Organic Basis for the Pain Associated with Soft Tissue Injuries
By Richard H. Adler
October 13, 1993
A recent study published in Spine, “Acute Injuries to Cervical Joints: An Autopsy Study of Neck Sprain,” by J.R. Taylor, M.D., Ph.D., and L.T. Twomey, Ph.D., establishes an organic basis for pain-associated cervical soft tissue injuries not visible on standard radiography.
Since the objective of this study was to search for cervical soft tissue injuries and lesions, only spines without radiologically visible cervical fractures or dislocations were included. The study was a comparative one of cervical spines from sixteen subjects who died of major trauma and sixteen controlled subjects who died of natural causes. The findings of this study were significant:
15 of 16 spines from victims of major trauma showed linear clefts within the cartilage plate in one or more cervical discs (average of 3 discs affected). The linear clefts, which varied from 3 mm. to 2 cm. in length, ran close to and parallel to the vertebral end-plate.
These linear clefts most often affected the peripheral part of the disc, near the vertebral rim, where the cartilage plate lamellae are continuous with the lamellae of the annulus fibrosus.
These cervical rim lesions lie between the transversely oriented lamellae of the cartilage plate and extend around the lamellae of the annulus. According to the authors, “this represents a split between the tissue planes of the cartilage plate and annulus where these are continuous with each other.” (p. 1118)
“Rim lesions are strongly associated with trauma in this study, but not with degenerative change. They principally involve the avascular cartilage plates but often extend into the outer annulus, which contains blood vessels and nerves, and sometimes into the bony vertebral end-plate, which is highly vascular.” (p. 1119 -1120)
The authors believe that chronic pain associated with soft tissue injuries to the cervical spine may occur because of “delayed healing and pre-disposition to premature degeneration as a result of the rim lesions in the intervertebral discs.” (p. 1121)
The authors conclude that these type of lesions or clefts would cause “acute pain at the time of the injury and would be likely to progress to early disc degeneration, with extension of the clefts and vascularization within the clefts. The discs may degenerate because the clefts separate the center of the disc from its sources of nutrition in the vessels of vertebral marrow and the outer annulus. These degenerative changes would also be likely to contribute to chronic pain and dysfunction of the cervical spine.” (p. 1121)
Since the wide spread use of seat belts, many patients survive motor vehicle accidents, yet many of them have persistent neck pain. Neck sprain without fracture or other objective sign of injury may pose a difficult diagnostic problem for practitioners. This undoubtedly adds to a patient’s distress, because there is no objective display of an injury to account for the pain. On occasion, such patients have been regarded as having a psychosomatic illness with little organic basis. However, this notion has been discarded over the years by strong empirical, clinical, and analytical studies. In fact, a substantial portion of neck sprains remain symptomatic for more than two years with little or no evidence of organic disease.
Current medical research confirms that soft tissue injuries can be very disabling and result in permanent problems. In one study, 45 percent of the patients continued to have symptoms 2 years after their legal cases had been resolved. In another study, 12 percent of the patients who suffered whiplash were still significantly disabled several years after the injury. X-ray studies reveal evidence that a whiplash victim is about 6½ times more likely than the general population to develop degenerative disc disease in the 4 year period following an injury. Additionally, 205 patients with neck pain were evaluated clinically and by repeat x-rays. After 10 years, 32 percent had moderate or severe residual pain. Another study reported that 43 percent of 146 patients followed for 5 or more years had significant permanent disability. In 1985, other researchers reported that 59 percent of patients state their injury caused some interference in their daily lives, especially with work and driving.
The Taylor and Twomey study published in Spine may represent another piece of the puzzle confronting cervical soft tissue injury victims and their health care providers. Mounting evidence indicates that a number of mechanisms may be responsible for the often chronic pain associated with whiplash and other sprain/strain-type injuries. An obvious gap has existed between the conventional teaching, which predicted complete recovery from this type of injury, and focused on the apparent absence of objective evidence to explain chronic pain symptoms. Research into areas such as myofacial disease, pain sensitivity of various soft tissue structures, and soft tissue healing processes have all helped to generate an understanding of the residual problems reported by trauma victims with non-radicular conditions. Physicians who are familiar with, or at least mindful of the accumulating literature, can play a critical role in the fair resolution of a trauma victim’s legal claim. The more information that is available and brought to bear in the case, the greater the likelihood of a just result in the legal arena.
At the law firm of Adler Giersch, P.S., we believe doctors, health care professionals, and experienced counsel form the first line of defense between the victim and debilitating physical injury and financial loss. The medical-legal connection is natural and best serves the interests of the patient-turned-client when both health care and legal communities work together. If we can assist any of your patients, simply have them give us a call. Consultations are without cost.
1 M.F. Gargan, G.C. Bannister, “Long Term Prognosis of Soft Tissue Injuries of the Neck,” J. Bone Joint Surgery, 1990, 72B:901-903; C. Hildingsson, G. Toolanen, “Outcome After Soft Tissue Injury of the Cervical Spine,” Acta Orthop Scand, 1990, 61:357-359; I. MacNab, “The Whiplash Syndrome,” Clinical Neurosurgery, 1973, 20:232-251; K.M. Porter, “Neck Sprains After Car Accidents: A Common Cause of Long-Term Disability,” British Medical Journal, 1989, Editorial 298:973-974.
2 T.W. Mead, S. Dyer et al., “Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Out-Patient Treatment,” British Medical Journal, 1990, Vol. 300, pp. 1431-1437.
3 Macnab, “Acceleration Extension Injuries of the Cervical Spine,” The Spine, 2nd ed., Vol. 1.
4 Gotten, “Survey of 100 Cases of Whiplash After Settlement of Litigation,” JAMA, Vol. 162, p. 865.
5 M. Hohl, “Soft Tissue Neck Injury,” The Cervical Spine, 1983, p. 285.
6 Donald R. Gore, M.D., Susan B. Sepic, M.S., Gena M. Garoner, B.S., and M. Patricia Murray, Ph.D., “Neck Pain: A Long-Term Follow-up of 205 Patients,” Spine, 1987, Vol. 12:1, pp. 1-5.
7 M. Hohl, “Soft Tissue Injuries of the Neck in Automobile Accidents: Factors Influencing Prognosis,” J. Bone Joint Surgery(M), 1974, Vol. 56, pp. 1675-1682.