JPR Dove Medical Press


Whiplash injury occurs when there are sudden forward, backward, or sideway movements of the neck caused by acceleration-Deceleration force transfer to the neck, usually resulting from a motor vehicle collision.1,2 This results in injury to the cervical spine (intervertebral discs, facets, and ligaments) and soft tissues of the neck (muscles and tendons), causing neck pain, headache, stiffness, and loss of neck movement.3 Although approximately 50% of patients with whiplash injury recover completely, the remaining 50% are known to have some degree of persistent symptoms.4 Recovery from whiplash injury mostly occurs within 3 months of the injury, and the recovery rate significantly declines after this period, with only minimal improvement occurring more than 1 year after the injury.1,5,6

Numerous studies in the past have examined the results of whiplash injuries. They found that a higher incidence of gender, age, and intense initial neck pain were the main risk factors that could lead to a poor prognosis for neck pain resulting from whiplash injuries. 5,7-10 However the factors that could be used to predict the long-term outcome for chronic neck pain following a whiplash injuries have not been studied.

The facet joint in the cervical region is the most frequent cause of chronic neck discomfort. 11,12 During the course of a whiplash injury overstressing the facet joints by the force of movement could cause the tear of joint capsule as well as the capsular ligament facet joint hemarthrosis cartilage damage to the articular surface and synovial fold dislocation. 11,12 Inflammation in as well as around joint capsule can cause neck pain and whiplash injuries that are related to whiplash. However, the inflammation can be effectively managed by corticosteroid injections. In addition, intra-articular facet joint injections are effective in managing whiplash-related neck pain. 13-17 Furthermore injuries on the joint capsule may be repaired through the healing process. But the moment neck pain becomes chronic, treatment becomes more difficult. 18 Chronic pain is not just an extension of pain that is acute; it could trigger neural plasticity and sensibilization to the system of nerves, including the nerves of peripheral origin, spinal cord, as well as the the brain. 18,19 In this way, it triggers changes in the nervous system. 18,19 Because corticosteroids play no role in controlling the process of neural sensitization or plasticity and reduce pain, the effects of intra-articular corticosteroid injections are generally diminished when utilized to treat chronic pain. Sensitized pain can be resistant to various pain-reducing treatments and the prognosis for it is often low. 18,19

We think that the absence of reaction to intra-articular corticosteroid injection for patients suffering from chronic neck pain caused by whiplash injuries indicates the fact that pain in neck is mostly related to sensitization or plasticity in the central nervous system. So, the outlook for chronic neck pain resulting from whiplash injury is not good.

In the present study, we analyzed the extent to which the corticosteroid injections intra-articular to the facet joint will predict the long-term prognosis (at minimum 5 years after the first sign of injury) of chronic whiplash injury that is related to neck pain.



The study was carried out retrospectively. Patients suffering from chronic cervical pain caused through whiplash injury. Patients attended the pain clinic at the hospital of a university in November 2013 and had received injections into the facet joints of their intra-articular from November 2013 until November 2016. The criteria for inclusion were as following: (I) age between 20 to 79 years when they suffered the the whiplash injuries; (II) persistent whiplash neck pain that is the result of injury sustained between 3 and 12 months after injury with an NRS (NRS) score >3 (NRS zero to 10 zero pain; 10 worst pain possible); (III) failure to respond to oral pain medicines; (IV) >= 80percent short-term pain relief following a diagnostic block using intra-articular injections of 0.3 milliliters of lidocaine 2; (V) received intra-articular corticosteroid injections 3-12 months after the onset of symptoms the onset of pain; and (VI) there were no radicular signs. Patients who have an previous history of neck discomfort prior to whiplash injury, rheumatic conditions or psychiatric issues were not included. The study was accepted through the Yeungnam university hospital review board (2021-06-021). The informed consent was obtained orally , by asking participants to a phone assessment and was subsequently approved by the Yeungnam review board of the university hospital since a face-to-face meeting with participants was a challenge and the study was not associated with any potential to harm patients. We adhered to all of the Declaration of Helsinki guidelines.

