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Whiplash Related Neck Pain

Taking a History
Patients with facet joint pain often present with neck pain, headaches, dizziness and a limited range of motion. The pain is dull and may radiate to the upper trapezius and medial scapula area. Neck pain can refer from the cervical facet joints into the arm in an extra segmental pattern of radiation. A more sharp shooting severe pain in a segmental distribution suggests a radicular origin of the pain.

Physical Findings
Examination in facetogenic pain often reveals a non-capsular pattern of movement limitation associated with local tenderness to palpation over the joints or segmental dysfunction/fixation. Paraspinal muscles are often tender and pain is especially prevalent on extension with combined rotation. In pure facetogenic pain there is an absence of neurological findings.

Referred patterns of pain have been mapped (Dwyer 1990):

  • C2/3 facet joints refer pain to the posterolateral upper cervical region and the head.
  • C3/4 facet joints refer pain to the posterolateral middle cervical region.
  • C4/5 facet joints refer pain to the posterolateral middle and lower cervical region and to the top of the shoulder.
  • C5/6 facet joints refer pain to the posterolateral middle and primarily lower cervical spine and the top and the lateral parts of the shoulder and more caudally the spine of the scapula.
  • C6/7 facet joints refer pain to the top lateral parts of the shoulder which extends to the infraspinous and medial aspect of the scapula.

These pain maps have been shown to be a powerful diagnostic tool when evaluating patients with cervical pain (Aprill 1990). Pain patterns for the occipito-atlantal joints were variable and extended from the top of the skull to the C5 level. Pain patterns for the atlanto-axial joints were located posterolateral to the C1/2 segmental region (Dreyfuss 1994, Star 1992). Blood tests are not routinely indicated in the diagnosis of cervical facet joint pain.  

Imaging
Radiographs are sometimes helpful, especially if combined with flexion extension views or fluoroscopic screening to rule out excessive translation at intervertebral levels. Horizontal movement of one vertebral body on the next should not be more than 3.5 millimetres and the angular displacement of one body on the next should be less than 11 degrees.

Acute Neck Pain
In the first instance, the object is to reduce pain and inflammation and increase the pain free range of motion. Cold or ice therapy is indicated in the acute stage to decrease blood flow and subsequent haemorrhage into injured tissues. This will result in a reduction of local oedema. Ice application may also reduce muscle spasm. Consequent use of ultrasound or other electrical stimulation may also reduce muscle spasm. Manual therapy, mobilisation and myofascial treatment along with stretching and exercises are also helpful. Passive range of motion treatments followed by active range of movement exercises should progress in a pain free range and finally strengthening and stabilisation using various techniques of dynamic stability, balance and kinetic control should be instigated.  

Surgery
Surgical intervention is only considered when either non-surgical treatment has failed or for severe injury grossly effecting stability and for subluxations/dislocation, etc.

Other Treatment Options
The object of this article is not to detail physical treatment and other manual approaches to neck pain but to outline options once these conservative measures have failed or have provided inadequate improvement.

Facet Joint Injections Under Fluoroscopic X-Ray Guidance
Some studies of intra-articular facet joint injections report only minor relief for days to weeks (Moran 1988, Barnsley 1994) while others report substantial relief for weeks to months (Dorey 1983, Fairbank 1981 and Roy 1988). Therefore it is evident that these procedures are worth trying in many situations since anecdotal reports also claim significant improvement with this approach.