Surgical fasciectomy of the trapezius muscle combined with neurolysis of the Spinal accessory nerve; results and long-term follow-up in 30 consecutive cases of refractory chronic whiplash syndrome^[*]

Abstract

Background Chronic problems from whiplash trauma generally include headache, pain and neck stiffness that may prove refractory to conservative treatment modalities. As has previously been reported, such afflicted patients may experience significant temporary relief with injections of local anesthetic to painful trigger points in muscles of the shoulder and neck, or lasting symptomatic improvement through surgical excision of myofascial trigger points. In a subset of patients who present with chronic whiplash syndrome, the clinical findings suggest an affliction of the spinal accessory nerve (CN XI, SAN) by entrapment under the fascia of the trapezius muscle. The present study was undertaken to assess the effectiveness of SAN neurolysis in chronic whiplash syndrome.

Methods A standardized questionnaire and a linear visual-analogue scale graded 0-10 was used to assess disability related to five symptoms (pain, headache, insomnia, weakness, and stiffness) before, and one year after surgery in a series of thirty consecutive patients.

Results The preoperative duration of symptoms ranged from seven months to 13 years. The following changes in disability scores were documented one year after surgery: Overall pain decreased from 9.5 +/- 0.9 to 3.2 +/- 2.6 (p < 0.001); headaches from 8.2 +/- 2.9 to 2.3 +/- 2.8 (p < 0.001); insomnia from 7.5 +/- 2.4 to 3.8 +/- 2.8 (p < 0.001); weakness from 7.6 +/- 2.6 to 3.6 +/- 2.8 (p < 0.001); and stiffness from 7.0 +/- 3.2 to 2.6 +/- 2.7 (p < 0.001).

Conclusions Entrapment of the spinal accessory nerve and/or chronic compartment syndrome of the trapezius muscle may cause chronic debilitating pain after whiplash trauma, without radiological or electrodiagnostic evidence of injury. In such cases, surgical treatment may provide lasting relief.

