An Overview of Cervical

Facet Injury Due to Rear-

Impact Automobile
Accidents

DR. BARRY L. MARKS

PRACTICE OF CHIROPRACTIC
---
EMPHASIS ON
AUTOMOBILE INJURIES

ORANGE, CALIFORNIA
(714) 938-0575
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“S” Shape Spine the Source of Damage to

Cervical Facet Joints in “Whiplash”
Injuries
In 1997 MM Panjabi and JN Grauer of the Dept. of
Orthopaedics and Rehabilitation at Yale University School of
Medicine conducted “whiplash” studies on human cadavers.
The cadavers were subjected to forces simulating a rear-impact
automobile collision while high speed motion x-rays caught the
effects on film. Researchers made a startling new discovery. It
was always thought that hyperextension occurred in the neck,
which resulted in “whiplash” injuries. This study in 1997 found
that the lower vertebrae of the neck (C5-6) actually changed
their axis of motion and spun backwards causing their posterior
joints (facets) to collide, while the top of the neck was bent
forward momentarily. At a given point into the collision, the neck
actually formed an “S-shape”.

This study found much attention and in 1998 Panjabi MM,

Cholewicki J, Nibu K, Grauer JN, Babat LB, Dvorak J and Bar
HF repeated the study at the Yale University School of Medicine
only this time using live human subjects. The principles of the
1997 study were able to replicate the results of the previous test
on live human volunteers. The same “S-shaped” configuration
was noted and the lower cervical facet extension was noted.
The test was performed at various collision speeds to find the
human tolerance for such an injury. The results were shocking.
The “S-shape” configuration was observed in speeds as low as
2.5 mph!

In 1999 Koji Kaneoka, Koshiro Ono, Satoshi Inami and Koichiro

Hayashi of the Department of Orthopedic Surgery at the
University of Tsukuba, Japan repeated the second Panjabi
study, again on live human volunteers. The results were the
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same. This third study confirmed for the world of spinal

researchers the mechanism by which human spines are
damaged in rear-impact automobile collisions.

Panjabi MM, Grauer JN (1997): "Whiplash produces a S-shape curvature of the neck
with hyperextension at lower levels. " Spine 22 (21): 2489-94.

Panjabi MM, Cholewicki J, Nibu K, Grauer JN, Babat LB, Dvorak J, Bar HF (1998-12-
01): "[Biomechanics of whiplash injury]." Orthopade 1998 Dec; 27(12): 813-9.

Koji Kaneoka, Koshiro Ono, Satoshi Inami and Koichiro Hayashi (99-04-15). "Motion
analysis of cervical vertebrae during whiplash loading." Spine 24(8): 763-770
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Summary of Panjabi & Kaneoka Studies

Human subjects were placed in vehicles that were subjected to
rear-impact collisions at various speeds. The spine was
recorded using high-speed motion X-rays, called
cineradiography.

At 50 milliseconds into the impact, the lower cervical vertebrae

at C5-6-7, rotate into extension causing stretching and tearing
of ligaments in front of the spine and compressing of facet joints
resulting in facet joint surface damage.

At maximum extension of C5-6-7, the upper vertebrae flex

forward making an S-shape curve, stretching and tearing soft
tissues of the back of the neck.

The damage occurs in fractions of a second, before the patient

is aware of the collision.

The tests proved:

1. The spine deforms into an S-shape
2. Damage of the facets occurs in rear-impact collisions due
to the rotation of the lower vertebrae into extension
3. The damage occurs prior to consciousness and before
reflexes can protect the neck
4. Damage occurs at very low speeds, as low as 2.5 mph
5. Damage occurs without so called, “hyperextension” of the
neck.
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“The study of Kaneoka et al now fills a critical gap in

the story of cervical facet pain. It provides the missing
biomechanical link. Theirs is the most significant
advance in biomechanics of whiplash since the
pioneering studies of Severy et al in 1955”

“As a result of this study, we no longer rely on

inference or speculation; we have a direct
demonstration of the mechanism of injury in
whiplash.” 1

