Cervical Facet Syndrome Treatment & Management

Rehabilitation Program

Physical Therapy

Kibler et al defined 3 phases of rehabilitation of soft-tissue injuries. ^[52] The goals of the first phase are to reduce pain and inflammation, and increase the pain-free ROM. Ice is indicated during the acute phase to decrease blood flow and subsequent hemorrhage into the injured tissues, as well as reducing local edema. Application of ice can also reduce muscle spasm. Therapeutic modalities such as ultrasound and electrical stimulation may also reduce painful muscle spasms. Manual therapy, joint mobilization, soft-tissue massage, and muscle stretching are often helpful. Passive range of motion (PROM) and then active range of motion (AROM) exercises in a pain-free range should be initiated in this phase. Finally, strengthening should begin with isometric exercises and progress to isotonic as tolerated.

Surgical Intervention

Cervical fusion should be considered with great caution and only after aggressive nonsurgical care has failed. The outcome for cervical fusion in the setting of cervical facet syndrome is significantly less favorable than for radicular pain. ^{[53, 54]} Surgical fusion should not be based on spondylotic changes on plain films of the spine, as these changes are seen in asymptomatic people as often as symptomatic people and do not correlate with neck pain. ^[6] In fact, cervical facet joint pain still can occur after anterior cervical fusion. This may be related to small movements in the joints or intrinsic mechanisms that are not motion dependent. ^[7]

Other Treatment

Intra-articular facet joint injections

Moran et al studied joint arthrograms in a cadaveric lumbar spine. ^[55] Selected facet joints were injected with methylene blue, and then the spine was divided in the sagittal plane so the epidural space could be examined. The results of this study indicated that after administration of 1-2 mL of medium, extravasation occurs into the epidural space from the sacral to the upper lumbar area. ^[55] The investigators thought that the methylene blue may have leaked out of the facet through the superior recess, ^[55] which is reinforced by the ligamentum flavum and is adjacent to the adipose surrounding the spinal nerve. ^[56]

Barnsley et al studied the efficacy of intra-articular facet joint injections for the treatment of chronic cervical facet pain after whiplash injury. ^[57] Patients enrolled in the study had been diagnosed with a painful cervical facet joint by responding to different facet joint nerve blocks on 2 separate occasions with Xylocaine and bupivacaine and receiving a longer period of relief with bupivacaine. After allowing time for their usual pain to return, the patients underwent random intra-articular facet joint injections with either bupivacaine or betamethasone. Fluoroscopy was used to ensure that there was no extravasation of contrast out of the joint capsule and into the epidural space. ^[57]

The end point of the study was the return of pain to 50% of the preinjection level. On follow-up, the bupivacaine group had 3.4 days of pain relief and the betamethasone group had 3 days of pain relief. No significant difference was found between the 2 groups. ^[57] The duration of pain relief from intra-articular facet joint injections is not constant among different investigators. Some studies of intra-articular joint injections have reported only minor relief of pain for days to weeks, ^{[55, 57]} whereas others report substantial relief for weeks to months. ^{[58, 59, 60, 61]} Therefore, cervical facet injections are not supported by the current medical literature.

Medial branch blocks

Barnsley and Bogduk studied the specificity of medial branch blocks in diagnosing cervical facet pain. ^[62] Sixteen patients with chronic neck pain underwent cervical medial branch blocks with 0.5 mL of local anesthetic, and 11 patients reported pain relief. These patients subsequently underwent repeat blocks with a double-blind, controlled protocol and obtained relief again. This study indicates that blocking the medial branch is a specific way to diagnose cervical facet pain. However, the false-positive rate of single, uncontrolled blocks has been found to be relatively high at 27%. ^[62] The sensitivity of a single uncontrolled block has been estimated to be 95%, and the specificity is 73%.

Medial branch blocks have also been performed using comparative local anesthetics. ^[62] Patients with chronic neck pain randomly received either Xylocaine or bupivacaine during the nerve block. If the first block relieved the pain, then a second block was performed a minimum of 2 weeks later with the other agent. Forty-five of the 47 patients investigated obtained relief from the first block, and all but 1 obtained relief from the second block. Thirty-four patients (77%) correctly identified the longer acting agent.

