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Successful treatment of whiplash-type injury induced severe pain syndrome with epidural stimulation: a case report
Pain 80 (1999) 441–443
Clinical note
Successful treatment of whiplash-type injury induced severe pain syndrome with epidural stimulation: a case report Olli A. Kirvela¨ a ,*, Esa Kotilainen b a
Department of Anaesthesiology, Turku University Hospital, Turku, Finland b Department of Neurosurgery, Turku University Hospital, Turku, Finland Received 5 August 1998; accepted 21 September 1998
Abstract Chronic severe cervico-facial pain syndrome associated with a whiplash-type injury was successfully treated with epidural spinal cord stimulation. The patient had been in pain for 9 years, responding temporarily only to stellate ganglion blocks. The patient has now been painless for 18 months. We have been unable to find a similar case reported in the literature to date. 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Spinal cord stimulation; Whiplash-type injury; Cervico-facial pain
1. Introduction Whiplash-type injury is, by definition, caused by the sudden jerky head movements of someone in a car which is hit by another vehicle from behind. This type of injury can also result from other violent hyperextension and hyperflexion cervical injuries. Patients with this type of problem tend to develop progressive neck pain and stiffness during the first days after the accident (Deans et al., 1987). These symptoms can persist over years and may become bizarre and disabling (Jonsson et al., 1994; Maimaris et al., 1988; Norris and Watt, 1983) and lead to prolonged and costly insurance litigation (Mendelson, 1982). If a chronic pain state develops it remains difficult to treat despite the modern multimodal approaches of today (Byrn et al., 1993; Evans et al., 1994; Lord et al., 1996). Electrical spinal cord stimulation (ESCS) has evolved over the past 20 years into an easily utilized technique for the treatment of intractable chronic pain in properly selected patients (North et al., 1993). Several studies have demonstrated the safety and effectiveness of ESCS for the treatment of chronic pain but no studies have looked at chronic * Corresponding author. Tel.: +358-2-261-2358; fax: +358-2-261-3960; e-mail: [email protected]
whiplash-type pain. We present a patient whose pain symptoms prompted us to successfully try ESCS.
2. Patient Our patient is a previously healthy navy officer (born 1963), who during his military service in 1988 was violently pulled out of bed. In the process his neck was sprained. He also hit his neck against the rail of the bed and the back of his head on the floor. Initially the neck was stiff, rotation was difficult, and the whole cervical area was sore. The soreness and stiffness gradually decreased but a persistent radiating pain developed. The pain was localized into the left side of the pharynx and the base of tongue radiating to the left cheek and ear. The pain persisted and the patient underwent tonsillectomy with no benefit. A styloideus-syndrome was suspected and one molar was extracted, dental pathology was excluded and night-time dental braces were ordered. Pain kept worsening, and subjectively, the worst symptoms were a painful, hyperesthetic area, and a sharp lancinating sensation in the left ear. In the chin the pain was pulsating and gnawing. Cold weather worsened the symptoms considerably. The patient was extensively studied with MRI CT
0304-3959/99/$ - see front matter 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S03 04-3959(98)002 18-8
442
O.A. Kirvela¨, E. Kotilainen / Pain 80 (1999) 441–443
scans, nerve and muscle conduction studies. Glossopharyngeal nerve damage was suspected but no evidence supporting this diagnosis was found. The patient was referred to the pain clinic in 1992 with the provisional diagnosis of neck-tongue syndrome. Physiotherapy, TNS-treatment, and trigger-joint injections were without benefit. It was felt that a diagnosis of whiplash-type syndrome was appropriate. Despite heavy medication (codeine, dextropropoxifen, paracetamol and tratsodone hydrochloride) the patient still had severe pain and side effects of the drugs caused problems at work, where he was facing retirement. As a sympathetic component to his pain had not been ruled out, a stellate ganglion block was tried. The first block was performed on the left side with 15 ml of 0.5% bupivacaine and pain disappeared for 3 days. The blocks were repeated bi-weekly and the duration of painless periods started to prolong, and medication was gradually decreased. Six months later the volume of bupivacaine was increased to 20 ml prolonging the painless period further to 10–14 days and patient stopped using medication. To achieve continuous sympathetic block an infusion port (Chemo-Port, HDC, CA) was installed 3 years later (1998). The tip of the catheter was placed at the stellate ganglion and the port beneath the channel on the left side. The system functioned well initially but was removed after 1 month due to occlusion. A new infusion port functioned for 2 months but had to be removed in mid 1996. Bi-weekly blocks were again restarted, but 3 months later the pain started to intensify and patient had to restart pain medication. At this phase epidural spinal cord stimulation seemed to be worth trying. A percutaneous technique was selected and in January 1997 the spinal cord stimulator electrode was inserted. The epidural electrode (Pisces Quad Plus, Medtronic, MN) was advanced under fluoroscopic control up to the level of the base of dens (foremen magnum). With trial stimulation, paresthesias were felt all over the painful area. After a week of stimulation the patient felt substantial relief of pain. The connecting wires of the trial stimulator were removed and the electrode was internalized and attached to a pulse generator (Itrel 3, Medtronic, MN) which was implanted below the right clavicle. The patient has now been without pain and analgesics for 18 months, and is doing well at work. He has experienced minor discomfort from the system while exercising, but otherwise the device does not interfere with his daily activities.
