The Late Whiplash Syndrome: Current Aspects of Functional Neuroimaging

  • Andreas Otte
  • Kurt Audenaert
  • Kathelijne Peremans
  • Karina Otte
  • Rudi A. Dierckx


Patients with persisting symptoms after a whiplash injury (the so-called late whiplash syndrome) are often left alone. However, their complaints are not only limited to neuropathic pain in the head and neck region, but there are also symptoms, which proceed from the brain. These brain symptoms comprise vertigo, dizziness, tinnitus, as well as concentration, attention and memory disturbances; also visual problems such as blurred vision and oscillopsia can occur. The whiplash injury is frequent, although only a small proportion of the patients develop the late whiplash syndrome. The incidence of whiplash injury in the industrialized countries is estimated up to 3.8 cases per 1,000 inhabitants per year. Rear-end car collisions are the most frequent causes of whiplash injury and only low speeds between 10 and 20 km/h are necessary to cause large acceleration forces on the head. The usual methods for the diagnosis of whiplash injury such as the neurological investigation or radiography of the cervical spine unfortunately forget that the brain (in addition to the cervical spine) can be damaged by an acceleration trauma. Therefore, research methods are necessary which objectively represent the condition of the brain. Conventional radiological imaging such as computerized tomography or magnetic resonance tomography of the brain can, however, only represent the morphological structures and not the possible functional alterations of the brain, as caused by whiplash injury. In contrast, the relatively new methods of nuclear medicine currently offer the only possibility of imaging such functional changes. In patients with late whiplash syndrome, a statistically significant metabolic reduction in the posterior parietal occipital region of the brain is found. This was shown in several studies with over 500 patients investigated by both cerebral blood flow single-photon emission computed tomography and fluorodeoxyglucose positron emission tomography. In individual cases, patients also showed regions with decreased metabolism which were not in the posterior parietal occipital location, but no statistically significant group differences could be determined between these patients and a healthy control group. In a further study from a research group in Zurich, somewhat different results were found; the results of this study seem, however, doubtful. — Posterior parietal occipital findings can also be observed in other diseases with brain affection, for example, in systemic lupus erythematosus, Alzheimer’s disease or migraine. Other diseases can easily be excluded by a purposeful clinical and neurological assessment. There are also diseases which show a similar clinical component like the late whiplash syndrome, for instance, primary depression. In these diseases, the posterior parietal occipital region is not affected however. In light of the ongoing medico-legal discussion in the field, a critical approach to the interpretation of these new research data from functional neuroimaging is of utmost importance. All treating physicians in the field should be familiar with these tools.


