, pp. 15-17.
Kartal A, Yildiran B, Senköylü A and Korkusuz F; Soccer causes degenerative changes in the cervical spine; European Spine Journal, February 2004, 13(1):76-82.
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