Objectives. Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. Methods. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion. Results. Peak anterior longitudinal ligament (ALL) strain ranged from 0.106 to 0.382 in a normal spine, and from 0.116 to 0.399 in a fused cervical spine. Strain increased from cranial to caudal levels. The mean strain increase in the motion segment immediately adjacent to the site of fusion from C2-C3 through C5-C6 was 26.1% and 50.8% following single- and two-level cervical fusion, respectively (p = 0.03, unpaired two-way t-test). Peak cervical strains following various lumbar-fusion procedures were 1.0% less than those seen in a healthy spine (p = 0.61, two-way ANOVA). Conclusion. Cervical arthrodesis increases peak ALL strain in the adjacent motion segments. C3-4 experiences greater changes in strain than C6-7. Lumbar fusion did not have a significant effect on cervical spine strain. Cite this article: H. Huang, R. W. Nightingale, A. B. C. Dang. Biomechanics of coupled motion in the cervical spine during simulated whiplash in patients with pre-existing cervical or lumbar spinal fusion: A Finite Element Study. Bone Joint Res 2018;7:28–35. DOI: 10.1302/2046-3758.71.BJR-2017-0100.R1

Study design: A prospective study of 135 subjects with whiplash injury. Objectives: To identify factors predictive of prolonged disability following whiplash injury. Summary of background data: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision. Methods: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome. Results: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p< 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome. Conclusions: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation

STUDY DESIGN: A prospective study of 135 subjects with whiplash injury. OBJECTIVES: To identify factors predictive of prolonged disability following whiplash injury. SUMMARY OF BACKGROUND DATA: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision. METHODS: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bi-variate and multi-variate analyses were undertaken to measure the association between putative risk factors and measures of outcome. RESULTS: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p< 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome. CONCLUSIONS: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors

Aims. To capture the views of various members of the healthcare system with regards to whiplash injuries and in particular, the cumulative effects of whiplash on a patient seeking compensation. Method. A questionnaire was set up on “Surveymonkey” which consisted of three scenarios outlining 1. single whiplash injury 2. Past history of neck pain with new whiplash injury 3. Chronic history of neck pain with a new whiplash injury seeking long term compensation and early retirement. The respondents were asked whether or not they agreed or disagreed with fictional expert opinions for each scenario. The questionnaire was distributed to orthopaedic surgeons, accident & emergency doctors, general practitioners and physiotherapists. Results. In Scenario 1, half of the respondents believed that after a single whiplash injury with no past history of neck pain a decision of 3 months worth of disability compensation was acceptable. In Scenario 2, 67% of respondents opined that a previous history of whiplash injury makes a patient more susceptible to further soft tissue damage. Finally, in Scenario 3 100% of respondents believe that a decision of 12 years of compensation and early retirement due to his new injury was unjustifiable. Conclusions. Our questionnaire revealed that the majority of respondents believe that whiplash injuries are cumulative in nature. They also are of the opinion that chronic neck pain, once settled, does not contribute to subsequent whiplash injury. Conflicts of Interest. None. Source of Funding. None