Positron Emission Tomography Cervical Spine Functional Magnetic Resonance Imaging Mild Traumatic Brain Injury Whiplash Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Alexander MP (1998) In the pursuit of proof of brain damage after whiplash injury. Neurology 51:336–340PubMedCrossRefGoogle Scholar
  2. Bicik I, Radanov BP, Schäfer N, Dvorak J, Blum B, Weber B, Burger C, von Schulthess GK, Buck A (1998) PET with 18fluorodeoxyglucose and hexamethylpropylene amine SPECT in late whiplash syndrome. Neurology 51:345–350PubMedCrossRefGoogle Scholar
  3. Buck A (1999) PET with 18fluorodexyglucose and hexamethylpropylene amine oxime SPECT in late whiplash syndrome. Neurology 52:1108Google Scholar
  4. Costa DC, Tannock C, Brostoff J (1995) Brainstem perfusion is impaired in chronic fatigue syndrome. QJM 88:767–773PubMedGoogle Scholar
  5. Croft AC (1998) Epidemiology of whiplash. In: Croft AC (ed) Understanding low speed rear impact collisions (LOSRIC). Spine Research Institute of San Diego, San DiegoGoogle Scholar
  6. Evans RW (1992) Some observations on whiplash injuries. Neurol Clin 10:975–997PubMedGoogle Scholar
  7. Freitag P, Greenlee MW, Wächter K, Ettlin TM, Radue EW (2001) fMRI response during visual motion stimulation in patients with late whiplash syndrome. Neurorehabil Neural Repair 15:31–37PubMedCrossRefGoogle Scholar
  8. Friston KJ, Frith CD, Liddle PF, Frackowiak RSJ (1991) Comparing functional (PET) images: the assessment of significant change. J Cereb Blood Flow Metab 11:690–699PubMedCrossRefGoogle Scholar
  9. Friston KJ, Holmes AP, Worsley KJ, Poline JB, Frith CD, Frackowiak RSJ (1995a) Statistical parametric maps in functional imaging: a general approach. Hum Brain Mapping 2:189–210CrossRefGoogle Scholar
  10. Friston KJ, Ashburner J, Poline JB, Frith CD, Heather JD, Frackowiak RSJ (1995b) Spatial realignment and normalization of images. Hum Brain Mapping 2:165–189CrossRefGoogle Scholar
  11. Goldenberg G, Oder W, Spatt J, Podreka I (1992) Cerebral correlates of disturbed executive function and memory in survivors of severe closed head injury: a SPECT study. J Neurol Neurosurg Psychiatry 55:362–368PubMedCrossRefGoogle Scholar
  12. Graham DG, Brierly JB (1984) Vascular disorders of the central nervous system. In: Adams J (ed) Neuropathology. Arnold, London, pp 125–207Google Scholar
  13. Ichise M, Chung DG, Wang P, Wortzman G, Gray BG, Franks W (1994) Technetium-99m-HMPAO SPECT, CT and MRI in the evaluation of patients with chronic traumatic brain injury: a correlation with neuropsychological performance. J Nucl Med 35:217–226PubMedGoogle Scholar
  14. Jacobs A, Put E, Ingels M, Bossuyt A (1994) Prospective evaluation of technetium-99m-HMPAO SPECT in mild and moderate traumatic brain injury. J Nucl Med 35:942–947PubMedGoogle Scholar
  15. Jörg J, Menger H (1998) Das Halswirbelsäulen-und Halsmarktrauma. Neurologische Diagnose und Differentialdiagnostik. Dtsch Ärztebl 95:B1048–B1055Google Scholar
  16. Johansson G, Risberg J, Rosenhall U, Orndahl G, Svennerholm L, Nystrom S (1995) Cerebral dysfunction in fibromyalgia: evidence from regional cerebral blood flow measurements, otoneurological tests and cerebrospinal fluid analysis. Acta Psychiatr Scand 91:86–94PubMedCrossRefGoogle Scholar
  17. Liotti M, Mayberg HS (2001) The role of functional neuroimaging in the neuropsychology of depression. Clin Exp Neuropsychol 23:121–136CrossRefGoogle Scholar
  18. Lorberboym M, Gilad R, Gorin V, Sadeh M, Lampl Y (2002) Late whiplash syndrome: correlation of brain SPECT with neuropsychological tests and P300 event-related potential. J Trauma 52:521–526PubMedCrossRefGoogle Scholar
  19. Moskowitz MA, Buzzi MG (1991) Neuroeffector functions of sensory fibers. Implications for headache mechanisms and drug actions. J Neurol 238[Suppl l]:18–22CrossRefGoogle Scholar
  20. Olsson I, Bunketorp O, Carlsson G et al (1990) An in-depth study of neck injuries in rear end car collisions. International IRCOBI conference, Bron, Lyon, France, 12–14 Sept, pp 1–15Google Scholar
  21. Ommaya AK, Faas F, Yarnell R (1968) Whiplash injury and brain damage: an experimental study. JAMA 204:75–79CrossRefGoogle Scholar
  22. Otte A (1998) Does whiplash trauma increase the risk of Alzheimer’s disease? J Vase Invest 4: 211–212Google Scholar
  23. Otte A (1999) PET with 18fluorodexyglucose and hexamethylpropylene amine oxime SPECT in late whiplash syndrome. Neurology 52:1107–1108PubMedCrossRefGoogle Scholar
  24. Otte A (2000a) Kognitive Störungen nach traumatischer Distorsion der Halswirbelsäule: Schleudertrauma, quo vadis? Dtsch Ärztebl 97:A463Google Scholar
  25. Otte A (2000b) The parieto-occipital region — confusions at the boundary? Eur J Nucl Med 27: 238–239PubMedCrossRefGoogle Scholar
  26. Otte A (2001) Das Halswirbelsäulen-Schleudertrauma: Neue Wege der funktionellen Bildgebung des Gehirns — ein Ratgeber für Ärzte und Betroffene. Springer, Berlin Heidelberg New YorkCrossRefGoogle Scholar
  27. Otte A, Mueller-Brand J (1997) Is there a chronic fatigue of the late whiplash syndrome? J Vase Invest 3:161Google Scholar
