Complications
All patients should be evaluated for vertebral artery dissection and disruption in posterior cranial circulation, as it can be caused by relatively minor trauma and can result in cerebrovascular accident. Cervical artery dissection is significantly related to prior cervical trauma.[48] Signs and symptoms include dizziness and balance difficulties.
Careful, thorough, and systematic evaluation of all patients presenting following any degree of cervical spine trauma is essential to prevent this catastrophic outcome.
Whiplash-injured patients who are most likely to develop chronic pain associated with central sensitisation of pain have been found to have prolonged pain after deep palpation of the trapezius and other musculature in the neck and upper back.[43] Anaesthetisation of the trigger points may give an indication of their contribution to the overall pain experienced by the patient.[10] In physiotherapy, simple advice has been found to be as effective as an intense exercise programme.[44]
Can include persistent pain for longer than 3 months, and/or spreading of symptoms into previously uninvolved body parts (lower back, hips, lower extremities), and/or persisting mood alteration, and/or sleep disturbance. Typically symptoms occur >3 months after the injury; however, symptoms of depression, difficulties sleeping, deconditioning, widespread pain symptoms indicative of central sensitisation and/or incipient fibromyalgia syndrome, and spreading pain may start 3 or 4 weeks after initial injury in some cases. Patients with persisting cervical axial pain after longer than 3 months that may be attributable to a disc derangement should initially undergo anteroposterior and lateral radiographs, and subsequently MRI of the cervical spine.[45] These patients may elect to try acupuncture, massage therapy, and other complementary and alternative medical therapies that may palliate symptoms.
All of these patients require further investigation to identify an anatomical pain generator, and they should be followed by a psychiatrist, especially if depression is a dominant component of their syndrome, to ensure the absence of suicidal ideations.
If headache persists for longer than 3 months, the patient should be evaluated by a pain specialist for greater occipital neuralgia, upper cervical facet (C2-3) derangement, or closed head injury. Management should include analgesia and consideration for occipital nerve block.
These symptoms most commonly involve the thoracic or lower back, upper extremity joints, and temporomandibular joint (TMJ). Persistent musculoskeletal injuries should be evaluated by an orthopaedic surgeon (upper or lower extremity) or by an oral surgeon (TMJ). If imaging is positive for a musculoskeletal injury (MRI evidence of, for example, TMJ injury, meniscus tear, or rotator cuff tear), then the neck injury is considered to have associated musculoskeletal injury. A specialist in that area should advise treatment. Rest and NSAIDs can be instituted while awaiting referral.
Symptoms include dizziness, easy distractibility, incoordination, or exaggerated emotional responses. Persistent head injury symptoms, particularly those including neurocognitive deficits, should be evaluated by a neuropsychologist. Persistent dizziness should be evaluated by an ENT specialist. Referral to a neuro-otology specialist is appropriate for persistent complaints, signs of vertigo, or imbalance.
Symptoms include progressive loss of muscle strength in the upper extremities and altered or decreased sensation. Referral to a neurologist is appropriate. If not already obtained, cervical spine imaging, including plain x-ray with anteroposterior, and lateral views and MRI, should be obtained. Possible extraspinal nerve entrapment should be considered, including thoracic outlet syndrome and carpal tunnel syndrome. EMG testing is indicated when such conditions are suspected. If imaging or other testing identifies a clear cause of the radiculopathy, then the injury is reconsidered to have a definitive pain origin.
If there is evidence of upper extremity neuropathy, including focal weakness or sensory loss, referral to a hand or upper extremity surgeon with expertise in brachial plexopathy is appropriate.
Signs of myelopathy include gait instability, hyper-reflexia, loss of bowel or bladder control, altered sensation in the upper and lower extremities, and muscle weakness in the upper or lower extremities. This patient group may also experience a cervical radiculopathy. MRI of the cervical spine is imperative to rule out any compressive force on the spinal cord.
Patients with persistent pain and a positive facet challenge test (reproduction of symptoms with ipsilateral cervical lateral flexion and extension) may respond to conservative treatments, but are more likely to require elective minimally invasive surgery or other surgical interventions, including cervical facet injection (cervical medial branch blocks and intra-articular injections), cervical branch radiofrequency ablation, epidural corticosteroid injection, disc decompression, or spinal stabilisation.[46][47] Rehabilitation with physiotherapy is typically carried out following such procedures.
Pain associated with ligamentous instability is often reported as worse with motion, typically in the mid- and lower cervical spine. On dynamic x-rays (flexion-extension views) it manifests as >3 mm anterior or posterior translation of the affected vertebra with respect to an adjacent one. In the upper cervical spine, ligamentous instability is most often found in the alar ligaments, as seen on MRI. Patients who have ligamentous instability on imaging and persistent symptoms should have a surgical evaluation to determine if spinal fusion is indicated.
The Medicines and Healthcare products Regulatory Agency (MHRA) in the UK advises that opioids should be used with caution as there is an increased risk of tolerance, dependence, and addiction, especially with prolonged use (longer than 3 months). The dose of opioid should be tapered slowly at the end of the treatment to minimise the risk of withdrawal reactions.[35]
If pain persists beyond the acute time frame (6 weeks to 3 months), referral to a specialised pain centre should be considered for detection of a pain generator and appropriate treatment. Pain generators may include spinal facet joints or disruption of the annular fibres of the cervical disc. Treatment is tailored to a block of the pain-generator spinal facet, weaning off opioid medications, or changing to non-opioid medications (such as amitriptyline).
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