Purpose: Whiplash injury occurs due to motor vehicle accidents has its long term consequence, nevertheless very little is written about its long-term follow up. The aim of the study is to find out the long-term follow up of Whiplash injury and the factors affecting the long-term follow up. Method: It is a retrospective study which was done in Russells Hall Hospital in the west midland in UK. 64 patients were selected in this study. Only 54 patients were replied. An inclusion criterion was Whiplash injury due to RTA in years 1995, 1996 and 1997. Initial examination was performed 5.6 +/ – 4.5 days after trauma, and follow-up examinations 3, 6, 12, and 24 months. Exclusion criteria were any cervical spine bony injury, associate head injury and poly-trauma patients. The outcome measures used for assessment are SF36, Whiplash Disability Questionnaire score WDQS, and questions to cover their present symptoms, work circumstances before and after the injury, current and previous treatment. Results: In our study we found that the time it takes for the patient’s symptoms to resolve varies, it took less than 6 weeks in 4 patients, between 6 weeks to 3 months in 10 patients, between 6 months to 1 year in 15 patients and more than one year in 3 patients. The average follow up time was 10.3 years. Our results did show these figures: 22 patients were still symptomatic 10 years after injury, 18 still complaining of pins & needles, 13 still having frontal headache and 7 having occipital headache. Headache was one of the symptoms which annoyed Whiplash injury patients. Headaches following Whiplash injuries were occipital, frontal or generalised. Headache was usually of Muscular contraction type, often associated with greater occipital neuralgia. 16 patients still had treatment in the form of pain killers or physiotherapy. The mean WDQS was less than 20 in 38 patients. The mean WDQS in patients with low back pain was 29.23 and for those without back pain were 12.53. In the smokers the mean whiplash score was 32.2. In the non-smokers the Whiplash score was 17.93. The mean WDQS in those who do not drink alcohol was 26.73 and in those who drink alcohol were 16.58. Conclusion: Whiplash injury patients have long term residual symptoms mainly pins & needles as well as headache and dizziness. Claiming compensation is a bad prognostic factor on the long-term outcome of Whiplash injury patients. Drinking alcohol, Gender, BMI, treatment given after the initial injury and smoking have no effect on the long-term outcome of these injuries. Age & Low back pains are bad prognostic factors. Whiplash Disability Questionnaire score, SF 36 (for body pain) and time for symptoms to be relieved are sensitive outcome measures to assess those injuries

Whiplash associated Disorder is a clinical entity that is well recognised by doctors patients and the legal profession. It is however a clinical syndrome that has few of the characteristics that are normally associated with the epidemiology and pathology of injury. The dilemma of Whiplash is the absence of hard evidence of any pathological process that would normally be considered evidence of a disease process. Epidemiology exposes some of the gaps in the current models of whiplash. There are unexplained cultural variations. The different legal mechanisms of claim should not influence a physical traumatic disorder. There is normally a clear relationship between the kinetic energy involved in injury and the tissue disruption that occurs. Experimental models using crash tests produce conflicting results. Studies of polytrauma reveal a very low incidence of post traumatic neck pain. A range of opinions are available in the literature on pathology and biomechanical factors. Systematic analysis reveals the level of evidence for the establishment of the disease of whiplash in the 1960’s to be level two or three, while the evidence for discarding whiplash as a physical disease in the modern literature is level one or two. It is much harder for physicians to discard a cultural fixed belief in a disease that may never have existed rather than to accept the verifiable logic of modern models of disease. Various historical arguments that have been used to support a physical basis for whiplash associated disorder have a flawed logic. The current best evidence would suggest that the acute phase of a whiplash disorder may be the result of a minor soft tissue injury, the natural history of which is recovery. There is little or no evidence to support a physical basis for chronic symptoms, which on the balance of probability are due to psychosocial factors. Whiplash is a ‘convenient’ model of illness which results in ‘gain’ for all those involved in its manifestations. It is a convenient disease

General Practitioner (GP) attendances for non-specific disease increase after life events. Whiplash injury has the effect of a life event in some people. The aim of this study was to compare GP attendance rates in the year before and after whiplash injury to establish their rate and cause. Ninety-eight subjects (62 women and 36 men) with whiplash injuries examined for medicolegal reports, with complete GP records for a year before and after injury. The number of attendances and the reason for attendance. Consultations after the accident were subdivided into those for neck pain and for other reasons. Subjects were reviewed more than one year after injury. All described neck pain 11% mild, 62% moderate and 27% severe. GP attendance rates before the accident were within the normal range but increased after (p=0.0001) because of neck pain symptoms. There was no association between attendance rates before and after injury but consultations for neck pain rose in proportion to severity of symptoms (p = 0.0015). Attendances unrelated to neck symptoms fell after injury (p = 0.002). GP attendances for non-specific disorders increase after life events, but not after whiplash injury as patients focus on their neck symptoms