^*This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• References

• 1 Brault JR, Wheeler JB, Sigemund GP, Brault EJ. Clinical response of human subjects to rear-end automobile collisions. Arch Phys Med Rehabil 1998; 79: 72-80 10.1016/S0003-9993(98)90212-X 9440422
• 2 Hagstrom Y, Carlsson J. Prolonged functional impairment after whiplash injury. Scand J Rehabil Med 1996; 28: 139-146 8885036
• 3 Ettlin TM, Kischka U, Reichmann S, Radii EW, Heim S, Wengen D, Benson DF. Cerebral symptoms after whiplash injury of the neck: a prospective clinical and neuropsychological study of whiplash injury. J Neurol Neurosurg Psychiatry 1992; 55: 943-948 1015197 1431958 10.1136/jnnp.55.10.943
• 4 Schlesinger I, Hering-Hanit R, Dagan Y. Sleep disturbances after whiplash injury: objective and subjective findings. Headache 2001; 41: 586-589 10.1046/j.1526-4610.2001.041006586.x 11437895
• 5 Fischer AJ, Huygen PL, Folgering HT, Verhagen WI, Theunissen EJ. Vestibular hyperreactivity and hyperventilation after whiplash injury. J Neurol Sci 1995; 132: 35-43 10.1016/0022-510X(95)00118-L 8523028
• 6 Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. Arch Phys Med Rehabil 1998; 79: 1089-1094 10.1016/S0003-9993(98)90176-9 9749689
• 7 Hildingsson C, Wenngren BI, Bring G, Toolanen G. Oculomotor problems after cervical spine injury. Acta Orthop Scand 1989; 60: 513-516 2603649
• 8 Kwan O, Friel J. A review and methodologic critique of the literature supporting ’chronic whiplash injury’: Part I - research articles. Med Sci Monit 2003; 9: 203-215
• 9 Aker PD, Gross AR, Goldsmith CH, Pelloso P. Conservative management of mechanical neck pain, systematic overview and meta-analysis. BMJ 1996; 113: 1291-1296
• 10 Rauschning W, Jónsson H. Injuries of the cervical spine in automobile accidents: Pathoanatomic and clinical aspects. In: Gunzburg R, Szpalski M. Whiplash injuries. Current concepts in prevention, diagnosis, and treatment of the cervical whiplash syndrome. Lippincott-Raven; New York: 1998: 33-52
• 11 Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine 1996; 21: 1737-1744 10.1097/00007632-199608010-00005 8855458
• 12 Krakenes J, Kaale BR. Magnetic resonance imaging assessment of craniovertebral ligaments and membranes after whiplash trauma. Spine 2006; 31: 2820-2826 10.1097/01.brs.0000245871.15696.1f 17108836
• 13 Schofferman J, Bogduk N, Slosar P. Chronic whiplash and whiplash-associated disorders: an evidence-based approach. J Am Acad Orthop Surg 2007; 15: 596-606 17916783
• 14 Panjabi MM, Ito S, Pearson AM, Ivancic PC. Injury mechanisms of the cervical intervertebral disc during simulated whiplash. Spine 2004; 29: 1217-1225 10.1097/00007632-200406010-00011 15167661
• 15 Freeman MD, Nystrom A, Centeno C. Chronic whiplash and central sensitization, an evaluation of the role of a myofascial trigger points in pain modulation. J Brachial Plex Peripher Nerve Inj 2009; 4: 2 2680858 19389231 10.1186/1749-7221-4-2
• 16 Herren-Gerber R, Weiss S, Arendt-Nielsen L, Petersen-Felix S, Di Stefano G, Radanov BP, Curatolo M. Modulation of central hypersensitivity by nociceptive input in chronic pain after whiplash injury. Pain Med 2004; 5: 366-376 10.1111/j.1526-4637.2004.04055.x 15563322
• 17 Duffy MF, Stuberg W, DeJong S, Gold KV, Nystrom NA. Case report: whiplash-associated disorder from a low-velocity bumper car collision: history, evaluation, and surgery. Spine 2004; 29: 1881-1884 10.1097/01.brs.0000137064.85554.fa 15534409
• 18 Hagert CG, Christenson JT. Hyperpressure in the trapezius muscle associated with fibrosis. Acta Orthop Scand 1990; 61: 263-265 2371824
• 19 Williams WW, Donell ST, Twyman RS, Birch R. The posterior triangle and the painful shoulder: Spinal accessory nerve injury. Ann R Coll Surg Engl 1996; 78: 521-525 2502864 8943637
• 20 Wetmore C, Elde R. Detection and characterization of a sensory microganglion associated with the spinal accessory nerve: a scanning laser confocal microscopic study of the neurons and their processes. J Comp Neurol 1991; 305: 148-163 10.1002/cne.903050114 1674515
• 21 Bremmer-Smith AT, Unwin AJ, Williams WW. Sensory pathways in the spinal accessory nerve. J Bone Joint Surg Br 1999; 81: 226-228 10.1302/0301-620X.81B2.9027 10204925
• 22 Battista AF. Complications of biopsy of the cervical lymph node. Surg Gynecol Obstet 1991; 173: 142-146 1925864
• 23 Gordon SL, Graham WP, Black JT, Miller SH. Accessory nerve function after surgical procedures in the posterior triangle. Arch Surg 1977; 112: 264-268 843216
• 24 Woodward G. Spinal accessory neuropathy and internal jugular thrombosis after carotid endarterectomy. J Neurol Neurosurg Psychiatry 2000; 68: 111-112 1760640 10671123 10.1136/jnnp.68.1.111
• 25 Bodack MP, Tunkel RS, Marini SG, Nagler W. Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report. J Pain Symptom Manage 1998; 15: 3213-3228 10.1016/S0885-3924(98)00008-6
• 26 Nederhand MJ, Ijzerman MJ, Hermens HJ, Baten CT, Zilvold G. Cervical dysfunction in the Chronic Whiplash Associated Disorder Grade II (WAD-II). Spine 2000; 25: 1938-1943 10.1097/00007632-200008010-00012 10908937
• 27 Larsson SE, Bodegard L, Henriksson KG, Oberg PA. Chronic trapezius myalgia. Morphology and blood flow studied in 17 patients. Acta Orthop Scand 1990; 61: 394-398 2239160