Cervical Facet Syndrome Clinical Presentation

Updated: Aug 28, 2018
  • Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD  more...
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Presentation

History

Patients with cervical facet joint syndrome often present with complaints of neck pain, headaches, and limited range of motion (ROM). The pain is described as a dull, aching discomfort in the posterior neck that sometimes radiates to the shoulder or mid back regions. Patients also may report a history of a previous whiplash injury to the neck.

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Physical

Clinical features that are often, but not always, associated with cervical facet pain include tenderness to palpation over the facet joints or paraspinal muscles, pain with cervical extension or rotation, and absent neurologic abnormalities. Signs of cervical spondylosis, narrowing of the intervertebral foramina, osteophytes, and other degenerative changes are equally prevalent in people with and without neck pain.

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Causes

Bogduk and Marsland studied patients with neck pain without objective neurologic signs to determine if the facet joints were the primary source of their pain. [43] Twenty-four consecutive patients presenting at a pain clinic with neck pain of unknown origin were entered into the study. Those with lower cervical spine pain underwent C5 and C6 medial branch blocks first. If these medial branch blocks did not provide relief, then adjacent levels were blocked until the pain was relieved. Those with upper cervical spine pain underwent third occipital nerve blocks, and then C3 and C4 medial branch blocks if necessary. Bupivacaine was used as the blocking agent and a positive response was considered total pain relief for at least 2 hours. [43]

Fifteen patients experienced complete relief of their neck pain, and repeat blocks had the same effect. Seven of these patients underwent intra-articular facet joint blocks, corresponding to the levels determined by the medial branch blocks, which also completely relieved their pain. [43] No clinical or radiologic features corresponded with the positive responses. This finding suggests that facet joints in the cervical spine can be a significant source of neck pain and that medial branch blocks can be used as both diagnostic and therapeutic tools in the management of this type of pain. [43]

Each facet joint seems to have a particular radiation pattern upon painful stimulation. Even in subjects without neck pain, stimulation of the facet joints by injecting contrast material into the joints and distending the capsule produces neck pain in a specific pattern corresponding to the specific joint.

In a study of 5 such subjects, joint pain referral patterns were mapped out. [44] The C2-C3 facet joint refers pain to the posterior upper cervical region and head, whereas the C3-C4 facet joint refers pain to the posterolateral cervical region without extension into the head or shoulder. The C4-C5 joint refers pain to the posterolateral middle and lower cervical region, and to the top of the shoulder. The C5-C6 joint refers pain to the posterolateral middle and primarily lower cervical spine and the top and lateral parts of the shoulder and caudally to the spine of the scapula. The C6-C7 joint refers pain to the top and lateral parts of the shoulder and extends caudally to the inferior border of the scapula.

These pain referral maps were subsequently used to predict the segmental origin of neck pain in 10 symptomatic patients, who were referred for radiologic evaluation of possible facet joint pain. [45] Each of these patients was interviewed before the procedure and recorded the distribution of their pain on a diagram. These diagrams were compared with the maps previously generated from the asymptomatic subjects, and the facet joint or joints thought to be responsible for the pain patterns were predicted. Afterward, the patients underwent diagnostic facet joint nerve blocks at the predicted levels, and the pain was completely relieved in all but one patient. [45] This result suggests that these pain referral maps may be a powerful diagnostic tool when evaluating patients with cervical pain.

Facet joint pain referral patterns have also been documented in the OA joint and the lateral AA joint. Dreyfuss et al studied 5 asymptomatic subjects and injected the right AA joint and the left OA joint in each participant with contrast medium to distend the capsule. [46] The resultant pain referral patterns for the AA joints were similar and located posterior and lateral to the C1-C2 segments. The patterns for the OA joints were variable and extended from the vertex of the skull to the C5 segment. Perceived pain was also greater with the OA injections compared with the AA injections. Pain referral patterns have also been documented in symptomatic patients and correspond well to those obtained from asymptomatic subjects. [47]

Fukui et al created pain referral patterns from the OA facet joint to the C7-T1 joint. [4] The investigators studied 61 patients with neck pain and stimulated the painful joints by the following 2 methods: injection of contrast medium into the joints and electrical stimulation of the medial branches. Two separate pain referral maps were constructed, and the facet joints and their corresponding medial branches correlated relatively well. [4]

Windsor et al electrically stimulated the medial branches of the C3-C8 posterior primary rami with or without the third occipital nerve in 9 subjects. [48] This study demonstrated that the medial branch and third occipital nerve, when stimulated individually, have a separate and distinct referral pattern from the facet joint referral patterns previously mentioned. These medial branch referral maps may provide additional insight in the evaluation of patients with suboccipital, cervical, or shoulder girdle pain.

A composite drawing of the referral patterns of 9 A composite drawing of the referral patterns of 9 subjects derived from the minimal threshold stimulation of their right occipital nerve and C3-C8 medial branches
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