Barbara J. Wallis

Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint-pain

BACKGROUND Chronic pain in the cervical zygapohyseal joints is a common problem after whiplash injury, but treatment is difficult. Percutaneous radiofrequency neurotomy can relieve the pain by denaturing the nerves innervating the painful joint, but the efficacy of this treatment has not been established. METHODS In a randomized, double-blind trial, we compared percutaneous radio-frequency neurotomy in which multiple lesions were made and the temperature of the electrode making the lesions was raised to 80 degrees C with a control treatment using an identical procedure except that the radio-frequency current was not turned on. We studied 24 patients (9 men and 15 women; mean age, 43 years) who had pain in one or more cervical zygapophyseal joints after an automobile accident (median duration of pain, 34 months). The source of their pain had been identified with the use of double-blind, placebo-controlled local anesthesia. Twelve patients received each treatment. The patients were followed by telephone interviews and clinic visits until they reported that their pain had returned to 50 percent of the preoperative level. RESULTS The median time that elapsed before the pain returned to at least 50 percent of the preoperative level was 263 days in the active-treatment group and 8 days in the control group (P=0.04). At 27 weeks, seven patients in the active-treatment group and one patient in the control group were free of pain. Five patients in the active-treatment group had numbness in the territory of the treated nerves, but none considered it troubling. CONCLUSIONS In patients with chronic cervical zygapophyseal-joint pain confirmed with double-blind, placebo-controlled local anesthesia, percutaneous radio-frequency neurotomy with multiple lesions of target nerves can provide lasting relief.

The prevalence of chronic cervical zygapophysial joint pain after whiplash.

Study Design. A survey of the prevalence of cervical zygapophysial jooint pain was conducted. Objectives. To determine the prevalence of cervical zygapophysial joint pain in patients with chronic neck pain after whiplash. Summary of Backgound Data. In a significant porportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggests many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic blocks. Methods. Fifty consecutive, referred patients with chronic neck pain after whiplash injury were studid using double-blind, controlled, diagnotic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. Results. A positive diagnosis was made only if both blocks relieved the patients pain and bupivacaine provided longer relief, Painful joints were identified in 54% of the patients (95% confidence interval, 40% to 68%). Conclusion. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Lack of Effect of Intraarticular Corticosteroids for Chronic Pain in the Cervical Zygapophyseal Joints

BACKGROUND Chronic pain in the cervical zygapophyseal joints is a common problem after a whiplash injury. Treatment with intraarticular injections of corticosteroid preparations has been advocated, but the value of this approach has not been established. We compared the efficacy of a depot injection of a corticosteroid preparation with the efficacy of an injection of a local anesthetic agent in patients with painful cervical zygapophyseal joints. METHODS Sixteen men and 25 women with pain in one or more cervical zygapophyseal joints after automobile accidents (mean age, 43 years; median duration of pain, 39 months) were randomly assigned to receive an intraarticular injection of either bupivacaine (0.5 percent) or betamethasone (5.7 mg) under double-blind conditions. The patients were followed by means of regular telephone contact and clinic visits until they reported a return to a level of pain equivalent to 50 percent of the preinjection level. The time from treatment to a 50 percent return of pain was compared in the two groups with the use of a survival analysis. RESULTS Less than half the patients reported relief of pain for more than one week, and less than one in five patients reported relief for more than one month, irrespective of the treatment received. The median time to a return of 50 percent of the preinjection level of pain was 3 days in the 21 patients in the corticosteroid group and 3.5 days in the 20 patients in the local-anesthetic group (P = 0.42). CONCLUSIONS Intraarticular injection of betamethasone is not effective therapy for pain in the cervical zygapophyseal joints after a whiplash injury.

False-positive Rates of Cervical Zygapophysial Joint Blocks

Objective:To determine the false-positive rate of anesthetic blocks of the medial branches of the cervical dorsal rami in the diagnosis of cervical zygapophysial joint pain. Design:Comparison between single diagnostic blocks, and a criterion standard of double-blind, controlled, differential anesthetic blocks. Setting:Tertiary referral center. Patients:The first 55 consecutive patients with neck pain for >3 months after and attributable to a motor vehicle accident, and who had completed a second diagnostic block after an initial positive response. A total of 60 joints was studied, with five patients providing two joints each. The mean age was 41 years: 61% were female. Methods:Each patient had been investigated with radiologically controlled blocks of the medial branches of the cervical dorsal rami to anesthetize the target cervical zygapophysial joint. The initial block was performed using either 0.5% bupivacaine or 2% lignocaine, randomly selected. The duration of pain relief was assessed in a double-blind fashion. The procedure was repeated with the complementary anesthetic. Only patients experiencing a longer period of pain relief from bupivacaine were considered to have true-positive responses. Results:The second block failed to relieve pain in two of the tested joints. In a further 14 joints, the control blocks relieved pain, but the patient failed to correctly discriminate the longer acting anesthetic. The remaining 44 joints met the criteria for true-positive responses. The false-positive rate of single blocks was 16 of 60 or 27% (95% confidence interval 15%, 38%). Conclusion:Uncontrolled diagnostic blocks are compromised by a significant false-positive rate that seriously detracts from the specificity of the test.

