What is the workup for a patient with a sensation of whiplash after diving in a pool?

Workup for Whiplash Sensation After Diving in a Pool

A patient with a sensation of whiplash after diving in a pool requires immediate evaluation for potential cervical spine injury, with imaging studies being the cornerstone of diagnosis. The mechanism of injury suggests a possible cervical spine trauma that needs thorough assessment to prevent serious neurological complications.

Initial Assessment

• Vital signs and neurological status: Assess for signs of altered mental status, weakness, numbness, or tingling in extremities
• Cervical spine examination: Check for pain, tenderness, limited range of motion, and muscle spasm
• Neurological examination: Evaluate motor strength, sensory function, reflexes, and cranial nerve function
• Assess for associated injuries: Look for signs of head trauma, drowning, or other trauma

Imaging Studies

Primary Imaging

• Plain radiographs of cervical spine: AP, lateral, and odontoid views to evaluate for fractures, alignment abnormalities, and degenerative changes
• CT scan of cervical spine: For detailed evaluation of bony structures when:
  • Abnormalities are detected on plain films
  • Patient has neurological deficits
  • Pain is severe or persistent despite normal radiographs

Secondary Imaging

• MRI of cervical spine: Indicated when:
  • Neurological deficits are present
  • Ligamentous injury is suspected
  • Persistent symptoms despite normal CT findings
  • MRI can detect occult fractures, bone contusions, and muscular/ligamentous injuries that may not be visible on other imaging 1

Special Considerations for Diving Injuries

Diving accidents in swimming pools have specific risk factors that should guide the workup:

• Cervical spine injuries from diving most commonly affect C5-C7 levels (70% of cases) 2
• Shallow water diving is a significant risk factor for cervical spine injury 3, 4
• The biphasic movement of the head during diving (reclination followed by inclination) can cause injury to bony, muscular, and ligamentous elements 1

Management Algorithm

1. Stabilize the patient:

   • If found in water, remove from water by fastest means available 5
   • Consider cervical spine immobilization if there are obvious clinical signs of injury, alcohol intoxication, or history of diving into shallow water 5

2. Evaluate for respiratory compromise:

   • Drowning victims may have associated respiratory issues
   • Provide supplemental oxygen if needed

3. Imaging pathway:

   • Begin with plain radiographs of the cervical spine
   • If abnormal or high clinical suspicion despite normal films → CT scan
   • If persistent symptoms or neurological deficits → MRI

4. Treatment planning:

   • Conservative treatment for at least 6 months is recommended for acute and subacute whiplash-associated disorders 6
   • Active mobilization is slightly better than passive treatment for whiplash injuries 6
   • Surgical consultation for unstable fractures or significant neurological deficits

Pitfalls and Caveats

• Do not dismiss normal imaging: Whiplash injuries often show no specific imaging findings despite significant symptoms 1
• Delayed symptom onset: Pain, stiffness, and tenderness of the neck may occur with a latency of several hours after the injury 1
• Risk of chronic symptoms: Some patients may develop chronic symptoms despite appropriate initial management
• Alcohol assessment: Consider alcohol as a contributing factor, as it was reported in 47% of spinal cord injuries from diving 4
• Depth assessment: Shallow water (less than 1.4m/4.6ft) is associated with 52% of pool diving injuries and 79% of natural site diving injuries 4

By following this systematic approach to evaluation, clinicians can ensure appropriate diagnosis and management of patients with whiplash sensation after diving in a pool, potentially preventing serious neurological complications and optimizing outcomes.