Intra-Articular Facet Joint Corticosteroid Injection

Injections of corticosteroid intra-articular to the facet joint were administered using an anterior approach to C-arm fluoroscopy while the patient was in a prone posture (Siemens, Munich, Germany). The patients were positioned on their thorax, resting it upon two cushions, with their necks fully bent, and their heads moved 60-90 deg away from the injection site. Following neck flexion C-arm tube was rotated in a cephalic direction until it was an angle that was tangent to the joint space between the cervical facet. A 26-gauge 90mm spinal needle then was inserted with microscopes parallel to the C arm beam. After confirming intraarticular accessibility by injecting 0.3 milliliters of contrast in the CFJ space, we administered 10 mg (0.25 milliliters) of triamcinolone acetonide with 0.25 milliliters of 0.125 percent Bupivacaine. The intraarticular injection was successful for all patients recruited.

Evaluation on the Five-Year Outcome Whiplash Neck Pain resulting from injury

In all, 65 people were enrolled and one researcher was the one to conduct all interviews via telephone to assess the five-year outcomes of neck pain caused by whiplash. In the course of our investigation we were asked: (I) “Are you still suffering from neck pain caused through the injury?”; (II) “Rate the intensity of neck pain you are experiencing on the scale of 0-10 with 0 representing no pain, and 10 being the most painful pain you can imagine”; (III).

Are you taking pain medication recommended by a physician or receiving injections in an in-hospital or pain clinic to relieve neck pain resulting from the accident? And (IV) “Is you job at your workplace or at home affected due to your neck discomfort?”

Data Collection through Chart Review and Group Division

Age and gender, the time from the time of injury until NRS assessment prior to injection of corticosteroid time from the onset of injury until the day of the telephone interview the severity of neck discomfort (NRS) between 3 and 12 months following injuries from whiplash (prior to intra-articular corticosteroid injection) and the severity in neck discomfort (NRS) one month following intra-articular corticosteroid injections were gathered through a chart review. We defined a positive response to intra-articular injections of steroid by a greater than 50% reduction in pain one month after having the injection. A low response as less than 50 percent reduction in pain at one month following the injection. We classified the patients between “good responders” as well as “poor reaction group.”

Analysis of Statistical Analysis

We compared demographics along with the longer-term outcome (at minimum 5 years following the injury began) among the two group employing the Mann-Whitney U-tests (age and duration between the time of onset of injury to NRS examination before injection and the period between the time of onset of the injury until date of the phone interview, the severity of neck pain prior to injection as well as one month after injection, and the severity of neck pain for at minimum five years following the onset of injury) in addition to Chi-square tests (sex as well as the existence of persistent neck pain, whether taking oral pain medications or receiving injection therapy as well as any injuries-related disruptions that occur during work for at minimum five years following the onset of injury). A p-value lower that 0.05 was considered to be statistically significant. The analysis was conducted using SPSS Version 26.0.


Of the 65 patients recruited forty (47.6 +/- 12.2 years old at time of accident; M:F = 17:23) took part in the phone interview (Table 1. Additional 1.). In all 40 patients, accidents involving traffic caused injuries to the neck. Results from the NRS that was administered one month following the intra-articular corticosteroid injection were available for all 40 patients in Table 1. The good as well as the poor-response groups there were differences in age, sex ratio, time between the onset of injury and NRS assessment before corticosteroid injection time from the beginning of injury to the date of interview and NRS scores for neck pain prior the injection did not differ significantly (age: 0.150; sex ratio: 0.080 while sexuality (p = 0.150 The time period from the time of onset of injury until the NRS examination completed just prior to the injection the p value was 0.327 and the time between the onset of the injury until date of the phone interview: the p value was 0.645; NRS scores indicating neck pain prior to injection the p value was 0.265) (Table 1.). The NRS score for neck pain after one month following having the injections was lower for the group with a high response when compared to the group with poor response (p = 0.001 Good response group = 1.9 + 1.0 and low response group = 4.1 +1.5). 1.5).

Table 1. A Comparison between Demographic Information as well as Long-Term Results (at at least 5 years after the onset from Whiplash Injuries) Between the Good Response Group and the Poor Response Group

A follow-up of at five years from the whiplash injury was found to be that the percentage of patients suffering from persistent neck pain resulting from whiplash injuries is significantly less in the group with a high response compared to the group with poor response (p = 0.011 Good responders, 64.7% vs poor response group, 95.7%). Additionally to this, the NRS score of the group with a high response was lower that of those in the low response group (p = 0.007 (good responders = 2.1 + 2.0 vs. poor response group = 4.0 + 2.1).