Whiplash vertigo syndrome is often seen in victims of rear-end vehicle collisions. These patients commonly complain of headache, vertigo, tinnitus, poor concentration, irritability, and sensitivity to noise and light. Sixteen patients (medium age, 39,5 years) that they refered in orthopaedic examination because of long-lasting subjective complaints after cervical spine injury underwent clinical, laboratorial and psychometric examinations. The mean posttraumatic interval was 43 months. Ten patients were injured in road accidents, 5 during sports and one at work, all with mechanism trial of whip. Each patient was evaluated with otorhinolaryngologic examination, audiometry tests, CT: petrus – internal auditory meatus and cerebellopontine corner. Also each patient was evaluated with neurologic examination, psychological well-being scale (sf-36), and personality profile scale. None of the patients had neurologic symptoms, and no lesions of the cervical spine were identified. All the patients had negative clinical, radiological and standard laboratorial control, but may be is a critical point that the eleven of these patients had pathologic OGTT (Oral Glucose Tolerance Test). Also did not exist differentiations from the mean values in psychological well-being scale (SF-36), and personality profile scale of healthy population. Test results were unrelated to the length of the post-traumatic interval. However, 2 distinct syndromes were identified. Ten patients had cervicoencephalic whiplash type syndrome (CES), characterized by headache, vertigo, tinnitus poor concentration, and disturbed adaptation to light intensity. Six patients had the lower cervical spine whiplash type syndrome (LCSS), characterized by vertigo, tinnitus cervical and cervicobrachial pain. The verification of Whiplash Vertigo syndrome require more objective clinical means. This article proposes that exists an organic base for the syndrome, but does not promote that whiplash injury certainly cause it

The Quebec Task Force defined whiplash as “an acceleration–deceleration mechanism of energy transfer to the neck”. It is logical that the lower the velocity change following impact, the lower the risk of injury. The accepted velocity change (delta-v) for whiplash injuries following rear impact has been quoted as 5 mph. There is some debate as whether this is valid in the clinical setting. We aimed to investigate this further. A series of low speed controlled crash simulations were undertaken. There were a total of 27 runs on 23 individuals. Accelerometers were placed on the head and chest of the volunteers. Video recordings were analysed to assess relative displacement of the head and chest. The presence of symptoms was documented over a period of 7 days. The volunteers consisted of 23 males and 1 female with an average age of 38 (range 20–56). The average delta-v achieved was 2.3 mph (range 1.8–3.1 mph). The average maximum accelerations recorded were 3.46g at the chest and 2.93g at the head. The average difference was 0.53g. There was no significant displacement between the head and body. No symptoms were reported beyond 1 hour. Whiplash is triggered if the disparity between movements of the head and neck is of sufficient magnitude. It seems logical that there is a threshold below which whiplash will not occur. Our results have shown that below a delta-v of 3 mph there is little difference in the magnitude and timing of the movements of the head and chest. Therefore the whiplash mechanism of injury does not occur at these changes of velocity

Purpose: To describe the characteristic examination findings post whiplash injury of relevance to the shoulder surgeon and an injection test, which can be used to abolish these signs and distinguish neck from shoulder pathology. 5A large amount has been written about whiplash injuries of the neck, but many of these patients are often referred to shoulder units for assessment either acutely or years after the accident because of continuing symptoms. Although neck pain is the commonest complaint tenderness on examination is sided and within the trapezius muscle in virtually all cases. Pain referred to the shoulder is also reported in 36 – 67% whilst interscapular pain occurs in 20 – 72%, depending on the time from injury. We have reviewed a personal series of the senior author of over 700 cases. The consistent finding in these patients is tenderness localised to a specific part of the trapezius in the base of the neck, which is sided. Tenderness on the same side is also present along the vertebral border of the scapula to its lower pole in over 90%, provided the scapula is protracted. A further finding in some patients is a high arc of pain on abducting the arm, thus simulating an acromioclavicular joint problem, but in these cases the pain is localised to the trapezius. These findings are in addition to those of the neck, which may show some restricted movement due to pain. The trapezius tenderness can be abolished by the injection of local anaesthetic into the trigger spot at the base of the neck (whiplash injection test), which also resolves most of the above signs and allows further assessment of the shoulder without the referred pain from the injected area. Conclusions: Shoulder examination in patients who have suffered whiplash injuries is often difficult due to referred pain. Knowledge of the signs specifically due to the whiplash injury is required so that shoulder pathology is not assumed. A new whiplash injection test not previously described has been found very useful in abolishing the whiplash signs to enable accurate shoulder assessment in our practice

