Cervical radiofrequency neurotomy in patients with chronic whiplash: a study of multiple outcome measures

A 13-Year Long-Term Follow-Up of a Case Report With Continued Improvement in Severe Chronic Neck and Head Pain Alleviated With Chiropractic BioPhysics® Spinal Rehabilitation Protocols

Alleviation of headaches (HAs), neck pain (NP), and disability is a desirable clinical outcome for the billions globally who suffer from these conditions. Chiropractic BioPhysics® (CBP®) methods may provide an option for head and neck-injured patients. A 62-year-old female historically injured multiple times including two motor vehicle collisions (MVC), and a strike to the face with a hockey puck; all resulting in chronic pain and suffering. The subject sought and received successful treatment in 2016 using this conservative protocol at a facility in the USA. The resolution of symptoms following 36 treatments was previously reported. Following 13 years without treatment beyond home exercises, the subject was re-evaluated and found to be stable in the long term for pain, structural and functional assessment. Thirty-six treatments over 12 weeks in 2016 led to an improvement in numerical pain rating scale (NPRS) for NP (5/10 to 1/10), and HA (9+/10 to 0/10), resolution of NP disability (6/100 to 0/100) as well as normalization of ROM without pain and resumption of all activities of daily living including high-level athletics without pain and disability. A 13-year follow-up found continued stability objectively and subjectively. We provide a case of successful conservative treatment using specific traction, exercises, and spine manipulation procedures. CBP® provides an option to treat pain and this case adds to growing evidence.

Longitudinal Changes and Associations Between Quantitative Sensory Testing and Psychological Factors in Whiplash-Associated Disorders: A Systematic Review and Meta-Analyses-Based Data Synthesis

Whiplash-associated disorders (WAD) represent a multifactorial condition often accompanied by altered nociceptive processing and psychological factors. This systematic review on acute and chronic WAD aimed to investigate the relationship between quantitative sensory testing (QST) and psychological factors and quantify whether their trajectories over time follow a similar pattern to disability levels. Eight databases were searched until October 2022. When 2 prospective studies examined the same QST or psychological variable, data synthesis was performed with random-effects meta-analysis by pooling within-group standardized mean differences from baseline to 3-, 6-, and 12-month follow-ups. From 5,754 studies, 49 comprising 3,825 WAD participants were eligible for the review and 14 for the data synthesis. Altered nociceptive processing in acute and chronic WAD, alongside worse scores on psychological factors, were identified. However, correlations between QST and psychological factors were heterogeneous and inconsistent. Furthermore, disability levels, some QST measures, and psychological factors followed general positive improvement over time, although there were differences in magnitude and temporal changes. These results may indicate that altered psychological factors and increased local pain sensitivity could play an important role in both acute and chronic WAD, although this does not exclude the potential influence of factors not explored in this review. PERSPECTIVE: Acute WAD show improvements in levels of disability and psychological factors before significant improvements in nociceptive processing are evident. Facilitated nociceptive processing might not be as important as psychological factors in chronic WAD-related disability, which indicates that chronic and acute WAD should not be considered the same entity although there are similarities. Nonetheless, pressure pain thresholds in the neck might be the most appropriate measure to monitor WAD progression.

The Effectiveness of Cervical Medial Branch Thermal Radiofrequency Neurotomy Stratified by Selection Criteria: A Systematic Review of the Literature

Objective

To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria.

Design

Comprehensive systematic review.

Methods

A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.

Outcome Measures

The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief.

Results

Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used.

Conclusions

Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.

Tonic Investigation Concept of Cervico-vestibular Muscle Afferents

Introduction Interdisciplinary research has contributed greatly to an improved understanding of the vestibular system. To date, however, very little research has focused on the vestibular system's somatosensory afferents. To ensure the diagnostic quality of vestibular somatosensory afferent data, especially the extra cranial afferents, stimulation of the vestibular balance system has to be precluded.

Objective Sophisticated movements require intra- and extra cranial vestibular receptors. The study's objective is to evaluate an investigation concept for cervico-vestibular afferents with respect to clinical feasibility.

Methods A dedicated chair was constructed, permitting three-dimensional trunk excursions, during which the volunteer's head remains fixed. Whether or not a cervicotonic provocation nystagmus (c-PN) can be induced with static trunk excursion is to be evaluated and if this can be influenced by cervical monophasic transcutaneous electrical nerve stimulation (c-TENS) with a randomized test group. 3D-video-oculography (VOG) was used to record any change in cervico-ocular examination parameters. The occurring nystagmuses were evaluated visually due to the small caliber of nystagmus amplitudes in healthy volunteers.

