Literature Review

Dr. Esmail continually reviews relevant Orthopaedic literature. The following literature may be of interest to you. Please scroll down to review the literature:

1.Pain Generation in Lumbar and Cervical Facet Joints
    John M. Cavanaugh, MD, Ying Lu, MS, Chaoyang Chen, MD and Srinivasu Kallakuri, MS
    The Journal of Bone and Joint Surgery (American). 2006;88:63-67.

This article demonstrates that, where a whiplash event is severe enough to injure the joint capsule, facet capsule overstretch is a possible cause of persistent neck pain. This is due to excessive capsule stretch, which activates nociceptors and leads to prolonged neural after discharges. This stretch can cause damage to the capsule, as well as to the axons in the capsule.

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2. Predictors of Persistent Neck Pain After Whiplash Injury
    K. Atherton, N J Wiles, F E Lecky, S J Hawes, A J Silman, G J Macfarlane, and G T Jones
    Emergency Medicine Journal. 2006;23:195-201.

Psychological distress and aspects of pre-collision health are the greatest attributes towards persistent neck pain following a motor vehicle accident – not usually the collision itself.

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3. The Effect of Pre-injury Physical Fitness on the Initial Severity and Recovery from Whiplash Injury, at Six-month Follow-
    Mark Geldman, Ann Moore, Liz Cheek
    Clinical Rehabilitation. 2008;22(4):364-376.

Medium to high-levels of pre-injury physical fitness can aid in early recovery from whiplash injury over low-levels of pre-injury physical fitness.

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4. Mechanical Initiation of Intervertebral Disc Degeneration
     Michael A. Adams, PhD, Brian J. C. Freeman, FRCS, Helen P. Morrison, MBChB, Ian W. Nelson, FRCS, and Patricia Dolan, PhD
     Spine. 2000;25(13):1625-1636.

This article outlines how minor damage to a vertebral body end-plate leads to structural changes in the adjacent intervertebral discs.

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5. The Incidence of Whiplash Trauma and the Effects of Different Factors on Recovery
     Ylva Sterner, Goran Toolanen, Bjorn Gerdle and Christer Hildingsson
     Journal of Spinal Disorders & Techniques. 2003;16(2):195-199.

From a prospective study of patients, this article concluded that poor prognosis of whiplash trauma to the cervical spine can be significantly associated with the following factors: pre-traumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2-3.

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6. Widespread Pain Following Whiplash-associated Disorders: Incidence, Course, and Risk Factors
     Lena W. Holm, Linda J Carroll, J David Cassidy, Eva Skillgate and Anders Ahlbom
     Journal of Rheumatology. 2007;34(1):193-200.

This study showed that widespread pain occurred early after a motor vehicle collision. Continuous widespread pain following the incident was rare. People with whiplash-associated disorder who also reported early depressive symptoms with more severe neck injury symptoms were more likely to develop widespread pain following a motor vehicle collision.

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7. Relationship Between Symptoms and Psychological Factors Five Years after Whiplash Injury
     BM Stalnacke
     Journal or Rehabilitation Medicine. 2009;41(5):353-359.

Assessing possible relationships between symptoms, depression and post-traumatic stress in persons with long-term problems after whiplash injury is important. The treatment of these symptoms, especially depression, should be stressed. Social support in relationships should also be examined.

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8. Work Disability after Whiplash: a Prospective Cohort Study
     Buitenhuis, J MD; de Jong, Peter PhD; Jaspers, Jan P.C. PhD; Groothoff, Johan W. MSc, PhD
     Spine. 2009;34(3):262-267.

Long-lasting work disability can be attributed to independent factors such as age and concentration complaints. No evidence indicated that manual labour or education level was involved in persistent work disability in post-whiplash syndrome.

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9. Long-Term Outcome after Whiplash Injury: a 2-year Follow-up Considering Features of Injury Mechanism and Somatic, Radiologic, and Psychosocial Findings
     Radanov, Bogdan P. MD, Sturzenegger, Mathias MD, Di Stefano, Giuseppe MA>
     Medicine. 1995;74(5):281-297

During this study, the following patients suffered from persistent injury related symptoms:
- 51 patients after 3 months
- 36 patients after 6 months
- 28 patients after 12 months
- 21 patients after 2 years

These symptomatic patients were significantly older, but there were no differences regarding gender, vocation, or subjective initial crash assessment.