  28. Otte A, Ettlin TM, Mueller-Brand J (1995a) Comparison of Tc-99m-ECD with Tc-99m-HMPAO-brain-SPECT in late whiplash syndrome. J Vase Invest 1:157–163Google Scholar
  29. Otte A, Mueller-Brand J, Fierz L (1995b) Brain SPECT findings in late whiplash syndrome. Lancet 345:1513–1514PubMedCrossRefGoogle Scholar
  30. Otte A, Ettlin T, Fierz L, Mueller-Brand J (1996a) Parieto-occipital hypoperfusion in late whiplash syndrome: first quantitative SPET study using Tc-99m-bicisate (ECD). Eur J Nucl Med 23:72–74PubMedCrossRefGoogle Scholar
  31. Otte A, Ettlin TM, Fierz L, Kischka U, Muerner J, Högerle S, Bräutigam P, Mueller-Brand J (1996b) Zerebrale Befunde nach Halswirbelsäulendistorsion durch Beschleunigungsmechanismus (HWS-Schleudertrauma): Standortbestimmung zu neuen diagnostischen Methoden der Nuklearmedizin. [Cerebral findings after distortion of the cervical spine induced by acceleration injury (whiplash injury): assessment of current isotopic scanning techniques for diagnosis.] Schweiz Rundschau Med Praxis 85:1087–1090Google Scholar
  32. Otte A, Ettlin TM, Fierz L, Kischka U, Muerner J, Mueller-Brand J (1997a) Brain perfusion patterns in 136 patients with chronic symptoms after distortion of the cervical spine using single-photon emission computed tomography, technetium-99m-HMPAO and technetium-99m-ECD: a controlled study. J Vase Invest 3:1–5Google Scholar
  33. Otte A, Ettlin TM, Nitzsche EU, Wächter K, Hoegerle S, Simon GH, Fierz L, Moser E, Mueller-Brand J (1997b) PET and SPECT in whiplash syndrome: a new approach to a forgotten brain? J Neurol Neurosurg Psychiatry 63:368–372PubMedCrossRefGoogle Scholar
  34. Otte A, Ettlin TM, Otto I, Mueller-Brand J (1997c) Manipulation-triggered visual disturbances after cervical spine injury. J Vase Invest 3:197–198Google Scholar
  35. Otte A, Mueller-Brand J, Ettlin TM, Wächter K, Nitzsche EU (1997d) Functional imaging in 200 patients after whiplash injury. J Nucl Med 38:1002PubMedGoogle Scholar
  36. Otte A, Weiner SM, Peter HH, Mueller-Brand J, Goetze M, Moser E, Gutfleisch J, Hoegerle S, Juengling FD, Nitzsche EU (1997e) Brain glucose utilization in systemic lupus erythematosus with beginning neuropsychiatric symptoms: a controlled PET study. Eur J Nucl Med 24:787–791PubMedGoogle Scholar
  37. Otte A, Goetze M, Mueller-Brand J (1998a) Statistical parametric mapping in whiplash brain: is it only a contusion mechanism? Eur J Nucl Med 25:306–307PubMedGoogle Scholar
  38. Otte A, Juengling FD, Nitzsche EU (1998b) Rethinking mild head injury. J Vase Invest 4:45–46Google Scholar
  39. Otte A, Stratz T, Wächter K, Nitzsche EU, Zajic T, Goetze M, Ettlin TM, Mueller-Brand J (1998c) Brain SPET Statistical Parametric Mapping (SPM) in fibromyalgia syndrome: is brainstem perfusion impaired? J Vase Invest 4:111–116Google Scholar
  40. Otte A, Weiner SM, Hoegerle S, Wolf R, Juengling FD, Peter HH, Nitzsche EU (1998d) Neuropsychiatry systemic lupus erythematosus before and after immunosuppressive treatment: a FDG PET study. Lupus 7:57–59PubMedCrossRefGoogle Scholar
  41. Poeck K (1999) Kognitive Störungen nach traumatischer Distorsion der Halswirbelsäule? Dtsch Ärztebl 96:A2596–A2601Google Scholar
  42. Radanov BP, Bicik I, Dvorak J, Antinnes J, von Schulthess GK, Buck A (1999) Relation between neuropsychological and neuroimaging findings in patients with late whiplash syndrome. J Neurol Neurosurg Psychiatry 66:485–489PubMedCrossRefGoogle Scholar
  43. Ryan GA, Taylor GW, Moore V, Dolinis J (1993) Neck strain in car occupants. Med J Aust 159: 651–656PubMedGoogle Scholar
  44. Schmid P (1999) Whiplash-associated disorders. Schweiz Med Wochenschr 25:1368–1380Google Scholar
  45. Spitzer WO, Skovron ML, Salmi LR et al (1995) Quebec Task Force on Whiplash-Associated Disorders: scientific monographs of the Quebec Task Force on Whiplash-Associated Disorders. Redefining “whiplash” and its management. Spine 20[Suppl]:1–73Google Scholar
  46. Talairach J, Tournoux P (1988) Co-planar atlas of the human brain. Thieme, StuttgartGoogle Scholar
  47. Talairach J, Tournoux P (1993) Referentially oriented cerebral MRI anatomy. Atlas of stereotaxic anatomical correlations for gray and white matter. Thieme, StuttgartGoogle Scholar
  48. Tashiro M, Juengling F, Reinhardt M, Moser E, Nitzsche E (2000) Psychological response and survival in breast cancer. Lancet 355:405–406PubMedCrossRefGoogle Scholar
  49. Weiner SM, Otte A, Schumacher M, Klein R, Gutfleisch J, Otto P, Brink I, Nitzsche EU, Moser E, Peter HH (2000) Diagnosis and monitoring of central nervous system involvement in systemic lupus erythematosus: value of F-18 fluorodeoxyglucose PET. Ann Rheum Dis 59:377–385PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2004

Authors and Affiliations

  • Andreas Otte
    • 1
  • Kurt Audenaert
    • 2
  • Kathelijne Peremans
    • 3
  • Karina Otte
    • 4
  • Rudi A. Dierckx
    • 1
  1. 1.Division of Nuclear MedicineUniversity Hospital GhentGentBelgium
  2. 2.Department of Psychiatry and Medical PsychologyUniversity Hospital GhentGentBelgium
  3. 3.Department of Medical ImagingFaculty of Veterinary MedicineMerelbekeBelgium
  4. 4.Legal DepartmentUniversity Hospital FreiburgFreiburgGermany

Personalised recommendations