diagnosed for a long time, which is not uncommon with this type of pain (Evans et al., 1994). Sympathetic involvement has been proposed as one factor in prolonged whiplash-type pain (Bonica, 1990). Traction injuries of the autonomic nerves surrounding the vertebral artery, tethering of the brainstem, and post-concussion cerebral disorders could explain these symptoms (Evans et al., 1994; Jonsson et al., 1994). Our patient had sympathetic nervous system related symptoms, e.g. coldallodynia and as a form of confirmation stellate ganglion blocks proved beneficial. We were greatly encouraged by the gradual success of these blocks and, optimistically expected even longer pain relief to be achieved. As this did not happen, the patient was twice scheduled for surgical sympathectomy. However, the patient is relatively young, and as the beneficial effect of sympathectomy inevitably would be temporary, but with the possibility that side effects could be permanent (Loeser et al., 1990), the procedure was canceled. Instead, a subcutaneous delivery system was installed to achieve continuous sympathetic block. Our patient was quite happy with it while it worked, but technical problems proved difficult to overcome. When the pain state started to worsen, trying SCS seemed appropriate. Successful use of SCS in the treatment of reflex sympathetic dystrophies (Barolat et al., 1989; SanchezLedesma et al., 1989). As it is important to achieve stimulation paresthesias in the topographical representation of the patient’s pain (North et al., 1994), we were forced to advance the tip of the electrode to the level of the base of the dens until satisfactory paresthesias were achieved. Interestingly, the first subjective feeling from stimulation was a warm, almost burning sensation over the previously painful area. During the trial stimulation pain symptoms started to disappear. First to give way were allodynia and hyperesthestia around the left ear. Last to disappear were the lancinating sensations, which sporadically appeared even a few weeks after the internalization of the system. SCS is an expensive and invasive way to treat pain. However, in addition to relieving pain and improving the quality of life of our patient, it has already caused considerable savings. The patient no longer needs his bi-weekly hospital visits, sick leave or medication. His performance at work has improved and he has been able to return to work outdoors as cold allodynia has subsided. Our case shows that SCS can offer an alternative treatment in whiplash-type pain syndrome of this complexity.
3. Discussion
References
Whiplash-type injuries result in long-term disability with up to 6% of patients not returning to work after 1 year. Worsening and intractable symptoms caused our patient to face retirement due to the side-effects of medication and the disabling pain. Our patient, who clearly had a whiplash-type neck distortion with associated pain symptoms was not
Barolat, G., Schwartzman, R. and Woo, R., Epidural spinal cord stimulation in the management of reflex sympathetic dystrofy, Stereotact. Funct. Neurosurg., 53 (1989) 29–39. Bonica, J.J., Neck pain. In: J.J. Bonica (Ed.), The Management of Pain, Lea and Febiger, Beckenham, UK, 1990, pp. 848–867. Byrn, C., Olsson, I., Falkheden, L., Lindh, M., Ho¨sterey, U., Fogelberg, M., Linder, L.-E. and Bunketorp, O., Subcutaneous sterile water injec-
O.A. Kirvela¨, E. Kotilainen / Pain 80 (1999) 441–443 tions for chronic neck and shoulder pain following whiplash injuries, Lancet, 341 (1993) 449–452. Deans, G.T., McGalliard, J.N., Kerr, M. and Rutherford, W.H., Neck sprain. A major cause of disability following car accidents, Injury, 18 (1987) 10–12. Evans, R.W., Evans, R.I. and Sharp, M.J., The physician survey on the post-concussion and whiplash syndromes, Headache, 34 (1994) 268– 274. Jonsson, H., Cesarini, K., Sahlstedt, B. and Rauschning, W., Findings and outcome in whiplash-type neck distortions, Spine, 19 (1994) 2733– 2743. Loeser, J.D., Sweet, W.H., Tew, J.M. and van Loveren, H., Neurosurgical operations involving peripheral nerves: sympathectomy. In: J.J. Bonica (Ed.), The management of pain, Lea and Febiger, 1990, pp. 2050–2056. Lord, S.M., Barnsley, L., Wallis, B.J., McDonald, G.J. and Bogduk, N., Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain, N. Engl. J. Med., 335 (1996) 1721–1726.