Symptomatic patients reported more rotated or inclined head position at the time of collision, and also were more concerned about the possibility of long term symptoms. They also had a greater variety of subjective complaints at the initial examination, such as the prevalence of a pretraumatic headache. Initial pain ratings for headache and neck pain were higher, but initial symptom onset was shorter.

These patients also reported more symptoms of radicular deficit as well as more signs of preexisting cervical spine osteoarthrosis. There were no group differences regarding psychosocial stress or other psychological variables. The symptomatic group, however, performed worse on tests requiring a more complex level of attentional processing.

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10. Rehabilitation of Chronic Whiplash: Treatment of Cervical Dysfunctions or Chronic Pain Syndrome?
     Jo Nijs, Jessica Van Oosterwijck, Willem De Hertogh
     Clinical Rheumatology. 2009;28:243-251

In chronic WAD, there is a lack of objective signs of injury; this calls for an assessment of cervical dysfunctions such as joint mobility, functional stability, cervical proprioception and increased muscle tone.

Reduced neck mobility is not characteristic of chronic WAD and is unable to explain the complexity of the syndrome.

In patients with chronic WAD, a multi-modal physiotherapy program consisting of specific stabilization exercises, low-velocity mobilizing techniques and ergonomic advice was proven to be superior over a self-management program.

Feelings of helplessness, rumination and magnification concerning pain are associated with heightened pain and disability of people with chronic WAD. Psychological factors such as depression, anxiety, distress and expectations for recover are also important factors. Coping strategies such as diverting attention and increasing activity have been shown to aid in these situations.

A coping mechanism includes a 10-week psychosocial intervention program that aims to minimize psychosocial barriers to rehabilitation. This includes graded activity.

Pain psychology education was effective in reducing pain catastrophizing in those with chronic low back pain. A 4-week program with exercise to change pain cognitions and strategies resulted in a positive outcome for patients with chronic WAD.
Table 2
Hypertonic muscles/fascia and trigger points may sustain the process of central sensitization and should therefore be treated.
Treatment of hypertonic muscles/fascia should be performed below pain threshold.
Retrain proprioception and movement control of the craniocervical region to prevent/treat sensorimotor incongruence.
Address cognitive-emotional sensitization by using the progressive goal attainment program or by using intensive pain neurophysiology education.
Be careful with time-contingent exercise or activity interventions.
Use a flexible and gentle way of performing specific (e.g. cervical motor control training) and general (aerobic) exercise or graded activity interventions where the client is instructed to adopt exercise intensity and duration to stay below pain threshold.

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11. Head Position & Impact Direction in Whiplash Injuries: Associations with MRI-Verified Lesions of Ligaments and Membranes in the Upper Cervical Spine
     Bertel Rune Kaale, Jostein Krakenes, Grethe Albrektsen, Knut Webster
     Journal of Neurotrauma 2005;22(11):1294-1302

MRI abnormalities of the alar and transverse ligaments and the tectorial and posterior atlanto-occipital membranes (graded 0-3) were examined. For all neck structures, whiplash patients had more high-grade lesions (grade 2 or 3) than the control persons. An abnormal alar ligament was most common. The whiplash patients that had been sitting with their head or neck turned to one side at the moment of collision often had high-grade lesions of the alar and transverse ligaments. Severe injuries in these ligaments were more common in front versus rear end collisions. The difference in MRI-verified lesions of WAD patients vs control persons indicate that these lesions were caused by whiplash trauma.

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12. The Behavioural Response to Whiplash Injury
     Martin Gargan, Gordon Bannister, Chris Main, Sally Hollis
     J Bone J Surg [Br]. 1997;79-B:523-6

This article featured 50 consecutive patients who had encountered rear-end vehicle collisions. Their symptoms and psychological test scores were recorded at 1 week, 3 months and 2 years after injury. Psychological test scores were normal in 82% of the group within 1 week, but became abnormal in 81% of patients with intrusive or disabling symptoms at over 3 months. At 2 years, this remained abnormal in 69% of patients. Clinical outcome at 2 years could be predicted at 3 months by neck stiffness (76% accuracy), psychological score (74% accuracy) and by a combination (82% accuracy). Symptoms which are established after two years tend to persist over time. A final state of recovery was generally reached by patients within three months of injury.