In a related study, the sensitivity and specificity of comparative local blocks were evaluated. ^[63] These were compared with placebo-controlled blocks in a randomized, double-blind trial. The sensitivity was found to be 54%, which is low and indicates that there were many false-negative results (46%). ^[63] The specificity was found to be 88%, indicating that there were few false-positive results (12%). Therefore, when surgical decisions are based on the results of the medial branch blocks, placebo-controlled triple blocks are indicated.

The spread of contrast material during medial branch blocks has also been evaluated. In the previous study, it was shown that a volume of 0.5 mL of local anesthetic injected in the location of the medial branch, followed by 0.5 mL of contrast medium does not spread far enough to affect other structures other than the intended nerve. ^[64] At levels C3-C7, the contrast density was greatest at the needle target point and incorporated 5 mm of the medial branch. No spread of contrast occurred above or below the intended level, no spread occurred anteriorly to the ventral ramus, and no spread occurred laterally beyond the semispinalis muscle. At the C2-C3 level, the contrast was seen to wrap around the posterior aspect of the joint or travel over the lamina of C2. Therefore, this block does not anesthetize any other structures that may be a source of chronic cervical pain other than the facet joint.

A randomized controlled trial by Pasuhirunnikorn et al compared the effects of lidocaine or bupivacaine for cervical medial branch block in 62 patients with chronic cervical facet syndrome. Lidocaine significantly alleviated pain for up to 16 weeks and improved neck function for up to 8 weeks, whereas bupivacaine significantly reduced pain for up to 8 weeks and improved neck function for up to 4 weeks. ^[65]

Cervical medial branch blocks are technically easier to perform than intra-articular joint blocks. The medial branch is located at the waist of the articular pillar and is more readily accessible than the joint, which can be narrowed by degenerative changes. Medial branch blocks also are less risky than joint blocks. The epidural space, intervertebral foramen, and vertebral artery may be entered when attempting a joint block; these structures are not as accessible when performing a medial branch block. However, there are reported adverse effects with medial branch blocks, and transient disequilibrium and presyncope have been noted. ^[64]

Percutaneous radiofrequency neurotomy

Radiofrequency neurotomy denervates the facet joint by coagulating the medial branch of the dorsal ramus, which denatures the proteins in the nerve. ^[66] This blocks the conduction of painful messages along the nerve to the dorsal root ganglion (DRG). However, the nerve is not destroyed, because the medial branch cell bodies in the DRG are not affected. In addition, the nerve may grow back to its target facet joint after 6–9 months (depending on the radiofrequency lesion site) at which time the painful messages may again pass through the nerve to the brain if the joint remains painful. Repeating the neurotomy is an option, as the medial branch appears to regrow in its anatomic path. The procedure should not be performed bilaterally at multiple segments at the same time because of increased risk of cervical muscular fatigue with activities of daily living (ADLs). ^[67]

The efficacy of radiofrequency neurotomy was evaluated in a randomized double-blind trial. ^[18] Twenty-four patients with chronic neck pain secondary to motor vehicle accidents were selected. The painful facet joints were confirmed by placebo-controlled, diagnostic blocks. Then, the patients were assigned randomly to the treatment group or the control group. The treatment consisted of heating the nerve to 80°C for 90 seconds. In the control group, the temperature was maintained at 37°C. ^[18] It took the 12 patients in the treatment group 263 days to perceive a return of their pain of at least 50% of the preoperative level. The 12 patients in the control group perceived this in just 8 days. At 27 weeks, 1 patient in the control group and 7 in the treatment group remained pain free. ^[18]

Long-term efficacy of radiofrequency neurotomy for chronic cervical pain was evaluated in 28 patients with neck pain secondary to motor vehicle accidents. ^[67] Complete relief was reported in 71% of the patients after the initial procedure. The mean duration of pain relief in this group was 422 days after the initial procedure and 219 days after a repeat procedure. If the initial procedure did not provide at least 30 days of pain relief, then the repeat procedure was a failure. Some patients maintained pain relief for years with multiple repeat procedures. ^[67]

Rehabilitation Program

Physical Therapy

Patients with cervical facet syndrome should transition into the recovery phase of rehabilitation when they are nearly pain free. The goals of this phase are to eliminate pain and further increase ROM, strength, and neuromuscular control. Manual therapy with soft-tissue massage and mobilization may still be required, but emphasis is placed on improving strength, flexibility, and neuromuscular control.

