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Department of Pain Medicine - Roermond September 27, 2010

This information is intended for people who suffer from:

Chronic neck pain - Pain derived from the cervical vertebrae 
This group includes:
- cervicobrachialgia (neck- and shoulder pain)
- cervicogenic headache (headache eminating from the cervical vertebrae)
- post-whiplash syndrome

Pain eminating from the cervical vertebral column is quite common. As a pain condition, it is surpassed in prevalence, only by chronic low back pain. As with most chronic pain conditions, the treatment can approached from different angles: medically, supportively (physical therapy/TENS)
, invasively (techniques involving needles), or by means of rehabilitation and/or behavioral therapy. With cervicobrachialgia, the pain is derivedfrom the lower part of the neck while with cervicogenic headache the upper part of the neck is involved. With whiplash syndrome, there are usually no visible signs on X-rays but the symtoms ar very much like the other two syndromes, though often more persistent. 

Cervicobrachialgia (neck/schoulderpain) 

This term is used to descibe a complex of symptoms that include neck pain with irradiation to one or both shouldersand beyond, with pain often extending as far as the fingers. In many cases, there is no specific cause for the pain other than degeneration or arthrosis ov the vertebral column. If the pain is limited to one specific cervical spinal nerve, the pssibility of a niated disc should be considered. Only in rare cases, the pain is caused by a tumor or infectious process. Traditionally we tend to look on pain as "merely a sypmtom"  of an underlying disease, however, pain specialists condider pain to be a disease in its own right. Especially since we usually cannot find a specific cause, ane even when we can we cannot always treat the cause. Moreover the treatment of the cause may involve a surgical intervention. This is not always feasible or desirable. What's left may be termed symptomatic treatment.

Typical features of cervicobrachialgia, include pain that is provoked by movement, such as bending forward or backward and ratation of the head. These movements may case irradiating pain to the shoulders and/or arms. Rotation case pain on either side. People who wuffer from this are likely to have pain when working above shoulder level or carrying weight.

Before initiating symptomatic treatment, there are a number of diagnostic considerations to be teken into account::
• There should be a recent X-ray of the cervical spine, preferably including specific studies to detect instability (photos taken in extension and flexion)
• Physical examination of the shoulder joint. If there is reason to believe that there ar abnormalities of the shoulder joint, referral to an orthopedic surgeon should be considered.
• Consultation by a neurologist should be considered if thare is reason to believe that a herniated disc may be involved. is would require an MRI or a CT-scan.

Examples of symptomatic treatment include:
1. prescribing analgesic drugs
2. physical therapy including drugs that are use for neuropathic pain
3. invasive pain treatment
      - cervical facet joint block by means of readiofrequency lesioning
      - pulsed radiofrequency lesiong of the dorsal root ganglion
      - epidural corticosteroid injections (through the translaminar approach)

cervicogenic headache

Headache is commonplace and is among the top ten health complaints. In some cases, patients have only occasional headaches while in others the headache is continuous. In about 10% of all headaches, find their origin in the neck vertebrae. This type of headache is called cervicogenic headache.

photo of a
facet nerveblock in the neck region

The features of cervicogenic headache are:

  • The pain is often provoked by certain movements, particularly extension and rotation of the neck. These movements sometimes have a limited range of motion.
  • The pain radiates from the neck to the back of the head and from there to the forehead.
  • The classic form is one-sided, but can also be bilateral.
  • The pain is sometimes difficult to distinguish from migraine. The two diagnoses are not mutually exclusive.

photo of an translaminar cervical epidural injection

When a patient has frequent or almost continuous headache for a periods of moere than three months, his headache is considered to be chronic. Chronic headache can be very debilitating, making many daily activities difficult or impossible to perform. Headache experts divide headaches into different categories. Thes can be seen in a separate appendix to this webpage.

whiplash associated disorder

Like the aforementioned pain syndromes, WIP finds in origin in the cervical spine. However, the p[ain is caused not by degeneration of the spine, but is initiated by a trauma. The most common trauma is a sudden extention of the neck such as can be expected when sitting in an automobile and getting hit from behind.Other forms of violence may also initiate this sydrome, such as falling over backward or getting into a head grip. The twisting motion may lead to one/sided symptoms, but with most patients the pain is bilateral. The results of such a villent impact can vary from mild pain over a period of several days, to severe lifelong pain and inability to lead a normal life.

The dagnosis `whiplash` is made based on the following:
1. There must be a clear trauma
2. The trauma must be of such a nature, that it is likely to have had an impact on the cervical spine.
3. The pain symptoms must start within 48 hours of the trauma and there were no symptoms prior to the trauma, are if there were any, they should have been much less severe.
4. The pain must be present in the neck or emanate from the neck.
5. The pain is aggravated by movement of the neck, by tension or by remaining in one position for a prolonged period (reading watching TV or sitting at a computer).
6. Short term memory and ability to concentrate may be impaired.
7. Physical findings and anatomical defects are often lacking.
8. An X-ray of the cervical spine should be taken, preferably with additional lateral projections with the neck in extension and flexion. Generally there are either no abnormal findings, or if there are any, they are likely to be pre-existent.

Treatment of post-whiplash syndrome (whiplash-associated disorder) is similar toe that of cervicobrachialgia. Psychological and social factors require additional attention, since these often play a part in pain behavior and may even be prominent. Medical treatment includes the classic painkillers, but drugs used for treating neuropathic pain should be considered because the pain is often amplified by central nervous system hyperexcitability. Physical therapy may be helpful, for example TENS . Invasive treatmenst include: radiofrequency treatment of the facet joints, pulsed radiofrequency treatment of the dorsal root ganglion and epidural corticosteroid injections adhesiolysis).

When looking at a patient whose symptoms have only recently developed, the prognosis is favorable. 80% of the patients who develop symptoms, will find that the symptoms remit within a year. The remaining 20% can be problematic. The Quebec Task Force has develop a scale of severity for patients with post whiplash syndroom.

Grade 1: complaints of pain, tenderness  and stifness of the neck, without physical abnormalities or limitations.

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