443
Maimaris, C., Barnes, M.R. and Allen, M.J., Whiplash injuries of the neck: a retrospective study, Injury, 19 (1988) 393–3965. Mendelson, G., Not ‘cured by a verdict’: effect of legal settlement on compensation claimants, Med. J. Aust., 2 (1982) 132–134. Norris, S.H. and Watt, I., The prognosis of neck injuries resulting from rear-end vehicle collisions, J. Bone J. Surg., 65 (1983) 608–611. North, R.B., Kidd, D.H., Zahurak, M., James, C.S. and Long, D.M., Spinal cord stimulation for chronic, intractable pain: experience over two decades, Neurosurgery, 32 (1993) 384–395. North, R.B., Kidd, D.H., Lee, M.S. and Piantadosi, S., A prospective randomized study of spinal cord stimulation versus reoperation for failed back surgery syndrome: initial results, Stereotact. Funct. Neurosurg., 62 (1994) 267–272. Sanchez-Ledesma, M.J., Garcia-March, G. and Diaz-Cacajo, P., Spinal cord stimulation in deafferentation of pain, Stereotact. Funct. Neurosurg., 53 (1989) 40–45.
Clinical note
Successful treatment of whiplash-type injury induced severe pain syndrome with epidural stimulation: a case report Olli A. Kirvela¨ a ,*, Esa Kotilainen b a
Department of Anaesthesiology, Turku University Hospital, Turku, Finland b Department of Neurosurgery, Turku University Hospital, Turku, Finland Received 5 August 1998; accepted 21 September 1998
Abstract Chronic severe cervico-facial pain syndrome associated with a whiplash-type injury was successfully treated with epidural spinal cord stimulation. The patient had been in pain for 9 years, responding temporarily only to stellate ganglion blocks. The patient has now been painless for 18 months. We have been unable to find a similar case reported in the literature to date. 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Spinal cord stimulation; Whiplash-type injury; Cervico-facial pain
1. Introduction Whiplash-type injury is, by definition, caused by the sudden jerky head movements of someone in a car which is hit by another vehicle from behind. This type of injury can also result from other violent hyperextension and hyperflexion cervical injuries. Patients with this type of problem tend to develop progressive neck pain and stiffness during the first days after the accident (Deans et al., 1987). These symptoms can persist over years and may become bizarre and disabling (Jonsson et al., 1994; Maimaris et al., 1988; Norris and Watt, 1983) and lead to prolonged and costly insurance litigation (Mendelson, 1982). If a chronic pain state develops it remains difficult to treat despite the modern multimodal approaches of today (Byrn et al., 1993; Evans et al., 1994; Lord et al., 1996). Electrical spinal cord stimulation (ESCS) has evolved over the past 20 years into an easily utilized technique for the treatment of intractable chronic pain in properly selected patients (North et al., 1993). Several studies have demonstrated the safety and effectiveness of ESCS for the treatment of chronic pain but no studies have looked at chronic * Corresponding author. Tel.: +358-2-261-2358; fax: +358-2-261-3960; e-mail: [email protected]
whiplash-type pain. We present a patient whose pain symptoms prompted us to successfully try ESCS.
