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Whiplash Related Neck Pain

Medial Branch Blocks
The sensitivity of a single uncontrolled block has been estimated to be 95% and the specificity 73% (Barnsley 1993). It has been shown that local anaesthetic does not spread beyond the area of the medial branch (Barnsley 1993). This indicates that the block does not anaesthetise any other structures that may be a source of chronic cervical pain, other than the facet joint.

Cervical medial branch blocks are easier to perform than intra-articular blocks, the patient is often lying on the side with a lateral view obtained by fluoroscope. The needle is then introduced onto the middle of the articular pillar and the resulting effect is noted over the consequent four hours. The patient makes a physical record using a pain scale and when it has confirmed that a particular cervical facet joint pain has been obliterated by the medial branch blocks then this diagnostic technique can leave the physician to continue with a more permanent technique known as radiofrequency neurolysis.

Radiofrequency Neurolysis/Ablation
Radiofrequency neurolysis results in denervation of the facet joint by passing a radiofrequency current through the medial branch of the posterior primary ramus (dorsal ramus). This denatures the proteins in the nerve (Zervas 1972). There was also a heating effect produced by a vibration of ions. Afferent transmission of pain along the nerve to the dorsal root ganglion is obliterated. The nerve is not completely destroyed since the medial branch cell bodies in the dorsal root ganglion are not affected, so it has been noted that the nerve may grow back to its target joint in nine to twelve months depending upon the lesion site. This can result in a recurrence of the pain.

There is an option of repeating the medial branch radiofrequency neurolysis with equal effect and without any further side effects. The procedure is not performed bilaterally at multiple segments at the same time because of a risk of cervical muscular fatigue with daily activity (McDonald 1999). In a randomised double blind controlled trial radiofrequency neurolysis was assessed heating the nerve to 80 degrees C for 90 seconds and the patients in the treatment group took an average of 263 days before the pain returned to 50% of the pre-operative level, whereas the patients in the control group perceived this return of pain in just eight days (Lord 1996). In another study, complete relief of pain was reported in 71% of patients after the initial procedure. The total duration of pain relief was 422 days after the initial procedure and 219 days after the repeat procedure (McDonald 1999).  

Greater Occipital Nerve Radio Frequency Neurolysis
Radiofrequency can be used for intractable headache and occipital pain as a result of greater occipital neuralgia and which responds to greater occipital nerve blockade with local anaesthesia. These headaches are often referred to as tension headaches and are related to hypertonicity in the suboccipital musculature, pain refers from the occiput as far as the parietal area and often causes retro-orbital pain.  

Cervial Epidural Injections
Cervical epidurals can be of use in discogenic cervico brachialgia when an MRI has shown a disc protrusion and the clinical signs have demonstrated significant neurological deficit, dural tension and irritation. The most common levels involved are C5/6 and C6/7 resulting in C6 and C7 radiculopathy respectively.

Transforaminal Epidural
Cervical transforaminal epidural injections (nerve blocks) are sometimes carried out under X-ray guidance but there is reluctance on behalf of some pain clinicians to carry out these procedures in view of the higher incidence of intravascular or possibly intra-arterial injection which increases the risk of adverse reactions. Cervical epidurals tend to be the treatment of choice in these cases.

Blind Cervical Nerve Root Injections
There is a recognised technique of injecting onto the transverse process of C7 without X-ray control and this has been shown in small studies to be an effective method of controlling radicular pain from C7 radiculitis. This can be a very effective and safe approach for the acute cervico-brachialgia that exists when patients present with neck and arm pain and the inability to sleep due to the severity and intensity of the pain. These patients often have to sleep with their arm behind their head and often in a sitting position. This is catastrophic when it lasts more than a few days and patients are often desperate for a procedure to relieve their pain.

Prolotherapy
Prolotherapy is an injection of Glucose (12.5%), Glycerol and Phenol (1%) around the supporting capsular and supraspinous/interspinous ligaments under X-ray control on three separate occasions at weekly intervals. This procedure has been shown to thicken collagen fibres and may help to strengthen and stabilise the intervertebral segments (Hackett,Cyriax, Ongley, Dorman, Reeves etc). Prolotherapy is used frequently by musculoskeletal and some sports physicians in the lumbar spine but it can be of particular use in the cervical spine if mild instability or recurrent or chronic neck pain exists which is refractory to other treatments.

On the basis that neck ligament strength is decreased following whiplash type trauma (Tominaga et al and Panjabi), it seems logical that prolotherapy to thicken ligament tissue would be a rational approach in whiplash type injury. Prolotherapy was shown in a prospective case series on neck pain to reduce sagittal translation at the unstable level and to reduce pain.( Centeno, Elliot et al 2005).