Nikolai Bogduk, MD, PhD, DSc, FAFRM

Dept. of Anatomy and Musculoskeletal Medicine
University of Newcastle
Newcastle Bone and Joint Institute
Royal Newcastle Hospital
Newcastle, New South Wales, Australia

1
Spine 1996; 21: 1737-1745
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The Facet Joints are the Primary Area of

Damage and Pain in the Neck from
Whiplash Injuries
“Cervical (facet) joint pain is common among patients
with chronic neck pain after whiplash… and has
proven to be of major clinical importance” 2
Nikolai Bogduk, MD, PhD, DSc, FAFRM

Due to the S-shape deformation of the cervical spine on impact,

the facet joints are severely compressed causing damage to the
articular cartilage surface. This results in predictable pain
patterns that are readily identified on physical examination.

The pattern of pain from an injured facet joint has been referred
to as “Sclerotomal” pain. Unlike dermatomal pain, which
describes pain from a nerve root to it’s corresponding body part
like in a herniated cervical disc radiating pain into the arm or
hand, Sclerotomal pain corresponds with embryonic origin of
tissues so that a source of pain may be widely separated from
it’s radiation pattern and has no corresponding neurologic
connection. In the cervical spine facet joints, damage sends
pain to the lateral aspect of the neck and down into the scapula
region. It can be aggravated for diagnostic purposes by bending
the neck laterally and into extension, compressing the facets
and reproducing the pain pattern.

Facet joint injuries CANNOT be found on MRI or

electrodiagnostic tests like EMG and NCV, but objective proof
can be found if the practitioner know how to find it.

2
Pain, 54 (1993) 213-217
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Sclerotomal pain pattern of the cervical

facet joints as described by Dwyer, Fracs,
Aprill and Bogduk in December 1989
Annals of Surgery
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Documenting Facet Joint Injuries

As we have seen cervical facet joints are the leading factor in
neck pain form automobile collisions. We have also learned that
they occur even in very low speed collisions and that they
cannot be visualized on MRI or with EMG or NCV tests.
The documentation of facet joint injury and damage is done in
two manners:

1. Clinical examination
Subjective pain patterns for facet joints are predictable. Careful
documentation of the patient’s complaints leads to a suspicion
of facet joint damage after a MVC.

Objective examination procedures that provoke the facet joints

can be employed and is a reproducible means of locating facet
joint damage. Particularly, simultaneous lateral flexion and
extension of the suspected joint will yield the characteristic pain
pattern described earlier.

2. Imaging
Digital Motion Fluoroscopy is the imaging procedure used by
Panjabi and Kaneoka in their landmark studies on whiplash
injuries. It is a high speed x-ray that is able to display the
skeleton as it actually moves. In essence, it is a live x-ray video.
The images can then be analyzed by a radiologist for defects in
motion. The most common defects found are of the alar and
accessory ligaments of the C1-C2 vertebrae and the facet
capsular ligaments of C2 through C7.
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Poor Prognosis for Chronic Whiplash

“25% of whiplash injuries will progress to chronic
symptoms. These patients injured their discs or facet
joints. These patients will not resolve spontaneously
and they do become chronic. They may improve over a
period of 2 years, but are unlikely to improve after 2
years.”
“10% of patients with whiplash injuries develop
constant severe indefinite neck pain.” 3
Other studies have found the chronic cases number to be even
higher. A consensus of recent research found the chronicity rate
to be 38% 4

Osteoarthritis 6 Times More Likely

After Whiplash
Damage to the facet joint surface leads to breakdown of the
tissue and permanent arthritic changes.

