Cervical Plexus Block (CPB) in Whiplash Associated Disorder (WAD)
Condition: Whiplash Associated Disorder
MeSH terms: Whiplash Injuries
Study type: Observational

Summary: 
      Whiplash is the most common injury associated with motor vehicle accidents and a major cause
      of disability and litigation. An acute whiplash injury follows sudden or excessive
      hyperextension, hyper flexion, or rotation of the neck affecting the soft tissues. It
      typically results from rear-end or side-impact motor vehicle collisions. Patients commonly
      present with pain and stiffness in the neck, headache, and upper backache. Chronic whiplash
      syndrome is characterized by symptoms of neck pain that persist for more than 3 months (1,
      2). With over half a million people making whiplash injury claims per annum in the UK, it has
      a major impact on the healthcare and legal systems and also the economy. Over 40% of patients
      with whiplash injury report chronic neck pain and this is often refractory to conservative
      management (pain relief medications, physiotherapy). Current treatment involves burning the
      small nerves that supply the joints (facet joints) in the neck. Although they provide pain
      relief that can last 6-9 months, the nerves re-grow and the treatment has to be repeated.
      This treatment is a complex procedure that requires extensive training and has the potential
      to cause serious harm. There is new evidence to show that the pain in whiplash injury could
      be due to an impaired function of the neck muscles arising from whiplash trauma. Current
      treatment for this condition is injection of numbing medicine or steroids directly into the
      muscle. Although this treatment is safer than burning the facet nerves, it provides
      short-term relief.

      The investigators have shown that a novel treatment targeting the nerves that supply the
      muscles in the neck can provide durable relief in patients with chronic neck pain. The
      medication is injected into a specific area (plane) in the neck of the patient and is called
      cervical plexus block (CPB). The investigators currently offer CBP treatment as a standard
      treatment in the management of patients with chronic neck pain arising from whiplash injury.
      There are two types of CPB: CPB with numbing medicine (CPB-LA) and CPB with steroid.

      Aim of the study is to evaluate the effectiveness of two types of Cervical Plexus Block (CPB)
      treatment in reducing pain at three months in patients with refractory chronic neck pain from
      whiplash injury

      Methods: The proposed study is a prospective, observational pilot study that will be
      conducted at Leicester General Hospital over 36 months. Potential participants will be given
      an information sheet by the clinical team when they are seen in the outpatient clinic. The
      participants will have 24 hours to read the information sheet. Thereafter, the research team
      will approach the potential participant to obtain informed consent. After providing written
      consent, adult patients with chronic neck pain from whiplash injury will receive ultrasound
      guided CPB-LA in the theatre. If treatment provides >30% relief at 3 months, they will be
      re-assessed at six months and CPB-LAi will be repeated as per waiting list. If at 3 months,
      the pain returns to the baseline, CPB with steroid will be performed. If CPB with steroid
      does not provide any benefit, the participants will receive a rescue treatment (trigger point
      injection) within three months. Participants will be asked to complete questionnaires on pain
      scores and mood. Participation in the study will end at 9 months following the first CPB
      treatment on completion of relevant questionnaires.
    

Detailed description: 
      Whiplash is the most common injury associated with motor vehicle accidents and a major cause
      of disability and litigation. An acute whiplash injury follows sudden or excessive
      hyperextension, hyper flexion, or rotation of the neck affecting the soft tissues. It
      typically results from rear-end or side-impact motor vehicle collisions. Patients commonly
      present with pain and stiffness in the neck, headache, and upper backache with or without
      paraesthesia of the upper limbs. Chronic whiplash syndrome is characterized by symptoms that
      persist for more than 3 months. With over half a million people making whiplash injury claims
      per annum in the UK, it has a major impact on the healthcare and legal systems and also the
      economy. In 1995, whiplash-associated disorder (WAD) was defined by the Quebec task force as
      'Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. The
      incidence of WAD is very variable, averaging to about 9 per 1000 people in the UK, the
      highest in Europe.

      Around 40% of patients suffer from symptoms of WAD beyond 3 months (chronic whiplash) and 2 -
      4.5% of patients are left permanently disabled.

      There is evidence that neck pain in WAD could arise from either cervical facet joint or due
      to impaired function of neck muscles (Cervicothoracic Myofascial Pain Syndrome, CTMPS) or
      both. The investigators have recently reported on ultrasound guided cervical plexus block
      with depot steroids in the management of refractory cervicothoracic myofascial pain. This
      intervention involves a single injection that targets a number of muscles that are commonly
      involved in causing chronic WAD. The treatment has a definite end point that helps to
      standardize the intervention with a good safety profile.

      The present study is an observational study on the effectiveness of two types of cervical
      plexus block (CPB-Local Anaesthesia and CPB-Steroids) treatment as a part of standard care in
      providing durable analgesia. The objective is to collect data to inform the design a larger
      multicentre study
    

Intervention name(s): Cervical Plexus Block with Local Anaesthesia; Cervical Plexus Block with Depot Steroids
Intervention type(s): Procedure; Procedure
Intervention description(s): Ultrasound guided intermediate cervical plexus block; Ultrasound guided intermediate cervical plexus block
Intervention MeSH terms: Anesthetics
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        This study is based on a cohort of adult patients present with chronic neck pain arising
        from whiplash injury Chronic Neck Pain is defined as persistent neck pain that lasts for
        more than three months.
      
Keywords: Cervical Plexus Block; Whiplash injury; WAD