Whiplash

GA Malanga and SF Nadler Published by Hanley & Belfus Inc.: Philadelphia, USA: 2002. ISBN: 1 56053 438 9; $45.00, pp 460.

Comprehensive is certainly the right word to describe the areas covered in this work. But neither comprehensive nor balanced is it in displaying disinterestedly both sides of the continuing controversies. The editors are a physician, Director of sports, spine and orthopaedic rehabilitation, and an osteopath, Director of sports medicine, both from New Jersey. Their New Jersey colleagues write 15 of the 26 chapters, the remainder are largely from other US departments of physical medicine and rehabilitation.

The editors' preface and introductory chapters are sound and objective, declaring their intent, instructing contributors to `provide current scientific information and not opinions or anecdotal experiences'. Unfortunately, some contributing authors have failed to implement this counsel. The editors fairly acknowledge that `the monetary potential creates an environment of mistrust, false expectations, and inappropriate care … the system is a result of the multitude of frivolous lawsuits brought about in the quest for dollars.' But this common and important issue is heeded in only two chapters. Barnsley Lord and Bogduk, whose work stems from Bogduk's department of anatomy, omit mention of many papers disclosing clinical views contrary to their own; Grzesiak et al acknowledge the lower reported rate in countries with limited access to law or damages, and they reluctantly concede that litigation may be implicated in pain behaviour – whatever psychiatric entity that may be.

Unfortunately, the selection of syndromes considered is predicated on whiplash as a mechanism, not a symptom complex, and thus they include injuries to nerve roots, spinal cord and major fracture dislocations in various sections. Temporomandibular joint disorders attributed to neck injury get detailed consideration, despite the fact that their very relation to whiplash relies on evidence that is either anecdotal or based on temporal association. A distinct mechanism whereby a neck sprain can affect a TM joint that has not been directly injured is not revealed. It is strange indeed to read whole chapters on mild traumatic brain injury, and spinal cord injury, entities remote from a book on the whiplash syndrome. This reflects the compulsion to be all embracing when speculating on such ill-defined and intrinsically uncertain territories. But sadly, such desiderata have little meaning to doctors dealing with these cases, and their very inclusion hints at the thin ice on which so much whiplash literature stands. These uncontroversial physical lesions are mixed without separation from the bread and butter soft tissue injuries of the neck that consume so much clinical and legal attention.

The text includes sound chapters on anatomy and radiology, but because of too broad a definition, these also survey some areas irrelevant to clinical practice. A useful section (Gay and Levine) instructs us on biomechanics, and shows that the notion of a hyperextension injury oversimplifies the mechanism. Hyperextension of the lower cervical region and hyperflexion of the upper region (S-shaped curve) stress the lower cervical motion segments before the head strikes the headrest and before full cervical extension. Low impact velocities (4.8–9 mph) result in change in velocity (delta-V) of 4.8–6 mph, and a delta-V of less than 5 mph is unlikely to cause injury, though no actual data or threshold for injury is established. Cadaveric studies are of little value in deducing mechanisms in living tissues.

Pathophysiology, clinical features and treatments both physical and psychological are considered at length in many chapters that overlap too often. It is nowadays generally accepted that a healthy disc does not rupture or prolapse as a consequence of a single injury; yet a whole chapter (Slipman and Chow) is devoted to whiplash-induced cervical disc and radicular pain, despite the authors' statement that `although rare, acute traumatic cervical disc herniations do occur' and, `there is little literature regarding disc herniation due to hyperextension injury'. As with so much in this text, it is an interesting and useful chapter, but it is out of place in the context of the common disorders arising from whiplash injury, if this is correctly defined. Similarly, a chapter on imaging rightly states `imaging is indicated not by the occurrence of `whiplash' (a mechanism of injury) but rather by clinical signs and symptoms … ' Yet it goes on to deal with plain radiographs, CT and MRI, examinations deemed usually unnecessary by the Quebec task force, the American College of radiology task force, and many radiological papers, including a comment by Malanga and Nadler themselves in the concluding chapter.

Most neurologists and orthopaedic surgeons have come to minimise periods of splinting the neck in a collar, physical therapies and analgesic and muscle relaxant drugs, confining them to a short period after injury; the harmful effects of prolonging treatments in a self limiting pathology are well established by the Quebec task force and many other authorities. It is thus ironical to find extensive dissertations on medications, interventional spine procedures, complementary and alternative medicine, chiropraxis, rehabilitation, psychological theory and practice, and surgical indications. Much is anecdotal, based largely on either personal conviction or uncontrolled studies rather than on evidence based medical science.

Some reference lists are alphabetical; others are in non-alphabetical sequence, which does not suggest the tightest editorial supervision.

This book contains a lot of data and references, and many valid opinions, not least the legal dilemmas (US) framed by R Rubenstein. Most opinions, however, are misplaced in the overwhelmingly common condition of neck sprains uncomplicated by demonstrable injury to disks, facet joints, nerve roots and spinal cord. Such a confused base of reference negates the editors' introductory adumbration and appraisal. Unfortunately, Malanga and Nadler have failed to focus the efforts of their contributors on the essentials of the many difficult problems of common whiplash injury. The book is adequately published with acceptable diagrams and illustrations; but it is difficult to envisage a readership that would benefit from the scientifically uncritical, muddled approach.