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Whiplash Related Neck Pain

by Dr Simon Petrides MB BS DO DM-SMed Dip Sports Med FFSEM (UK&I)
Musculoskeletal & Sports Physician | The Blackberry Clinic, Milton Keynes

It’s Not Improving So What Next?
This article addresses the issues concerning whiplash related neck pain. There is also extensive discussion on the injection procedures that can be carried out to relieve chronic persistent whiplash related pain.

Our knowledge regarding specific anatomical components injured during the process of whiplash is incomplete, but MRI and autopsy examination has shown significant damage to cervical ligaments, facet joints and discs in people suffering from a whiplash type injury, otherwise known as a cervical acceleration deceleration (CAD) injury. There is evidence to suggest that a significant proportion of patients have pain originating in the cervical facet joints and capsular ligaments  (Lord 1995, Lord 1996).

Whiplash injuries resulting in chronic pain are extremely prevalent in the UK and US. The resulting cost to the NHS and to the Department of Work & Pensions is huge.

Between 5% and 8% of whiplash sufferers develop longstanding symptoms severe enough to affect their ability to work (Lovell 2002, Freeman 1999, Sterner 2004). Studies using medial branch block and radiofrequency neurolysis of facet joint sensory nerves have demonstrated the existence of the facet joint pain in whiplash injury.

Artificial reconstruction of the whiplash injury during rear end collisions demonstrated injury to the anterior longitudinal ligaments and annular fibres in the middle and lower cervical spine (Ivancic 2004, Panjabi 2004). Other studies have shown the facet capsules at C5 - C7 were found to be at risk due to excessive motion during impact (Ito S, 2004).

These studies have led to the conjecture that microscopic injuries of the cervical ligaments may affect mechanoreceptors and nociceptors leading to chronic pain after a certain period of time.

Significant decreases have been reported in ligament strength following simulated whiplash injury supporting the evidence that in patients with whiplash syndrome, there is significant pain relief to be gained following medial branch facet block, and/or radiofrequency neurolysis of the relevant zygapophyseal joint afferent nerves fibres (Lord 1995, Lord 1996).

Any reduction in ligament strength is likely to lead to relative instability at intervertebral segments and further injury to the disc annulus, posterior longitudinal ligament, ligament flavum and other surrounding ligaments, muscles and connective tissue.

Non-Whiplash Neck Pain
There are a few epidemiological studies reporting an accurate prevalence of neck pain, however it is estimated to be in the region of 34% of the general population. Chronic neck pain lasting more than six months is estimated at approximately 14% (Bovim 1994, Makela 1991).

In 1933. Ghormley coined the term facet syndrome to describe a collection of symptoms and signs associated with degenerative change of the lumbar spine (Ghormley 1933). The term cervical facet syndrome implies “axial pain secondary to involvement of the posterior elements of the cervical spine”. This may or may not be associated with referred pain.

The facet joints have been found to be a possible source of neck pain by specific medial branch block.

Clinical Signs & Symptoms
The clinical features that are often associated with pain of cervical facet joint origin include tenderness to palpation over the joints or paraspinal muscles. This is often detectable as dysfunction, “subluxation” or “fixation” as detected by osteopaths, chiropractors and physiotherapists with the relevant manual skills. Pain is usually experienced on extension or rotation in a capsular or non-capsular pattern, and in pure facet joint pain there is an absence of neurological deficit.

Imaging
The use of MRI, CT and X-ray are usually not helpful, with the exception of ruling out other more serious sources of pain and also to exclude disc protrusion, vertebral fracture or subluxation. Although the signs of disc narrowing and foraminal encroachment, osteophytes and other degenerative changes are frequently associated with the level of pain there is not any proven relationship in view of the fact that these changes are equally prevalent in people without neck pain (Friedenberg 1963).

This is not to say that the degenerative levels are not related causally to the level of pain, and anecdotally they often are: ‘Absence of evidence is not evidence of absence.’

It has been shown that between 26% and 65% of patients with neck pain following an injury have at least one symptomatic facet joint in the cervical spine (Aprill 1992).

In a large study of 500 patients with chronic spine pain the prevalence of the facet joint being the origin of the pain was determined using comparative controlled local anaesthetic blocks, but which indicated that cervical facet joint pain had a prevalence of 55%.