The percentage of patients who took oral painkillers prescribed by a physician or receiving injections in an in-hospital or pain clinic for the treatment of neck pain were lower for the group with a good response than the group with poor response (p = 0.005 (good reaction group 29.4 percent vs. poor response group 73.9 percent). The percentage of patients who stated that their job (workplace or at home) had been affected because of current neck pain was less for the high-response group than the group with poor response (p = 0.017 (good response group is 41.2 percent vs. poor response group = 78.3 percent).


The study analyzed the long-term effects (at minimum 5 years after injury) of neck injuries resulting from whiplash. pain that occurred three to six months following the beginning of the injury, following the response to intra-articular corticosteroid injections to the facet joint. The results of our research showed that even though about 35% of the patients who had a positive response to corticosteroid injections had no pain from whiplash injuries The overall outlook of the patients included was not very favorable. From the patients that responded to the survey, 88 percent had neck pain caused by whiplash injury five years after the initial onset of injury. Additionally, those who didn’t have an adequate response to the intra-articular facet joint injections were significantly less likely to have a long-term outcome than those who had a positive response. Most of the patients, with the exception of one patient in the low response group, experienced chronic neck discomfort.

The recovery of neck pain following whiplash injury is thought to be limited after one year after the onset of pain, 1 we sought out patients suffering from whiplash injury-related chronic neck pain that occurred within one year of the injury’s onset. Our study observed that the prognosis for patients was not optimal, even when neck pain caused by whiplash was present for 3 to 12 months following the onset of the injury. Concerning studies that have previously examined the prognosis for whiplash injury-related neck discomfort, Rasmussen and al reported that about 55% of patients suffering from whiplash injury had some issues between 12-14 years after the injury’s onset. 20 In the same way, Sameh et al reported that about 30 percent of patients were treated to alleviate neck pain about 10 years after the injury’s onset. 6 The reason for the higher percentage of chronic neck pain in our study as compared to prior studies may be due to the differing the inclusion criteria in our study and previous studies. Our study included patients who suffer from chronic neck pain as a result of whiplash injuries; however prior studies have examined the results of patients suffering from acute-stage whiplash injuries.

Additionally, in the past women’s age, older age sexual orientation, and the initial intense pain were believed as a factor in slow recovery from whiplash injuries. 5,7-10 However the result of whiplash injuries according to the effectiveness of treatment to reduce pain has not been assessed. So to our best knowledge this research is the only one to demonstrate that the effect of intra-articular corticosteroid injections are associated with the long-term outcome of chronic whiplash-related pain.

We believe that the weak response to corticosteroid injections into the facet joint of cervical spine suggests that the pain from whiplash injuries could be a centralized issue. 18,19 Additionally the inability to respond suggests that the severity of joint damage could be significant and constant mechanical irritation could be present at the joint’s cervical surface.

In conclusion, while the long-term outlook for whiplash-related pain isn’t good, if the reaction to corticosteroid injection into the articular region is positive, then we can consider that there is a possibility that whiplash injuries is able to be successfully recovered. However, a the lack of response to corticosteroid injections indicates an increased risk of having bad long-term results. Our belief is that the findings of our study offer valuable clinical information to help predict long-term outcomes for whiplash injuries that cause persistent neck pain. However, the study does have certain limitations. One is the limited amount of patients. The second reason is that approximately 30% of initially selected patients didn’t respond to the interview via telephone. But, since the ratio between “good responding group” in the “good response group” and “poor responders” for the 25 patients who were not involved in the interview via telephone was not different from one direction so the lack of response could not have had an significant effect on the results of the study. A third factor was that no control group was enrolled. Fourth, the various outcomes, including sleeping quality and wellbeing of the mind, were not examined. The intergroup differences in the gender ratio was not taken into consideration when analysing the findings. Thus, studies to can compensate for these weaknesses should be considered in the near future.


NRS Numeric Rating Scale.

Data Sharing Statement

Data are accessible upon reasonable request to the author.

The Ethics Committee has approved the ethics approval of their ethical approval and consent to Participation

The study has been cleared through the Yeungnam University Hospital review board (2021-06-021). Consent was given in writing.

Author Contributions

The authors all contributed significantly to the study described. All authors participated in the concept, study planning, execution, and acquisition of data study and analysis as well as and in writing or revising the manuscript. All authors have given final approval for the version that will be published, and they have been able to agree on the journal that the article will be submitted. Additionally, they have agreed to be responsible for the entire work.


The present study was supported by a National Research Foundation of Korea grant funded by the Korean government (Grant No: NRF-2019M3E5D1A02069399).