Studies by Hohl and Miyamoto et al. report increase incidence

of osteoarthritis following whiplash that is permanent often
leaving the victim with years or perhaps a lifetime of residual
pain and disability.5,6,7

3
Whiplash Injury Clinical Review Lord, Barnsley and Bogduk Pain 58, 1994, 283-307
4
9th Annual SRISD Scientific Conference, Coronado, CA November 2004
5
Foreman, D. and Croft, A., Whiplash: The Cervical Acceleration/Deceleration
Syndrome, 1989, Williams & Wilkins
6
Hohl M: Soft tissue injuries of the neck. Clin Orthop Rel Res 109:42-49, 1975
7
Miyamoto S: Spine 16(10):5495-5500, 1991
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Chiropractic Treatment Best for

Whiplash Injuries
Facet joint injuries require appropriate treatment to minimize or
prevent later complications such as arthritis.

A 1996 study by renowned researchers Gargan and Bannister,

indicated:

"…benefits can occur in over 90% of patients

undergoing chiropractic treatment for chronic
'whiplash' injury."

"No conventional (medical) treatment has proven to

6
be effective in these established chronic cases."
Therefore, chiropractic care is the patient's best chance of
improving when suffering from whiplash injuries.

Chiropractic treatment benefits the patient with damaged facet

joints by restoring normal motion and mechanics to the cervical
facet joints through manipulation and rehabilitative therapies
and exercises.

6
Injury 27(9): pp. 643-645
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Croft Guidelines for Whiplash

Severity & Treatment

In 1993, Arthur Croft, D.C., M.S., M.P.H., F.A.C.O., F.A.C.F.E.,

published a set of management guidelines in the ACA Journal.
These guidelines have also been published in Whiplash
Injuries: the Cervical Acceleration/Deceleration Syndrome,
second edition, in 1995 and in a recent Canadian practitioner's
guide to whiplash injuries, sanctioned by the Canadian
Chiropractic Association.

The Croft Guidelines have been a part of our literature now for
eight years. No competing guidelines relative to CAD treatment
have been published during that time, with the exception of the
Quebec Task Force Guidelines on WAD, but these are only
applicable for patients who remain on disability. Several
American state chiropractic organizations and associations, as
well as in at least one Canadian province, have now adopted
the Croft Guidelines.
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Grades of Severity of Injury

Grade 1 - Minimal; No limitation of motion; No ligamentous
injury; No neurological findings

Grade 2 -Slight; Limitation of motion; No ligamentous injury; No

neurological findings

Grade 3 - Moderate; Limitation of motion; Ligamentous

instability; Neurological findings may be present

Grade 4 - Moderate to Severe; Limitation of Motion; Some

ligamentous injury; Neurological findings present; Fracture or
disc derangement

Grade 5 - Severe; Requires surgical management and/or

stabilization

Guidelines for Frequency and Duration of Care in

Cervical Acceleration/Deceleration Trauma
Daily 3x/wk 2x/wk 1x/wk 1x/mo TD TN
Grade I 1 wk 1-2wk 2-3 wk <4 wk --1 <11 wk <21
Grade II 1 wk <4 wk <4 wk <4 wk <4 mo <29wk <33
Grade III 1-2 wk <10 wk <10 wk <10 wk <6 mo<56 wk <76
Grade IV 2-3 wk <16 wk <12 wk <20 wk --2 --2 --2
Grade V Surgical stabilization necessary - chiropractic care is post-surgical

TD = treatment duration; TN = treatment number

1
= Possible follow-up at 1 month
2
= May require permanent monthly or p.r.n. treatment
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Summary:
A consensus has been reached within the medical and scientific
community that the “facet” joints are the most common source
of pain and disability in whiplash type injuries.

These injuries have a consistent pattern of pain that can be

readily observed and replicated upon examination by a skilled
medical expert.

Fact joint injuries do not appear on MRI or electro-diagnostic

testing but can be found on physical examination, plain film
radiography and video fluoroscopy.

Facet joint injuries can be managed conservatively and respond

best to chiropractic manipulation.

The overall prognosis for motor vehicle collision induced facet

joint injuries are poor as at least 25% and upwards of 43% of
victims will suffer chronic intractable pain and disability.

Treatment guidelines have been established and adopted

specifically for chiropractic management of whiplash type
injuries. These guidelines are useful to treating chiropractors,
medical physician’s, attorneys and insurance adjuster to
establish whether treatment is within reasonable guides.