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Whiplash Related Neck Pain

Discogenic Pain
In 1993, Bogduk demonstrated that 41% of patients had a painful disc and facet joint at the same segment and an additional 23% had a painful facet joint but not a painful disc at the same segment. This demonstrates that the disc and facet joint are the most likely structures to be injured in whiplash and other injuries. Along with other studies, the apparent prevalence of facet joint pain after whiplash is 54%, making the facet/zygapopohyseal joint the most common cause of chronic pain after whiplash injury in the various populations that have been studied (Bogduk, 1993, Barnsley 1995).

The most common levels involved seem to be C2/3 and C5/6 (Lord 1996).

Clinical Anatomy
The cervical spine consists of seven vertebrae which provide mobility and stability to the head. The atlas articulates with the occiput superiorly and inferiorly with the axis at C2. The atlas does not have a body but the body has become part of C2 and is called the dens or odontoid peg. The atlas has an anterior and posterior arch with two lateral masses and two transverse processes. The transverse processes enclose the vertebral artery which travels through a foramen. There are superior and inferior articular processes with uniquely shaped facets which articulate with the occiput and C2.

The axis has a large vertebral body which contains the dens which articulates with the anterior arch of the atlas and this is held in place by the transverse ligament. The axis is comprised of a vertebral body, pedicles, laminae and transverse processes and it has convex superior articular facets.  

The remaining vertebrae, C3 to C7 are similar to each other but different from C1 and C2. Their vertebral bodies are concave on the upper surface, convex on the inferior surface. On the superior surface the bodies are raised laterally into uncinate processes which articulate with areas on the inferior aspect of the vertebra above. These “uncovertebral” joints are known as the joints of Luschka. The spinous process of C3 to C5 are usually bifid compared to C6 and C7,  C7 being the more prominent vertebra (verebra prominens).

The cervical facet joints are synovial with fibrous capsules. They are more lax in the lower cervical spine, allowing for gliding. The joints are at an angle of 45 degrees from horizontal and 85 degrees from the sagittal plane. The fibrous facet joint capsules are innervated by mechanoreceptors and by free nerve endings (McLain 1994).

The facet joints are innervated by both the ventral and dorsal rami. The OA and AA joint are innervated by the ventral rami of the 1st and 2nd cervical spinal nerves. The dorsal ramus of the 3rd cervical nerve gives off two branches which innervate the C2/3 facet joint. The medial branch of the dorsal ramus is known as the 3rd occipital nerve and this is frequently targeted for radiofrequency ablation therapy after whiplash injury.  

The cervical facet joints from C3/4 to C7/T1 are supplied by the medial branches of the dorsal rami that arise one level higher, at the same level and one level below the joint. The medial branches divide into articular branches as they pass around the waist of the articular pillar.

The discs in the cervical spine have a nucleus pulposus, an annulus fibrosus and two end plates either side of the disc are attached to the vertebral bodies.

The annular fibres are prone to injury with rotational force because of the orientation of the lamellae (Bogduk 1991).

The middle and outer third of the annulus is innervated by noceceptors and there have been inflammatory mediators found in the disc which may be a cause of pain (Bogduk 1988, Mendel 1992, Franson 1992).

Several ligaments provide stability and proprioception (Panjabi 1991). The transverse ligament which is the main part of the cruciate ligament arises from tubercles on the atlas and stretches across its anterior ring to hold the dens against the anterior arch. There is a synovial cavity located between the dens and the transverse process, thus rotation of the atlas on the dens is possible. The transverse ligament is the most important ligament in prevention of anterior translation of the atlas on the axis (Fielding 1974).

The ALAR ligaments run from the lateral dens to medial occipital condyles and to the atlas. They limit axial rotation and side flexion. If they are damaged in whiplash injury the joint becomes hypermobile and this can lead to irritation of the vertebral arteries and may be responsible for some of the symptoms of whiplash syndrome such as headache, neck pain and dizziness.

The anterior longitudinal and posterior longitudinal ligaments, ALL and PLL are the major stabilisers of the intervertebral joints. The ALL is closely adhered to the discs anteriorly but the PLL is not well developed in the cervical spine. The PLL prevents excessive flexion and distraction (Panjabi 1993).

The supraspinous ligament, interspinous ligament and ligamentum flavum maintain stability between the vertebrae.The supraspinous ligament attaches the tips of the spinous processes to each other and the interspinous ligament runs between the mid portion of the spinous processes. The ligamentum flavum runs between the vertebral arches and controls flexion and anterior translation along with the interspinous ligament (Panjabi 1993 and White 1990).     

The ligamentum flavum also connects and reinforces the facet joint capsules on their anterior aspect. The ligamentum nuchae is a continuation of the supraspinous ligament and has a prominent role in the stabilising of cervical spine. Motion between C2 and C7 is determined by orientation of the facet joints, the discs and the joints of Lushka.

There is a coupling of rotational lateral flexion, for example when the vertebrae side bend to the left they also rotate to the left. This is significantly less in the lower segments due to the difference in facet orientation. Horizontal translation of the vertebral body at more than 3.5 millimetres measured on lateral radiographic fluoroscopic screening during flexion and extension is considered the upper limit of normal (White 1975).