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Upper Cervical Facet Injury Following Whiplash

The so-called whiplash injury is a common consequence of automobile accidents throughout the world.  Fortunately, most patients with neck pain following these accidents recover without treatment.  The goals of management are to determine if any dangerous fracture has occurred and to make the patient comfortable while recovery takes place.  Unfortunately, about 20% of patients who suffer these injuries do not improve with time.  The best available data states that most patients begin to recover within three months and virtually all patients who are going to improve will at least begin to recover within the first year.  When improvement does not take place, it is important to try to determine the cause or causes of the pain, so that appropriate treatment can be employed

A number of injuries of the cervical spine following automobile accident have been described.  Disc injuries can occur.  Many can be seen on MRI.  However, painful discs can develop without obvious acute injury.  Sometimes major ligaments of the spine are torn and these can be seen with imaging.  Tears in the ligaments which can be visualized include the posterior longitudinal ligament, the alar ligaments, the anterior longitudinal ligament, and the interspinous ligaments.  These are large structures and major injuries are usually obvious.  X-rays, CT, and MRI will usually demonstrate bony fractures and major disc or ligament injuries.  Other diseases, such as arthritis can also involve all of these neck structures and cause pain.  Trauma is the most common however.

Many patients with these complaints have muscular and ligamentous injuries, but these cannot be visualized.  Most of these improve with time.   It is the patients with undetected significant injuries who continue to complain.

There is another injury which is common and cannot be seen on any of the current imaging studies because the structures involved are too small to be resolved by the imaging studies.  Injury to the facet ligaments was described by Bogduk nearly 20 years ago.  He and several collaborators have studied these injuries in detail and determined how to accurately predict their occurrence.  The usual patient who has sustained one of these injuries has a typical clinical picture.  These patients usually have pain in the back of the neck at the base of the skull.  It is worsened by all kinds of movements and improved by rest and support.  The pain typically radiates up the back of the head and can go across the forehead, to the eye and laterally into the temple.  It can also radiate more laterally up the head involving the ear and the side of the head.  The injury is to the ligaments which bind upper cervical joints together.  These ligaments are too small to be visualized on any of our currently available imaging studies in routine use.    Therefore, their presence must be inferred by the clinical complaints and the results of diagnostic blocks.

Patients with these kinds of complaints post injury need to be studied in the usual way with history, physical examination, and complete imaging studies.  When the clinical symptoms fit with the upper injury as I have just described, then diagnostic blocks may determine the likelihood of a joint injury existing even when imaging fails to show them.  We anesthetize the nerves which supply pain fibers to the joints.  These are typically the C2-C3 nerves.  Anesthetizing the nerves C2 and C3 can provide confirmatory evidence when the blockade of the joints is successful to relieve pain temporarily.  Occasionally the injury has been to the joint which binds the skull to the spine (occiput – C1) or C1-C2.  If the lower blocks do not provide relief, then blockade of these upper areas will help define patients with injuries in these locations.

When the blocks are really effective in relieving pain for a short time it is possible to destroy the pain nerves coming from these joints with needle techniques using radiofrequency heat.  This is an outpatient procedure and can be effective more than half the time.  However, some patients will require surgical fusion to obtain relief.  The important thing is to make an accurate diagnosis, so that the best specific therapies for the residual pain can be employed.

Because of the long waiting period in which we hope for spontaneous recovery, most patients have had adequate trials of physical therapy with exercise, relief of muscle spasm, and relief of local pain.  If those measures have not been employed, they should always proceed any of these block procedures.  In addition, it is important that thorough imaging has eliminated the possibility of any injury which can be visualized.

The key issues here are the location of the pain in the upper neck and base of the skull and its radiation up over the skull to the forehead temple and around the ear.  This is such a typical set of symptoms that these complaints following trauma should always raise the possibility of facet injury.