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13. MRI of the Tectorial and Posterior Atlanto-Occipital Membranes in the Late Stage of Whiplash Injury
     J. Krakenes, B. R. Kaale, G. Moen, H. Nordli, N. E. Gilhus, J. Rorvik
     Neuroradiology. 2003;45:585-591.

This study strongly indicates that whiplash trauma can damage the tectorial and posterior atlanto-occipital membranes. Sectioning of the anterior or posterior atlanto-occipital membrane alone did not make the neck unstable. Incision of the tectorial membrane was accompanied by translation in flexion. When all three membranes were incised, gross instability was observed, especially in the flexion. Cervical MRI protocols with 3-5 mm thick slices are inadequate to demonstrate such membrane lesions. Sections 2 mm thick gave adequate spatial resolution with fairly good signal-to-noise. The tectorial membrane plays a substantial role in maintaining stability in the craniovertebral junction, especially by limiting flexion. However, complete absence of the membrane, with normal or partially ruptured dura mater, was never found in the control group and we therefore regarded it as trauma-induced.

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14. Anatomical and Roentgenographic Features of Atlanto-Occipital Instability
     Mitchel B. Harris, Michael J. Duval, John A. Davis, and Philip M. Bernini
     Journal of Spinal Disorders. 1993:6(1):5-10.

The stabilizing role of the tectorial membrane in flexion was demonstrated by the gross anatomical and roentgenographic examinations. The first group of ligaments is the atlantooccipital ligaments. These are divided into the anterior atlantooccipital ligament and the posterior atlantooccipital ligament. The second group of ligaments is the occipital-axial ligaments, including the tectorial membrane, the alar ligaments and the apical ligament. The tectorial membrane is a continuation of the posterior longitudinal ligament and runs from the dorsal superior portion of the dens to the ventral surface of the foramen magnum. The alar and apical ligaments similarly take origin from the superior aspect of the dens, with the alar ligaments running to their respective occipital condyles and the apical ligament running into a confluence at the ventral surface of the foramen magnum. The alar ligaments consist of 2 portions - the atlantoalar and the occipitoalar. The occipitoalar portion forms the connection between the sides of the dens and the occipital condyles. The atlantoalar portion forms the connection between the dens and the lateral masses of the atlas. The alar ligaments are the main restraint against axial rotation in the occipito-atlantoaxial complex. Werne first demonstrated anatomically and Fielding later verified with dynamic radiographic studies, that any measurable (anteroposterior) sagittal translation of the skull on the atlas is abnormal and therefore indicative of instability.

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15. The Ability of a Computed Tomography to Identify a Painful Zygapophysial Joint in Patients with Chronic Low Back Pain
     Anthony C. Schwarzer, Shih-chang Wang, Diarmuid O'Driscoll, Timothy Harrington, Nikolai Bogduk, Rodger Laurent
     Spine. 1995;20(8):907-912.

This article demonstrates that computed tomography has no place in the diagnosis of lumbar zygapophysial joint pain. Currently, the only valid means by which zygapophysial joint pain may be diagnosed is by injection of local anesthetic agents either into the joint or onto the nerves that supply the joint. There is no demonstrable relationship between the degree of osteoarthritic change seen on CT and the presence or absence of zygapophysial joint pain.

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16. The Rate of Recovery following Whiplash Injury
     M.F. Gargan and G.C. Bannister
     Eur Spine J. 1994;3:162-164.