Rehabilitation Program

Physical Therapy

Patients with cervical facet syndrome are ready for the final phase of rehabilitation after they have achieved full and pain-free ROM, as well as a significant improvement in strength. The goals of the maintenance phase are to balance strength and flexibility and to increase endurance.

Other Treatment

Sherman et al conducted a randomized controlled trial to evaluate whether therapeutic massage is more beneficial than a self-care book for patients with chronic neck pain. Patients (n=64) were randomized to receive up to 10 massages over 10 weeks or a self-care book. Measurement of the Neck Disability Index at 10 weeks demonstrated more participants randomized to massage experienced clinically significant improvement (39%) compared with the participants in the self-care book group (14%) (relative risk [RR]=2.7; 95% confidence interval [CI], 0.99-7.5). The authors concluded that massage may provide short-term relief for chronic neck pain, although a larger trial is warranted to confirm these results. ^[68]

One study analyzed the short- and long-term efficacy of spinal manipulation therapy, medication, and home exercise for acute and subacute neck pain. Results indicated that in both the short and long term, spinal manipulation was more effective than medication. No significant differences in pain were found between spinal manipulation and home exercise. ^[69]

Return to play is an individualized process for athletes with cervical facet joint syndrome. No specific time frame exists for a particular injury. Safe return to play is allowed after the appropriate sport-specific rehabilitation program is completed and the athlete demonstrates full pain-free ROM and proper neutral spine posture with sport-specific activities.

Despite the extensive amount of literature regarding the surgical management of sport-related diseases of the cervical spine, there is a paucity of information concerning the indications for returning to sports after such procedures. Nonsurgical traumatic diseases include sprain/strain, spear tackler's spine, and "stingers."

Ligamentous injuries should be treated and observed with great caution. Radiographs in the neutral, flexed, and extended positions should be obtained and the degree of movement measured. Horizontal movement of one vertebral body on the next should not exceed 3.5 mm and the angular displacement of one body on the next should be less than 11°. These criteria may not always be applicable in the younger athlete, in whom ligamentous laxity may accentuate these measurements. More specifically, the normal translation of the OA joint in the sagittal plane is insignificant. The C1-C2 translation is normally between 2 and 3 mm, although some authors suggest 2.5 mm for adults and 4.5 mm for children as the upper limit of normal motion.

For the lower cervical segments (C2-T1), normal translation in the sagittal plane is between 2.7 mm and 3.5 mm. Ligamentous injuries, however, seem to be more common in the younger athlete (age < 11 y), and they are located in the cephalic portion of the cervical spine; osseous and more caudally located injuries are seen in the older athlete.

If any evidence of ligamentous instability exists, the athlete must be placed in a rigid collar. Flexion and extension radiographs must then be obtained 2-4 weeks after the injury. If there is no evidence of progression, or a return to normal, it is unlikely that any significant injury has occurred and the athlete can most likely return safely to contact sports.

"Wry neck" may suggest articular process subluxation or even unilateral dislocation (see the image below). The muscle tone may be severe enough to prevent reduction. The suspicion of wry neck requires careful investigation and diagnostic acuity. Neurologic status must be assessed before and after reduction and the neck protected for 6-8 weeks or until healing is complete.

Some authors recommend a cervical magnetic resonance imaging (MRI) study if symptoms following a stinger-type injury persist for more than a few minutes and an electromyography (EMG) evaluation if they last longer than 2 weeks.

As a general rule, any athlete with a permanent neurologic injury should be prohibited from participating in further competition. Athletes without spinal cord injuries, and with stable fractures as evidenced by flexion-extension radiographs, should be allowed to return to their normal daily activities. Those with paresthesias or brachial plexus injuries may return to play, once their neurologic examination returns to normal and they are asymptomatic at rest and at play. Those who require a halo vest or surgical stabilization should be withdrawn from contact sports altogether. In these cases, the spine is considered to be insufficient to withstand the load and stress encountered in collision sports. Even after healing has occurred, the altered biomechanics and loss of motion in the surrounding spinal segments may produce devastating future sports-related injuries.