Introduction: Impingement syndrome has been reported to occur in a proportion of patients (9%) following whiplash injuries to the neck. In this study we aim to examine this finding to establish the association and incidence of subacromial impingement following whiplash injuries to the cervical spine. Method and results: We examined 219 patients who had presented to a single surgeon for a medico-legal report, at an average of 13.8 months (range 1–52) following a whiplash injury to the neck. All patients were assessed for clinical evidence of subacromial impingement. The patients were asked if the symptoms had developed following their neck injury and those with past history of shoulder pain were identified and excluded. 56 patients (26%) had shoulder pain following the injury; of these, 11 (5%) had clinical evidence of impingement syndrome, however in the majority other clinicians had overlooked this. The seatbelt shoulder (driver’s right and front passenger’s left) was involved in 9 (82%) of the cases (p< 0.001). The average age was 38.2 years compared with 57.8 years in those with subacromial impingement (p< 0.05). Impingement is therefore likely to be due to direct trauma from the seatbelt in the older age group with an already compromised subacromial space. Conclusion: It is now established that subacromial impingement occurs following whiplash injuries to the neck. This is however, frequently overlooked and shoulder pain is attributed to pain radiating from the neck. It is important that this is appreciated and patients are specifically examined for signs of impingement so that appropriate treatment can be instigated. Direct trauma from the seatbelt is one likely explanation for this association

Objective: A review of scientific literature on whiplash associated disorders was conducted to inform appropriate messages for an evidenced-based patient educational booklet – The Whiplash Book. The booklet has been developed for use as both a clinical tool and general health intervention. Design and Results: A systematic literature search was conducted, using MEDLINE and psychINFO, together with hand searches, reference tracking, and the Internet. The Quebec Task Force report and the British Columbia Whiplash Initiative were taken as the starting point. The new evidence covered the period May 1994 through March 2001 (163 articles). All relevant articles were included, with a particular focus on management and treatment of whiplash associated disorders. The quantity, consistency and relevance of all retrieved articles was evaluated, and rated as:. *** consistent findings in multiple reports. ** consensus based on balance of various findings. * limited information (single report). Conclusions: The main messages from the literature suggest: serious physical injury is rare, reassurance about good prognosis is important, over-medication is detrimental, fastest recovery occurs with early return to normal pre-accident activities; self-exercise/manual therapy and positive attitudes/beliefs are helpful to regain activity levels; collars/rest and negative attitudes/beliefs delay recovery and contribute to chronicity

A review of scientific literature on whiplash associated disorders was conducted to inform appropriate messages for an evidenced based patient educational booklet, “The Whiplash Book.” The booklet is being developed for use as both a clinical tool and general health intervention. A systematic literature search was conducted, using MEDLINE and psychINFO, together with hand searches, reference tracking, and the Internet. The Quebec Task Force report and the British Columbia Whiplash Initiative were taken as the starting point. The new evidence covered the period May 1994 through March 2001 (147 articles). All relevant articles were included, with a particular focus on management and treatment of whiplash associated disorders. The quantity, consistency and relevance of all retrieved articles was evaluated, and rated as *** for consistent findings in multiple reports, ** for consensus based on balance of various findings, or * for limited information (single report). The main messages from the literature suggest: physical serious injury is rare, reassurance about good prognosis is important, over-medication is detrimental, fastest recovery occurs with early return to normal pre-accident activities, self-exercise/manual therapy and positive attitudes/beliefs are helpful to regain activities levels, collars/rest and negative attitudes/beliefs delay recovery and contribute to chronicity

Purpose of study and background: It is generally accepted that a biopsychosocial model is required to explain the complex phenomenon of whiplash associated disorders, particularly in the development of chronic pain and disability. Because the factors leading to chronicity are present early in the course of the disorder, clinical guidelines and recommendations have stressed the need for appropriate information and advice for patients. Following the success of patient educational material, in the form of an evidence-based booklet, in the management of low back pain, a similar booklet has been produced for whiplash patients. The messages for the booklet were synthesised from a comprehensive review of the available scientific evidence; the resultant text was intended to challenge unhelpful beliefs about whiplash, promote positive attitudes, and stimulate an active approach to recovery. Methods and results: Using samples of patients and non-patients, the booklet was evaluated for its ability to create a positive shift in beliefs, and for its ability to impart its intended messages about active management. The results showed that the booklet is considered easy to read, understandable, believable, and conveys its intended messages. Furthermore, it created a substantial and highly statistically significant positive shift in attitudes and beliefs about whiplash associated disorders, suggesting its suitability as patient educational material. Conclusion: This booklet changes beliefs about whiplash, however only a randomised clinical trials will determine whether such a booklet can have an effect on clinical outcomes

