"Don't worry, buddy. Hopefully I'll be back soon."

 

Less than two minutes into Saturday night’s game against the Habs, Toronto goaltender James Reimer took an elbow to the head courtesy of Brian Gionta. Reimer finished the period, but didn’t return after the first intermission, and wasn’t at practice yesterday. The hit knocked his mask off, and it took Reimer some time to get his act back together, get his mask back on, and keep playing. For his troubles, Gionta took a goalie interference penalty.

 

 

Listen carefully to what Leafs’ coach Ron Wilson says there: “…whiplash-type symptoms…” Whiplash is one of those words that people love to throw around, but whose real meaning is shrouded in mystery and Judge Judy episodes.

 

Seriously, what the heck is whiplash?

 

We most commonly associate the term with car accidents and people in giant foam neck braces (usually suing somebody). The term actually refers to an injury to the soft tissues of the neck (muscles, tendons, ligaments) after something causes the neck to move in a way that’s not part of its normal range of motion. Put simply, if your neck stretches too far in one direction, you get whiplash. And it hurts. Understanding whiplash is helped by understanding the cervical spine or c-spine (the part of the spine that makes up your neck), and how it’s built.

 

C-Spine: Important, complicated, easily offended.

 

The c-spine is made up of 7 vertebrae (cleverly referred to as C1-C7). C1 is known as the atlas because it holds the skull, C2 is the axis because that’s what C1 and the skull rotate on, and C7 is the one that sticks way out on the back of your neck. All of the vertebrae are connected by a variety of ligaments, and they’re surrounded by a lot of little complicated muscles (and big complicated muscles). Obviously there’s a lot of stuff in your neck that can get hurt.

 

Cervial vertebrae: Not what gets hurt in whiplash, but surrounded by things that do.

 

The ligaments that are attached to the vertebrae of your neck are there to keep things in order. They keep your neck from bending too far in any direction, and they help things come back to a neutral position after flexion (bending your head forward/looking down), extension (bending your head back/looking up), rotation, and lateral bending.

There are ligaments that connect C1 to the skull (the atlanto-occipital joint) and to C2 (the atlanto-axial joint). The skull-C1-C2 area is pretty important not just because that’s where the majority of neck rotation happens, but it has that whole keep-the-head-connected-to-the-neck thing going on.

After C2 the ligaments get less exciting, but thanks to their position are very sprainable. The major players are the anterior spinal ligament (which runs down the front of the vertebrae), the posterior spinal ligament (you get one guess where it goes), and the ligamentum flavum (which connects the laminae – the little wings on the back of the vertebrae). There’s also the nuchal ligament, which runs down the back of the spinous processes in your neck (the pointy bits on the very middle of your spine in the back).

 

Side view of the ligaments in your neck. Take home message: Holy hell, there's a lot of them.

 

It’s not hard to figure out why whiplash happens once you see how many ligaments are in the neck. Picture your neck snapping way forward/way back or twisting suddenly, and you can imagine any one of the numerous ligaments getting stretched or torn (sprained).

 

Wait a second, what about the muscles?

 

In much the same way that you can sprain a ligament, you can strain a muscle by stretching or tearing it. There are groups of muscles to flex and extend the head, flex and extend the neck, laterally bend and rotate the neck, and multiple others with jobs that aren’t relevant here (like swallowing, speaking, etc). The point is that in a structure with this many muscles, some of them are bound to get hurt. Even if there’s no actual muscular injury, issues can develop later as your natural mechanics are thrown out of whack by a ligamentous injury.

 

Neck muscles!

 

Consider the moment Gionta’s elbow meets Reimer’s head. The force of the moving elbow is transmitted to Reimer’s mask (which flies off) and through to his head, which is snapped back and twisted to his right. As this happens the muscles in his neck contract, and ligaments are stretched or compacted (depending on where they are). Reimer’s neck isn’t built to do what Gionta’s elbow insisted it do.

 

Diagnosis/Treatment

 

Whiplash is a clinical diagnosis (meaning it’s made based on what happened and what the patient complains of), because it’s not something that will show up on an x-ray. The exception would be a truly severe soft-tissue injury with massive swelling, in which case it might be possible to see distortion of the normal anatomy (ie. big spaces where there should be little spaces). A series of neck x-rays will rule out bony injury, but an MRI is the imaging modality that’s best for showing soft-tissue injury.

Whiplash is treated with anti-inflammatory medications (NSAIDs like ibuprofen or naproxen), icing the area, gentle range of motion exercises, massage, and rest. The giant foam collars are reserved for severe pain (and frankly are used way more on TV than in real life). In more serious cases with persistent pain, steroid injections may be used to decrease swelling (and therefore pain).

 

What does this mean for Reimer?

 

It’s really hard to say where this injury will lead. Reimer said yesterday that he was already feeling better, but according to Wilson he’s out for tonight’s game in Philadelphia. Reimer will undergo further medical evaluation today. The upshot is that he may or may not be back in time for Thursday’s game in New York.

Worst case scenario is this goes in a Marc Staal direction – Staal took a hit from his brother Eric in February and hasn’t started the season due to headaches that may be the result of “neck pressure” seen on MRI (in quotes because I refuse to acknowledge that’s an actual diagnosis). There’s been discussion that the injury is more neck than concussion related, but the point is something as simple as whiplash can turn out to be not-so-simple. Staal has had steroid injections and has been skating, but remains on injured reserve.

The best case scenario here is that Reimer returns Thursday, allowing Jonas Gustavsson and all of Toronto breathe a huge sigh of relief.