2. Patient Our patient is a previously healthy navy officer (born 1963), who during his military service in 1988 was violently pulled out of bed. In the process his neck was sprained. He also hit his neck against the rail of the bed and the back of his head on the floor. Initially the neck was stiff, rotation was difficult, and the whole cervical area was sore. The soreness and stiffness gradually decreased but a persistent radiating pain developed. The pain was localized into the left side of the pharynx and the base of tongue radiating to the left cheek and ear. The pain persisted and the patient underwent tonsillectomy with no benefit. A styloideus-syndrome was suspected and one molar was extracted, dental pathology was excluded and night-time dental braces were ordered. Pain kept worsening, and subjectively, the worst symptoms were a painful, hyperesthetic area, and a sharp lancinating sensation in the left ear. In the chin the pain was pulsating and gnawing. Cold weather worsened the symptoms considerably. The patient was extensively studied with MRI CT
0304-3959/99/$ - see front matter 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S03 04-3959(98)002 18-8
442
O.A. Kirvela¨, E. Kotilainen / Pain 80 (1999) 441–443
scans, nerve and muscle conduction studies. Glossopharyngeal nerve damage was suspected but no evidence supporting this diagnosis was found. The patient was referred to the pain clinic in 1992 with the provisional diagnosis of neck-tongue syndrome. Physiotherapy, TNS-treatment, and trigger-joint injections were without benefit. It was felt that a diagnosis of whiplash-type syndrome was appropriate. Despite heavy medication (codeine, dextropropoxifen, paracetamol and tratsodone hydrochloride) the patient still had severe pain and side effects of the drugs caused problems at work, where he was facing retirement. As a sympathetic component to his pain had not been ruled out, a stellate ganglion block was tried. The first block was performed on the left side with 15 ml of 0.5% bupivacaine and pain disappeared for 3 days. The blocks were repeated bi-weekly and the duration of painless periods started to prolong, and medication was gradually decreased. Six months later the volume of bupivacaine was increased to 20 ml prolonging the painless period further to 10–14 days and patient stopped using medication. To achieve continuous sympathetic block an infusion port (Chemo-Port, HDC, CA) was installed 3 years later (1998). The tip of the catheter was placed at the stellate ganglion and the port beneath the channel on the left side. The system functioned well initially but was removed after 1 month due to occlusion. A new infusion port functioned for 2 months but had to be removed in mid 1996. Bi-weekly blocks were again restarted, but 3 months later the pain started to intensify and patient had to restart pain medication. At this phase epidural spinal cord stimulation seemed to be worth trying. A percutaneous technique was selected and in January 1997 the spinal cord stimulator electrode was inserted. The epidural electrode (Pisces Quad Plus, Medtronic, MN) was advanced under fluoroscopic control up to the level of the base of dens (foremen magnum). With trial stimulation, paresthesias were felt all over the painful area. After a week of stimulation the patient felt substantial relief of pain. The connecting wires of the trial stimulator were removed and the electrode was internalized and attached to a pulse generator (Itrel 3, Medtronic, MN) which was implanted below the right clavicle. The patient has now been without pain and analgesics for 18 months, and is doing well at work. He has experienced minor discomfort from the system while exercising, but otherwise the device does not interfere with his daily activities.
diagnosed for a long time, which is not uncommon with this type of pain (Evans et al., 1994). Sympathetic involvement has been proposed as one factor in prolonged whiplash-type pain (Bonica, 1990). Traction injuries of the autonomic nerves surrounding the vertebral artery, tethering of the brainstem, and post-concussion cerebral disorders could explain these symptoms (Evans et al., 1994; Jonsson et al., 1994). Our patient had sympathetic nervous system related symptoms, e.g. coldallodynia and as a form of confirmation stellate ganglion blocks proved beneficial. We were greatly encouraged by the gradual success of these blocks and, optimistically expected even longer pain relief to be achieved. As this did not happen, the patient was twice scheduled for surgical sympathectomy. However, the patient is relatively young, and as the beneficial effect of sympathectomy inevitably would be temporary, but with the possibility that side effects could be permanent (Loeser et al., 1990), the procedure was canceled. Instead, a subcutaneous delivery system was installed to achieve continuous sympathetic block. Our patient was quite happy with it while it worked, but technical problems proved difficult to overcome. When the pain state started to worsen, trying SCS seemed appropriate. Successful use of SCS in the treatment of reflex sympathetic dystrophies (Barolat et al., 1989; SanchezLedesma et al., 1989). As it is important to achieve stimulation paresthesias in the topographical representation of the patient’s pain (North et al., 1994), we were forced to advance the tip of the electrode to the level of the base of the dens until satisfactory paresthesias were achieved. Interestingly, the first subjective feeling from stimulation was a warm, almost burning sensation over the previously painful area. During the trial stimulation pain symptoms started to disappear. First to give way were allodynia and hyperesthestia around the left ear. Last to disappear were the lancinating sensations, which sporadically appeared even a few weeks after the internalization of the system. SCS is an expensive and invasive way to treat pain. However, in addition to relieving pain and improving the quality of life of our patient, it has already caused considerable savings. The patient no longer needs his bi-weekly hospital visits, sick leave or medication. His performance at work has improved and he has been able to return to work outdoors as cold allodynia has subsided. Our case shows that SCS can offer an alternative treatment in whiplash-type pain syndrome of this complexity.