Results The results demonstrate: no influence of placebo-controlled c-TENS on the spontaneous nystagmus; a significant increase of the vertical nystagmus on the 3D-trunk-excursion chair in static trunk flexion with cervical provocation in all young healthy volunteers (n = 49); and a significant difference between vertical and horizontal nystagmuses during static trunk excursion after placebo-controlled c-TENS, except for the horizontal nystagmus during trunk torsion.

Conclusion We hope this cervicotonic investigation concept on the 3D trunk-excursion chair will contribute to new diagnostic and therapeutic perspectives on cervical pathologies in vestibular head-to-trunk alignment.

A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 5 - surgical and injection-based interventions for chronic WAD

Whiplash-associated disorder (WAD) represents a significant public health problem, resulting in substantial social and economic costs throughout the industrialized world. While many treatments have been advocated for patients with WAD, scientific support regarding their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence associated with various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any well-defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (more than 12 weeks) WAD. The present article, the fifth in a five-part series, evaluates the evidence for surgical and injection-based interventions initiated during the chronic phase of WAD. Twenty-five studies were identified that met the inclusion criteria, six of which were randomized controlled trials with 'good' overall methodological quality (median Physiotherapy Evidence Database score of 7.5). For the treatment of chronic WAD, there was moderate evidence supporting radiofrequency neurotomy as an effective treatment for whiplash-related pain, although relief is not permanent. Sterile water injections have been demonstrated to be superior to saline injections; however, it is not clear whether this treatment is actually beneficial. There was evidence supporting a wide range of other interventions (eg, carpal tunnel decompression) with each of these evaluated by a single nonrandomized controlled trial. There is contradictory evidence regarding the effectiveness of botulinum toxin injections, and cervical discectomy and fusion. The evidence is not yet strong enough to establish the effectiveness of any of these treatments; of all the invasive interventions for chronic WAD, radiofrequency neurotomy appears to be supported by the strongest evidence. Further research is required to determine the efficacy and the role of invasive interventions in the treatment of chronic WAD.

Whiplash: diagnosis, treatment, and associated injuries

Study design Focused review of the current literature. Objective To identify and synthesize the most current data pertaining to the diagnosis and treatment of whiplash and whiplash-associated disorders (WAD), and to report on whiplash-related injuries. Methods A search of OVID Medline (1996–January 2007) and the Cochrane database of systematic reviews was performed using the keywords whiplash and WAD. Articles under subheadings for pathology, diagnosis, treatment, and epidemiology were chosen for review after identification by the authors. Results A total of 485 articles in the English language literature were identified. Thirty-six articles pertained to the diagnosis, treatment, epidemiology of whiplash, and WAD, and were eligible for focused review. From these, 21 primary and 15 secondary sources were identified for full review. In addition, five articles were found that focused on whiplash associated cervical injuries. These five articles were also primary sources. Conclusions Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology, believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.

Reproducibility of Pressure Pain Threshold and Visual Analog Scale Findings in Chronic Whiplash Patients

BACKGROUND

Assessment of pain in patients with whiplash-associated disorders has been previously reported using a variety of instruments. However, the reproducibility of the findings derived from such measurements has not been explored with respect to this particular patients group.

OBJECTIVES

To evaluate the intratester and intertester reproducibility of pressure pain threshold (PPT) findings and the intratester reproducibility of visual analog scale (VAS) findings relating to the cervical region of chronic whiplash patients for the determination of smallest real difference values.

METHODS

Twenty-one chronic whiplash patients: 13 women and 8 men participated in this study. The intratester paradigm was based on 2 testing sessions over a period of 5 to 11 days (7.95+/-1.90) and incorporated recording of VAS scores and also PPT scores relating to 3 pairs of right and left homologous cervical sites. The intertester study was conducted within the first testing session and referred to the PPT measurement only. In this session, patients were also asked to fill in the Neck Disability Index questionnaire.

RESULTS

The interclass correlation coefficient-derived reproducibility of the PPT scores was good to excellent within and between testers ranging 0.85 to 0.91 and 0.88 to 0.97, respectively. There was, however, a significant difference between the testers. The VAS scores demonstrated lower reproducibility (interclass correlation coefficient=0.67). On the basis of the standard error of measurement, the smallest real difference of PPT ranged 40.2 to 58.9 kPa whereas the corresponding figure for the VAS was 3.76 cm.

CONCLUSIONS

On the basis of the current patient sample, this study demonstrates that although PPT findings may generally be applied for monitoring change in chronic whiplash patients, the use of VAS scores should be limited to patients whose initial score is above 4. It is also suggested that if the PPT is to serve as an outcome measure, its measurement should be performed by the same tester.