Whiplash

If you have ever been in a car crash and experienced pain in your neck, you have most likely had whiplash. Whiplash, also called neck sprain/strain, is an injury to the structures of the neck. This type of injury is often the result of rear-end car crashes (similar injuries may occur with side impact or front-end collisions). Whiplash can include injury to the intervertebral joints, discs, ligaments, cervical muscles and nerve roots. The most common structure injured in whiplash, the cervical facet joint (medically termed zygapophysial joint), is treatable with radiofrequency ablation procedures.

Each year, over 2 million North Americans are injured and suffer from whiplash. Whiplash can be caused by:

  • A motor vehicle accident. The most frequent cause of whiplash is a motor vehicle accident (MVA). The speed of the cars involved in the accident or the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as 8 miles per hour can produce enough energy to cause whiplash in occupants.
  • A sports injury
  • A fall
  • Being struck by a falling object
  • An assault

Whiplash, although not technically a medical term, is very real and can be very painful. We call it whiplash because, in an accident, your neck really can whip back and forth—first backward (hyperextension) and then forward (hyperflexion). In reality, the specific biomechanics of this injury are far more complex than this, but these details are beyond the scope of this discussion.

The key symptom of whiplash is neck or upper back pain. If you have whiplash you might feel:

  • Neck pain
  • Shoulder pain
  • Upper back pain
  • Tightness or spasms of the neck or upper back muscles
  • Burning or tingling

You may also experience other symptoms, such as:

  • Numbness and/or tingling
  • Headaches
  • Dizziness
  • Nausea
  • Blurred vision
  • Ringing in the ears or blurred vision
  • Difficulty concentrating or remembering
  • Irritability, sleep disturbances, fatigue

The pain can start immediately, or it can develop days, weeks, and sometimes even months after the accident. Some people only have a little pain, but some experience a lot. Traditionally, it was believed that most people with whiplash recover fully. We now know that a significant number of whiplash injuries fail to improve without further intervention

Anatomy of Whiplash

Cervical Spine Anatomy

The neck region of the spine is known as the Cervical Spine. This region consists of seven vertebrae, which are abbreviated C1 through C7 (top to bottom). These vertebrae protect the brain stem and the spinal cord, support the skull, and allow for a wide range of head movement. The first cervical vertebra (C1) is called the Atlas. The Atlas is ring-shaped and it supports the skull. C2 is called the Axis. It is circular in shape with a blunt peg-like structure (called the Odontoid Process or “dens”) that projects upward into the ring of the Atlas. Together, the Atlas and Axis enable the head to rotate and turn. The other cervical vertebrae (C3 through C7) are shaped like boxes with small spinous processes (finger-like projections) that extend from the back of the vertebrae

In a whiplash injury, it is possible to injure the joints, the discs, the vertebrae (bones), the ligaments, the nerve roots, and even the spinal cord itself. However, in 80 % of patients, the source of pain can be isolated to one of three main structures:

  • Joints (~55%)
    • C2-3 to C7-T1 facet joints (A.K.A. “z-joints” or “zygapophysial joints”)
    • C1-2 joint (A.K.A. “lateral atlanto-axial joint”)
  • Discs (~20%)
  • Nerve roots (~5%)

Diagnosis

It is critical to understand one major concept: it is very difficult for your physician to be 100% certain which particular structure in your cervical spine is injured, from the clinical assessment alone. To make an accurate diagnosis, your doctor will need to use a combination of tools and sophisticated technology. After reviewing your x-rays and MRI, listening to your history and performing a proper physical exam, your physician may form a strong suspicion that you are suffering from a specific spine pain disorder.

  • Joints: If your physician suspects that your neck pain is emanating from the joints in your neck, he may perform a diagnostic injection series to confirm the diagnosis. Under live x-ray guidance, local anesthetic is precisely injected to block the nerves that give sensation to the joint in question (medial branch block). If this provides complete or near complete relief of your neck pain, it is likely that the joint is the culprit. However, the block must be repeated a few days or a week later to make sure the original block was not afalse-positive result (“placebo effect”). Believe it or not the rate of false-positives is close to 40%!
  • Discs (~20%): In some cases you may be recommended for a test called a discography to confirm the diagnosis. This test involves injecting contrast dye into the affected disc (or discs) to create a clearer image. Because this diagnostic procedure can be uncomfortable, it is only performed to confirm your diagnosis prior to undergoing more invasive treatments such as surgery.
  • Nerve roots (~5%): Diagnostic Selective Nerve Root Block. A diagnostic selective nerve root block (SNRB) is purely diagnostic in nature (not a treatment) and is performed to confirm a diagnosis. Under live x-ray guidance, local anesthetic is precisely injected to block the nerve root that is thought to be irritated/compressed.

Treatment

Treatment for Joints

Radiofrequency neurotomy. The standard of care is a radiofrequency neurotomy. Facet neurotomy is a procedure which results in interruption of the nerve supply to a facet joint. This interruption known as denervation, is accomplished by a radio-frequency probe that heats the 2 small nerve branches to each facet joint.

Intra-articular steroid injection. There are a definite percentage of patients who suffer from joint pain that will respond the instillation of corticosteroids into the affected joint(s). This is a quick, safe procedure that is easy to tolerate. However it is typically only recommended in select patients because the results from this procedure do not measure up to those of radiofrequency neurotomy

Treatment for Discs

See degenerative disc disease.

Treatment for Nerve Roots

  • Medications
    • Anti-inflammatory medications help reduce swelling and pain
    • Narcotic painkillers are prescribed to alleviate acute pain (only if absolutely necessary)
  • Physical therapy. An exercise prescription tailored to your condition is provided to your physical therapist. A typical prescription involves:
    • Stretching exercises
    • Strengthening exercises
    • Scapular (shoulder blade) stability training. The shoulder girdle provides a platform or base for your cervical spine. Proper rehabilitation starts with a good foundation.
  • A therapeutic selective nerve root block (SNRB) series. This is otherwise known as a transforaminal epidural steroid injection (TFESI).
    • Many patients will benefit form a type of pinpoint epidural injection, under live x-ray guidance, of a strong anti-inflammatory medication (corticosteroid).
    • Maximum benefit typically occurs following 1 to 3 injections