50 patients with soft tissue neck injuries following rear end collisions were assessed for their rate of recovery. Patients were seen within 5 days of accident, at 3 months, 1 year and 2 years. Symptoms were classified into asymptomatic, nuisance, intrusive and disabling. 93% of patients who were asymptomatic at 3 months remained asymptomatic at 2 years. 86% of symptomatic patients remained symptomatic after 2 years. 52% believed they had recovered after 1 year, but symptoms for several returned after 2 years. Those who improved after 3 months or a year generally deteriorated to their previous status. For asymptomatic cases, a prognosis that is 93% accurate after 2 years can be given at 3 months. 86% of patients who are symptomatic after 3 months will remain so after 2 years. The severity of symptoms may vary. The doctor, faced with the task of giving a prognosis after whiplash injury, may do so with relative confidence in asymptomatic patients after 3 months, but will be wiser to wait until 2 years have elapsed before grading the long-term severity of the injury.

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17. Long-term Prognosis of Soft-tissue Injuries of the Neck
     M.F. Gargan and G.C. Bannister
     J Bone Joint Surg [Br]. 1990;72-B:901-903.

43 patients were reviewed, sustaining soft-tissue injuries of the neck after a mean of 10.8 years. Patients were divided into Group A: free of discomfort and considered themselves recovered, Group B: mild symptoms that did not interfere with work or leisure, Group C: intrusive symptoms requiring relief of analgesia, orthoses or physiotherapy and Group D: severe problems relying heavily on orthoses, and analgesics. Symptoms do not resolve even after a mean of 10 years - only 12% of patients recovered completely.

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18. The Prognosis of Neck Injuries Resulting from Rear-end Vehicle Collisions
     S.H. Norris and I. Watt
     Journal of Bone & Joint Surgery. 1983;65-B:608-611.

In clinical practice it is important to determine which factors are likely to affect prognosis adversely. In acute trauma, the energy of the impact would seem important. However, accurate estimation of the speed of impact was not possible. Also, wearing a seat belt has also been thought to be partly responsible for injuries to the neck, but no clear trend emerged from this. Head restraints also do not seem to produce more or less severe injuries. Assessment of the clinical status of the patient at presentation showed that patients with objective neurological signs clearly had a poorer prognosis than patients without such signs. Pre-existing degenerative changes in the cervical spine do not appear to affect the prognosis adversely. Abnormal curves in the cervical spine, presumably reflecting spasm of the neck muscles, are more common in patients with a poor outcome.

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19. Soft-Tissue Injuries of the Neck in Automobile Accidents
     Mason Hohl and Beverly Hills
     Journal of Bone & Joint Surgery. 1974; 56-A(8): 1675-1682.

5+ years following automobile accidents with patients sustaining soft-tissue injuries of the neck, symptoms occurred even with no pre-existing cervical degeneration. These included: numbness/pain in upper extremity, sharp reversal of the cervical lordosis visible on roentgenograms, restricted motion at one interspace as shown by flexion-extension roentogenograms, need for cervical collar, home traction, and physical therapy. Symptomatic recover occurred in 57% of patients, while degenerative changes developed after injury in 39%. A sharp reversal of the curve after injury, however, is a harbinger of degenerative changes in 60% of patients.

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20. Chronic Cervical Zygapophysial Joint Pain After Whiplash: A Placebo-Controlled Prevalence Study
     Susan M. Lord, Les Barnsley, Barbara J. Wallis, Nikolai Bogduk
     Spine. 1996; 21(15): 1737-1744.

Among patients with dominant headache, comparative blocks revealed the prevalence of C2-C3 zygapophysial joint point was 50%. Among those without C2-C3 zygapophysial joint pain, placebo-controlled blocks revealed the prevalence of lower cervical zygapophysial joint pain to be 49%. Overall, the prevalence of cervical zygapophysial joint point (C2-C3 or below) was 60%.

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21. Third occipital nerve headache: a prevalence study
     Susan M. Lord, Les Barnsley, Barbara J. Wallis, Nikolai Bogduk
     Journal of Neurology, Neurosurgery and Psychiatry. 1994;57:1187-1190.

The prevalence of third occipital nerve headache among all 100 whiplash patients was 27% and among those with dominant headache the prevalence was as high as 53%. There were no distinguishing features on history or examination that enabled a definitive diagnosis to be made before the nerve blocks. Third occipital nerve headache is a common condition in patients with chronic neck pain and headache after whiplash. Third occipital nerve blocks are essential to make this diagnosis.