Introduction. Whiplash injury following rear shunt Road traffic accident (RTA) has been associated with impingement syndrome of shoulder. However, the results of arthroscopic subacromial decompression (ASAD) for this group of patients have never been compared to the non accident group. In our study we aim to compare the results of ASAD in these patients to a group who did not sustain whiplash injury. Materials/Methods. Thirteen patients with impingement syndrome following rear shunt RTA were followed up (2004–09). After failed conservative management for at least 6 months ASAD was performed. This group was compared with a control group (not involved in an RTA) of 13 consecutive patients (age and sex matched). All patients were assessed with Oxford shoulder score preoperatively and twice post operatively (within 3 months and at one year). Results. In the RTA group all 13 patients showed improvement in their oxford score over one year. While the improvement was only Marginal (p= 0.08) at three months it was better at the end of a year (p=0.04). Comparatively in the cohort without the whiplash injury the improvement was more marked in the first three months (p=0.05) with significant improvement at the end of the year (p=0.03). The overall improvement in Oxford score was more in the cohort of patients who were not involved in a RTA as opposed to the RTA group (p= 0.05). Conclusion. The results of the study show that even though there was an improvement in shoulder scores after an arthroscopic subacromial decompression it was much slower and overall results were inferior in the RTA group as opposed to the controls and hence prognosis should be guarded when offering ASAD for patients with whiplash injury

Introduction: Sensory hypersensitivity, central hyper-excitability (lowered nociceptive flexion reflex (NFR) thresholds) and psychological distress are features of chronic whiplash. Relationships between these substrates are not clear. The aim of this study was to investigate relationships between psychological factors (distress, catastrophization) and pain threshold responses to sensory stimuli and spinal cord excitability as assessed by the NFR. The former assessments are considered as global pain responses to sensory stimuli as reported by the patient, whereas the latter, an objective measurement for spinal cord excitability to peripheral stimulation. Methods: 30 individuals with chronic (> 3 months) whiplash (Grade II or III; Grade IV were excluded) and 30 asymptomatic controls participated. Pressure pain thresholds (PPTs) and thermal pain thresholds (Thermotest, Somedic AB, Sweden) were measured at the cervical spine, upper and lower limbs. The NFR (intensity of electrical stimulation at the sural nerve required to elicit reflex EMG activity of biceps femoris) was measured as per previous protocols (1). Pain and disability levels (NDI), psychological distress (GHQ-28) and catastrophisation (PCS) were also measured in the whiplash group. Ethical clearance for this study was granted by the Medical Research Ethics Committee of the University of Qld. A MANCOVA was used to determine differences between the whiplash group and controls for sensory measures and the NFR. GHQ-28 and PCS scores were used as covariates in the analysis. Group differences for questionnaire data (GHQ-28 and PCS) were analysed using one way ANOVA. Pearson’s correlation coefficients were used to determine the relationship between the psychological measures (PCS and GHQ-28), pain and disability levels (NDI) and the pain threshold measures (mechanical and thermal) and to determine relationships between the psychological measures, pain and disability measures (NDI) and NFR responses (pain intensity at threshold, threshold). p< 0.05. Results: Whiplash injured participants (23 females, mean (SD) age: 37.7 (11.5) years, NDI: 46.2 (17.6) and VAS scores of pain: 4.2 (2.4)) demonstrated lowered pain thresholds to pressure and cold (p< 0.05); lowered NFR thresholds (p=0.003) and above threshold levels of psychological distress (GHQ-28) compared to controls and levels of catastrophisation comparable to other musculoskeletal conditions. There were no group differences for heat pain thresholds or pain at NFR threshold. In the whiplash group, PCS scores correlated moderately with cold pain threshold (r =0.51, p=0.01). In contrast there were no significant correlations between GHQ-28 scores and pain threshold measures or between psychological factors and NFR responses in whiplash participants. There were no significant correlations between psychological factors and pain thresholds or NFR responses in controls. Discussion: We have demonstrated that psychological factors have some association with sensory hypersensitivity (cold pain threshold measures) in chronic whiplash but do not seem to influence spinal cord excitability. This suggests that psychological disorders are important, but not the only, determinants of central hypersensitivity in whiplash patients. These findings suggest that both physical and psychological factors will need to be addressed in the management of whiplash

