- Kristjansson, BSc (Manip Ther),a and H. Jo´nsson Jr, MD, PhD
Objective: To reveal whether women with chronic whiplash-associated disorder (WAD) symptoms, grade I-II, demonstrate regional and/or segmental radiographic signs of altered cervical lordosis.
Design: Case-control study.
Setting: Radiography department at a university hospital.
Participants: Three age-balanced groups comprising 120 women. The case group included women with chronic whiplash syndrome (n 41), and the control group included women with chronic insidious onset neck pain (n 39) and an asymptomatic group (n 40), who were given baseline data. The sample was referred from informed doctors and physiotherapists.
Intervention: The women sat in a standardized sitting position and radiographs were taken in a lateral position with fluoroscopic control for alignment.
Outcome Measures: Two distinct measurements were taken; 1 of the angles of the upper and lower cervical curvatures, respectively, and 1 of the angles between the inferior borders of each pair of vertebrae in the lower cervical spine. The 3 groups were compared on the ratio of the lower to upper cervical spine angles and on the mean angular values for each segment in the cervical spine.
Results: The whiplash group showed a decreased ratio between the lower versus upper cervical spine but comparisons between groups were not statistically significant. The whiplash group was in a significantly more flexed position at the C4-C5 level compared with the asymptomatic group (P .007). The reliability measures have to be strengthened to render these results definitely conclusive.
Conclusion: The whiplash group exhibited a different configuration of cervical lordosis. This is clinically important and needs to be studied more closely.
Conflicting views exist about the clinical significance of variations in the sagittal configuration of the cervical spine in general1,2 and in patients with whiplash-associated disorders (WAD) in particular.3-6 Some researchers suggest that a straight cervical curve and angular kyphosis in patients with WAD indicate protective muscle spasm and/or disco-ligamentous injury with poor prognosis.5,6 The great variations in the configuration of the cervical curve in asymptomatic and symptomatic subjects have led to many different opinions regarding the clinical significance of different configurations.1-13 It is commonly believed that diminished or reversed cervical lordosis even with gross kyphotic angulations may represent a normal variant.2,3,4,7-11,14,15 However, this opinion has been opposed recently in an extensive literature review.1 When measuring cervical lordosis, most studies have been concerned with the lower cervical spine2-13 but have ignored the upper cervical spine perhaps because regional attenuation of the lordosis is the most often manifested protective posture in the lower cervical spine.16,17 However, because the upper and lower cervical spine are capable of moving independently of each other,18,19 each part has the potential to compensate for misalignment in the other part. Therefore, we hypothesize that decreased lordosis in the lower cervical spine may lead to increased lordosis in the upper part as a compensating mechanism, or vice versa, to keep the eyes level with the earth-horizontal. Similarly, decreased lordosis in the upper cervical spine and increased lordosis in the lower part may be interrelated. Measuring the lower and upper cervical curvatures independently and ascertaining their relation may, therefore, be a better indicator of overall changes in the cervical curvature. Intersegmental angulations are a measure of each individual vertebral position in the sagittal plane. Local alteration in the sagittal configuration of 2 adjacent vertebral segments may indicate traumatic or long-term consequences of a traumatic event.20,21 Curvatures of the spine are commonly measured by angular measurements, with landmarks at the bottom and top of the curve.22,23