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22. Symptoms and Signs of Irritation of the Brachia Plexus in Whiplash Injuries
     M. Ide, J. Ide, M. Yamaga, K. Takagi
     Journal of Bone & Joint Surgery. 2001;83-B:226-229.

Symptoms and signs attributable to stretching of the brachial plexus do occur in a significant proportion of patients after a whiplash injury. Their presence and persistence are associated with a poor outcome. The following criteria determined a diagnosis of irritation of the brachial plexus:
1) Persistent diffuse pain or paraesthesiae in the upper limb aggravated by carrying, lifting, overhead elevation or repetitive use of the arm.
2) A positive Tinel sign over the brachial plexus at the scalene muscles or supraclavicular fossa.
3) Reproduction of pain or paraesthesiae by maneuvers stressing the brachial plexus with the shoulder at 90 degrees of abduction in external rotation, or wit ha traction maneuver.

40% of patients have persistent discomfort and 10% are unable to return to work. Symptoms include neck pain, headache, nausea, dizziness, discomfort in the eyes, feeling unwell, tinnitus and sleeplessness. Most had neck pain, headache, and nausea. Other signs included a decreased range of movement of the neck, paraesthesiae in the upper arm, forearm and/or hand weakness, coldness, discoloration and hyperhydrosis in the upper limb, swelling, a positive Tinel sign over the scalene muscles or in the supraclavicular fossa, the cubital tunnel, the radial nerve at the elbow and/or the carpal tunnel, and discomfort with shoulders in 90 degrees of abduction and external rotation or in similar maneuvers causing traction to the brachial plexus.

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23. Computational Studies of 'Whiplash' Injuries
     C. R. Gentle, W. Z. Golinski and F. Heitplatz
     Proc Instn Mech Engrs. 2000;215-H:181-189

Based on a review of literature, Penning developed the theory that in whiplash, the primary mechanism of injury is not hyperextension, but hypertranslation of the head backwards relative to the body, i.e. in a rear-end collision the head effectively remains still while the trunk accelerates forward. The head's inertia is taken to lead to a situation of high shear in the top of the neck, causing overstretching of not only the ligaments but also the joint capsule between vertebrae. The familiar indications of whiplash injury, chronic disturbance of posture and equilibrium, are them explained by chronic ligamentous instability of the upper posterior cervical spine due to hyperflexion, coupled with some damage to the lower anterior cervical spine due to hypertension.

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24. The Neck Disability Index: State of the Art, 1991-2008
     Howard Vernon
     Journal of Manipulative & Physiological Therapeutics. 2008;31(7):491-502.

The NDI is a relatively short, paper-pencil instrument that is easy to apply in both clinical and research settings. It has strong psychometric characteristics and has proven to be highly responsive in clinical trials. The NDI is the most widely used and strongly validated instrument for assessing self-rated disability in patients with neck pain.

25. Biomechanical Consequences of a Tear of the Posterior Root of the Medial Meniscus
     Robert Allaire, Muturi Muriuki, Lars Gilbertson and Christopher D. Harner
     J Bone Joint Surg Am. 2008;80:1922-31.

This study demonstrated significant changes in contact pressure and knee joint kinematics due to a posterior root tear of the medial meniscus. Root repair was successful in restoring joint biomechanics to within normal conditions.

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26. The Long Term Outcome of Open Total and Partial Meniscectomy Related to the Quantity and Site of the Meniscus Removed
     A. Hede, E. Larsen and H. Sandberg
     International Orthopaedics. 1992;16:122-125.

200 patients were randomly selected for either a partial or total meniscectomy for a meniscal tear during open operation. They were followed for a median of 7.8 years after the operation. After partial meniscectomy, posterior horn tears had the worst outcome, but this was only apparent when more than 2/3 of the meniscus had been removed. Preservation of the peripheral rim of the meniscus following partial meniscectomy produces the best functional results.

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27. Mechanical Changes in the Knee after Meniscectomy
     William R. Krause, Malcolm H. Pope, Robert J. Johnson, David G. Wilder
     Journal of Bone & Joint Surgery. 1976;58-A(5):599-604.

The menisci perform a load-transmitting and energy-absorbing function in the knee joint. The stress acting across the joint increased significantly after meniscectomy.

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