Victims of motor vehicle accidents often seek health care following whiplash injuries. Their complaints (whiplash associated disorders, WAD) are classified on a 1–4 scale developed by the Quebec task force (QTF) in 1995. 1. A number of victims will not recover, developing chronic symptoms instead. 2. The pathophysiology of the complaints following a whiplash injury is largely unknown. Several different treatments are currently employed by health professionals to treat victims of whiplash injuries in the acute and chronic phase of the disorder. Responding to the acute symptoms with activity (act-as-usual and exercise) results in improved outcome. 3. There is evidence that sick-leave may be reduced by high-dose methylprednisolone given within 8 hours of injury in patients with QTF grade 3 WAD. 3. . Approximately 50 % of patients with chronic WAD suffer from zygapophyseal joint pain that will be relieved for a period of several months if treated with percutaneous radiofrequency neurotomy. 3. Moderate evidence supports multimodal rehabilitation programs for increasing levels of function. 3. and coordination exercise to reduce pain in chronic WAD. 3. . State-of-the-art treatment for acute WAD is available and needs to be implemented. Further research on the treatment of chronic WAD should focus on the patients’ cognitions and movement behavior

The incidence of reported cases of whiplash has risen dramatically in many Western Countries.There was an initial increase, in the United Kingdom, following the compulsory wearing of seatbelts for drivers and front seat passengers but since then the incidence has increased even more. This pattern has been reported in other regions. Many factors have been proposed to account for this increased incidence, including changes in car design, increased traffic density, psychosocial aspects and increased litigation. Although whiplash injury is defined as a “minor” injury it may be associated with prolonged morbidity. The factors causing chronicity are not well understood but do include the severity of the initial injury (WAD 3 injuries doing significantly worse than WAD 1 and 2 injuries), the development of psychological symptoms, age and bio-social factors. Prolonged litigation and prolonged inappropriate treatment also lead to chronicity

Whiplash remains a challenging condition because the pathology is undefined. The purpose of this study was to evaluate the response of chronic neck, shoulder and arm pain to decompression of the median nerve at the wrist and pronator teres level. In a prospective study of 150 cases following whiplash injury (108 carpal tunnel and 42 pronator teres syndrome) clinical symptoms were assessed by clinical, neurological, radiological and visual analogue scale. The pathophysiology of pain and effects of surgery have also been assessed by neuropeptide studies. Clinical and neurological examination revealed signs and symptoms of carpal tunnel and pronator teres syndrome along with severe neck, shoulder and arm pain. Local anesthetic infiltration around the median nerve at the wrist and forearm abolished the chronic neck and shoulder pain within 10mins of injection. This demonstrated the site of pathology and temporarily relieved upper limb symptoms and trapezius muscle spasm as well. Neurophysiological studies were always normal. Surgical intervention in successful cases cured chronic neck shoulder and arm pain with sensory and motor recovery. Also activities of daily life normalised permanently. The main neurotransmitter peptides Substance P and Calcitonin gene related peptide levels returned to control levels six weeks after surgery in successful cases (p< 0. 005 and p< 0. 05 respectively). This is the biochemical evidence of effect of surgery in relieving pain and neuroinflammatory process. Our study suggests that neck shoulder and arm pain following whiplash injury is caused by entrapment of the median nerve due to stretching. Surgical decompression of the carpal tunnel and pronator teres muscle yielded 93% and 80% good results respectively with the disappearance of chronic neck shoulder and arm pain. Consequently normalisation of daily activities were observed. Although mild hand symptoms caused by carpal tunnel syndrome have also been cured the primary aim of surgical intervention is to cure chronic neck shoulder and arm pain