The authors state that they do not have any conflicting interests in the research.


1. Bannister G, Amirfeyz R, Kelley S, Gargan M. Whiplash injury. J Bone Joint Surg Br. 2009;91(7):845-850. doi:10.1302/0301-620X.91B7.22639

2. Godek P. Whiplash injuries. Current state of the art. Ortop Traumatol Rehabil. 2020;22(5):293-302. doi:10.5604/01.3001.0014.4210

3. Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injuries. Chin J Traumatol. 2009;12(5):305-314.

4. Ritchie C, Sterling M. Prognosis and recovery pathways following whiplash injuries. Journal Orthop Sports Physical Therapy. 2016;46(10):851-861. doi:10.2519/jospt.2016.6918

5. Kamper, SJ Rebbeck TJ, Maher McAuley JH, Sterling M. Course and predictive factors associated with whiplash: A comprehensive review, meta-analysis and systematic study. Pain. 2008;138(3):617-629. doi:10.1016/j.pain.2008.02.019

6. Sameh E-S Mahmoud E-R. Mohamed MMM. Mifsud Rooney. Long-term follow-up after neck injury caused by whiplash. J Orthop Trauma Rehabil. 2013;17:583.

7. Cote P Cassidy JD Carroll L, Frank JW, Bombardier C. A systematic review of the treatment options for acute whiplash , and a brand new conceptual framework for synthesis of the literature. Spine. 2001;26(19):E445-E458. doi:10.1097/00007632-200110010-00020

8. Hendriks EJM, Scholten-Peeters GGM, van der Windt DAWM, Neeleman-van der Steen CWM, Oostendorp RAB, Verhagen AP. Prognostic factors that contribute to poor recovery in the acute case of whiplash. Pain. 2005;114(3):408-416. doi:10.1016/j.pain.2005.01.006

9. Norris SH, Watt I. The prognosis for neck injuries that result from rear-end collisions in vehicles. J Bone Joint Surg Br. 1983;65(5):608-611. doi:10.1302/0301-620X.65B5.6643566

10. Radanov Radanov BP, Sturzenegger M, Di Stefano G. Long-term outcomes following whiplash injuries. Two-year follow-up that examines the characteristics of the injury mechanism as well as physical, radiologic and psychosocial findings. Medicine. 1995;74(5):281-297. doi:10.1097/00005792-199509000-00005

11. Pearson AM, Ivancic PC, Ito S, Panjabi MM. Kinematics of the facet joint and injuries mechanisms in whiplash simulation. Spine. 2004;29(4):390-397. doi:10.1097/01.BRS.0000090836.50508.F7

12. Quinn KP, Dong L, Golder FJ, Winkelstein BA. Neuronal hyperexcitability in dorsal horn in the wake of a an injury to the facet joint that is painful. Pain. 2010;151(2):414-421. doi:10.1016/j.pain.2010.07.034

13. Dory MA. The neck facet joint. Radiology. 1983;148(2):379-382. doi:10.1148/radiology.148.2.6867328

14. Dussault RG, Nicolet VM. Cervical facial joint arthrography. J. Can. Assoc. Radiol. 1985;36(1):79-80.

15. Hove B, Gyldensted C. Cervical analgesic facet joint arthrography. Neuroradiology. 1990;32(6):456-459. doi:10.1007/BF02426454

16. Ng A, Wang D. Cervical facet injections in the treatment of Cervicogenic headaches. Curr Pain Headache Rep. 2015;19(5):484. doi:10.1007/s11916-015-0484-1

17. Roy DF, Fleury J, Fontaine SB, Dussault RG. Clinical examination of the neck facet joint irritation. Can Assoc Radiol J. 1988;39(2):118-120.

18. Ji RR, Nackley, Huh Y, Terrando N, Maixner W. Central sensitization and neuroinflammation in chronic and generalized pain. Anesthesiology. 2018;129(2):343-366. doi:10.1097/ALN.0000000000002130

19. Phillips K, Clauw DJ. Central mechanisms of pain in chronic states. It could be all in their heads. Best Practice Reclin Rheumatol. 2011;25(2):141-154. doi:10.1016/j.berh.2011.02.005

20. Rasmussen MK Kongsted A Carstensen T, Jensen TS, Kasch H. Re-examining risk stratified patients with whiplash 12-14 years after the injury. Clin J Pain. 2020;36(12):923-931. doi:10.1097/AJP.0000000000000877