The Epidemiology of Neck Pain

, Medical College of Wisconsin, Milwaukee, Wis.

In This Article

Post-Traumatic Pain

The most common post-traumatic neck pain syndrome is a whiplash injury and follows an automobile accident. The term was first used by Crowe[5] in 1928 in an unpublished report, then in an article by Davis[6] in 1945, and later by Gay and Abbott[7] in 1953. The original descriptions were of a mechanism of injury rather than a disease process. Although many now object to its use, the term "whiplash" is routinely used by laymen, lawyers, and medical professionals in reference to a patient with neck pain after an automobile accident in which a more specific diagnosis cannot be made.

The most frequent scenario is a patient whose vehicle is struck from behind causing a hyperextension motion of the neck. The combination of seat belts and properly adjusted head restraints reduces the likelihood of neck injuries.[8]

Recently Grauer and colleagues[9] have shown with cadaver studies that in a simulated whiplash injury the neck forms an S-shaped curve with initial hyperextension of the lower cervical spine and upper-level flexion, followed by extension of the entire cervical spine. It would be expected that if physiologic limits of motion are exceeded, than injury would occur. This physiologic limit of motion was reached in the lower cervical spine in their studies.

Hyperextension injuries of the neck can damage a number of structures, including the anterior muscles and ligaments, the disc, and zygapophyseal joints. These injuries have been demonstrated on cadavers and experimental animals and found in human autopsy studies of victims of motor vehicle accidents.[10]

Recently Jonsson and coworkers[11] reported on 50 consecutive patients with whiplash-type cervical spine distortions in automobile accidents. At 6 weeks, 24 had persistent neck pain and underwent MRI imaging. Of these, 8 were found to have large cervical disc protrusions and had surgery. Two patients had posterior fusions for instability based on lateral flexion and extension films. This report is in contrast to our own experience and that of others' where, despite careful evaluation of whiplash patients, conclusive objective pathology is rarely found.

Borchgrevink and associates[12] studied 201 patients with neck pain following automobile accidents. The patients were randomly divided into two treatment groups. In one group, immobilization by means of a cervical collar and sick leave from work was provided. In the other, no immobilization was used, no sick leave was given, and the patients were instructed to act as usual. At 6 months, the "act-as-usual" group showed more overall progress, as measured by subjective symptoms ratings. The researchers found, however, that 10% of this group still had severe symptoms at 6 months, which emphasizes that neck pain following an automobile accident in many patients is not a self-limited condition.

The symptom complex most frequently seen is neck pain that may not be present immediately after the accident but begins in most patients within 24 hours.[13] Other frequent complaints are headache, dizziness, paresthesia, and cognitive somatic and psychological sequelae.

This unrelated constellation of symptoms without objective evidence of structural injury has led to speculation that the condition is an emotional rather than a physical problem. Since the neck pain patient's vehicle has been struck from behind, causation and therefore liability usually rest with the other driver. Our current tort system favors documentation which encourages frequent physician visits, exaggeration of complaints, expensive testing, and extensive symptomatic treatment, most of which have no proven value in altering the natural history of the patient's symptoms.


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