Pain and psychologic symptoms of Australian patients with whiplash.

Study Design A survey of pain intensity and psychological symptoms in patients with chronic neck pain after whiplash injury. Objectives To describe the pain and psychological profiles of patients with chronic whiplash. Summary of Background Data Reports in the literature mention a constellation of symptoms associated with chronic whiplash injury but no systematic survey using objective patient report measures has been reported. Methods One hundred forty consecutive referred patients with chronic neck pain after a motor vehicle accident were studied using the SCL‐90‐R psychological profile and the McGill Pain Questionnaire. Results Psychological profiles and pain intensity ratings, similar to profiles obtained from patients suffering from rheumatoid arthritis and low back pain of organic origin, were obtained. Conclusions The SCL‐90‐R is a convenient instrument to administer to patients with whiplash. It yielded a characteristic profile of pain and appears to be more expedient than other psychometric tests for these patients.

Clinical competence of interns

A clinical supervisors rating form addressing 13 competencies was used to assess the clinical competence of graduates one year after qualification in New South Wales (NSW), Australia. Data from 485 interns (97.2%) showed that graduates from the problem‐based medical school were rated significantly better than their peers with respect to their interpersonal relationships, ‘reliability’ and ‘self‐directed learning’. Interns from one of the two traditional NSW medical schools had significantly higher ratings on ‘teaching’, ‘diagnostic skills’ and ‘understanding of basic mechanisms’. Graduates from international medical schools performed worse than their peers on all competencies. These results were adjusted for age and gender. Additionally, women graduates and younger interns tended to have better ratings. Junior doctors have differing educational and other background experiences and their performance should be monitored.

The Psychological Profiles of Patients with Whiplash-Associated Headache

Headache often compounds chronic neck pain following whiplash injury. To better understand post-traumatic headache, the SCL-90-R symptom checklist was used to determine the psychological profiles of patients with whiplash-associated headache and of patients with whiplash-associated neck pain without headache. The psychological profiles of these patients were compared with previously published SCL-90-R profiles of patients with post-traumatic and nontraumatic headache, and of the normal population. Patients with whiplash-associated headache were not significantly different from those with other forms of post-traumatic headache or with whiplash-associated neck pain without headache. However, when patients with whiplash-associated headache and patients with nontraumatic headache were compared to normal data, significant differences emerged. Patients with nontraumatic headache exhibited higher scores on all subscales, whereas patients with whiplash-associated headache differed from the normal sample only on somatization, obsessive-compulsive, depression and hostility subscales, and the global severity index. These differences imply that patients with whiplash-associated headache suffer psychological distress secondary to chronic pain and not from tension headache and generalized psychological distress.

Ratings of performance of graduates from traditional and non-traditional medical schools

We compared clinical supervisors’ ratings of intern competence in Newcastle University graduates (whose medical school emphasizes community relevance and interpersonal skills) and in medical graduates of the Universities of Sydney and New South Wales, which have more traditional curricula. A 12‐item anchored supervisor rating scale was used to assess the professional competence of 428 interns on five occasions throughout the intern year. Data analysis was performed using two factors of clinical competence and personal characteristics, as well as an average annual total score, linear regression analysis was employed to estimate the adjusted effects of age, sex, and graduating university on the three scores. All three scores were higher for interns who graduated at younger than 25 years, irrespective of university of graduation or sex. Women scored higher on average than men, and Newcastle graduates were rated significantly better on average than Sydney University graduates for the personal characteristics ...

Learning decision-making in clinical medicine: a card game dealing with acute emergencies for undergraduate use

A card game concerning the assessment and management of patients involved in medical emergencies was constructed for use by medical students who were beginning Year 3 of a 5‐year curriculum. Particular emphasis was placed on the identification by the student of priorities for action and the justification for decisions made on the basis of underlying mechanisms. Our aim was to help the student sharpen his problem‐solving skills in situations where decisions may have to be made and interventions undertaken before information gathering is complete. The game is simple in construct and may be played by individuals or groups. It has a major advantage over other forms of problem presentation in that the student can select and document his own decision‐making pathway with minimal cueing and he may compare his pathway with that of the experts at the end of the game. Students and tutors found this approach enjoyable and realistic and considered the game a useful tool in our problem solving curriculum.

A Problem-Based Course in Human Sexuality

A medical curriculum based on the exploration of clinical problems rather than traditional discipline content has provided an appropriate context for a course on human sexuality. The problem-based approach has ensured that students examine physical, psychological, social, religious and ethical aspects of the sexual difficulties with which doctors are commonly confronted. The course offers the opportunity for students to develop their capacity for effective communication. Assessments are also problem-based both in written format and in a role-played consultation. Explicit objectives direct student learning and tutors guide discussion in group tutorials with a minimum of formal teaching. Because the course precedes studies in the area of reproductive medicine, its aim is to equip students to communicate comfortably about sexual problems when opportunities arise later in the course.The effects of the course on the students was assessed using the Sexual Knowledge and Attitudes Test of Leif & Reid (1972). The ...