Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: a case report

Cranio-vertebral instability (CVI) due to loss of bony or ligamentous integrity is one of the sequelae that may result after a whiplash mechanism injury. Due to the lack of specificity of diagnostic tests, this condition is often missed and the default classification of whiplash associated disorder (WAD) is assigned. This case report describes a 14-year-old boy who was initially classified with WAD II after a rugby injury. He was initially advised to return to usual activity, a treatment recommended in clinical guidelines for WAD. Due to an adverse response to this course of action, his primary carer, a musculoskeletal physiotherapist, continued with facilitating secondary referrals that ultimately led to a specialist physiotherapist. The patient was subsequently found to have CVI arising from a loss of bony integrity due to spina bifida atlanto, a congenital defect in the atlas. Treatment thus was immobilization and stabilization, a treatment usually recommended against in WAD guidelines. The patient recovered and within 8 weeks had returned to school and non-contact sports. This case study, therefore, presents a scenario where current clinical guidelines for whiplash could not be followed, and where pursuing clinical reasoning led to accurate diagnosis as well as safe and tailored management. The case also highlights the integrated roles that primary and specialist health professionals should play in the clinical pathway of care after WAD. As a result, an expanded diagnostic algorithm and pathway of care for WAD are proposed.