3. Discussion
References
Whiplash-type injuries result in long-term disability with up to 6% of patients not returning to work after 1 year. Worsening and intractable symptoms caused our patient to face retirement due to the side-effects of medication and the disabling pain. Our patient, who clearly had a whiplash-type neck distortion with associated pain symptoms was not
Barolat, G., Schwartzman, R. and Woo, R., Epidural spinal cord stimulation in the management of reflex sympathetic dystrofy, Stereotact. Funct. Neurosurg., 53 (1989) 29–39. Bonica, J.J., Neck pain. In: J.J. Bonica (Ed.), The Management of Pain, Lea and Febiger, Beckenham, UK, 1990, pp. 848–867. Byrn, C., Olsson, I., Falkheden, L., Lindh, M., Ho¨sterey, U., Fogelberg, M., Linder, L.-E. and Bunketorp, O., Subcutaneous sterile water injec-
O.A. Kirvela¨, E. Kotilainen / Pain 80 (1999) 441–443 tions for chronic neck and shoulder pain following whiplash injuries, Lancet, 341 (1993) 449–452. Deans, G.T., McGalliard, J.N., Kerr, M. and Rutherford, W.H., Neck sprain. A major cause of disability following car accidents, Injury, 18 (1987) 10–12. Evans, R.W., Evans, R.I. and Sharp, M.J., The physician survey on the post-concussion and whiplash syndromes, Headache, 34 (1994) 268– 274. Jonsson, H., Cesarini, K., Sahlstedt, B. and Rauschning, W., Findings and outcome in whiplash-type neck distortions, Spine, 19 (1994) 2733– 2743. Loeser, J.D., Sweet, W.H., Tew, J.M. and van Loveren, H., Neurosurgical operations involving peripheral nerves: sympathectomy. In: J.J. Bonica (Ed.), The management of pain, Lea and Febiger, 1990, pp. 2050–2056. Lord, S.M., Barnsley, L., Wallis, B.J., McDonald, G.J. and Bogduk, N., Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain, N. Engl. J. Med., 335 (1996) 1721–1726.
443
Maimaris, C., Barnes, M.R. and Allen, M.J., Whiplash injuries of the neck: a retrospective study, Injury, 19 (1988) 393–3965. Mendelson, G., Not ‘cured by a verdict’: effect of legal settlement on compensation claimants, Med. J. Aust., 2 (1982) 132–134. Norris, S.H. and Watt, I., The prognosis of neck injuries resulting from rear-end vehicle collisions, J. Bone J. Surg., 65 (1983) 608–611. North, R.B., Kidd, D.H., Zahurak, M., James, C.S. and Long, D.M., Spinal cord stimulation for chronic, intractable pain: experience over two decades, Neurosurgery, 32 (1993) 384–395. North, R.B., Kidd, D.H., Lee, M.S. and Piantadosi, S., A prospective randomized study of spinal cord stimulation versus reoperation for failed back surgery syndrome: initial results, Stereotact. Funct. Neurosurg., 62 (1994) 267–272. Sanchez-Ledesma, M.J., Garcia-March, G. and Diaz-Cacajo, P., Spinal cord stimulation in deafferentation of pain, Stereotact. Funct. Neurosurg., 53 (1989) 40–45.