Facet Joint Disease in the Neck
The cervical facet joints are those present in the posterior cervical spine. Inflammation and degeneration of these joints can cause pain in the neck and back, and referred pain elsewhere in the body due to the possible impact on the nerves and blood vessels in the cervical spinal area. The term ‘facet syndrome’ was coined in the 1930s by Ghormley to describe a collection of symptoms involving the lumbar spine and degeneration of its structures. This has now been applied to the cervical spinal area in a similar fashion and describes axial pain due to problems of the cervical facet joints.
Structure of the Cervical Spine
The cervical spine has many structures that can be the source of neck pain, including inter-vertebral discs which may bulge or herniate, ligaments that may become calcified, muscles, nerves, and the facet joints. The diagnosis of osteoarthritis in the cervical facet joints may be one of exclusion, when all other possible aeitologies of pathology have been ruled out. Sometimes the disease is overlooked during investigations of pain and disease, despite being a significant long-term ramification of injuries such as whiplash.
Facet Joint Composition
The facet joints in the cervical spine are synovial joints contained within a fibrous capsule. There are superior and inferior facets forming joints in the spine to allow variable degrees of flexibility. The fibrous capsules contain free nerve endings and are innervated by mechanoreceptors. There are more mechanoreceptors in the cervical spine compared to the lumbar spine which may be of significance when noting the sensations of pain and muscle control involved in the health and pathology of this area.
Symptoms, Diagnosis & Treatments
Symptoms of facet joint disease may include tenderness of the area over the facet joints or paraspinal muscles, and nerve abnormalities, with inflammation of the facet joints in the cervical spine. Diagnosis through scans is usually not helpful as often patients have cervical spinal stenosis, spondylosis, and other degenerative spinal issues both with and without neck pain. Treatments often involve selective nerve root block of the facet joints, anti-inflammatory medication, physical therapy, and, on some occasions, surgery. Beneficial treatment relies on an accurate diagnosis, which in many cases is, unfortunately, not obtained.
Causes of Cervical Facet Joint Disease (Osteoarthritis)
Manchikanti (2004) conducted a review of a number of studies on facet joint disease and found that facet joints were implicated as a cause of chronic spinal pain in 15-45% of patients with low back pain, 48% of patients with thoracic pain, and 54-67% of those with chronic neck pain. Cervical facet joint disease is often a chronic condition exacerbated by acute trauma such as whiplash or contact sports injury. It can also be triggered by such trauma and progress into a chronic condition. Barnsley (1995) found evidence of chronic cervical facet joint pain in 60% of patients after whiplash injury with C2-C3 and C5-C6 the most frequently affected levels in the cervical spine.
Cervical Spine Levels
The cervical spine consists of the first 7 vertebrae, with the first two vertebral bodies structurally different to the rest of the spine. The atlas (C1) moves superiorly with the occiput and inferiorly with the axis (C2). The cervical spine is key to providing mobility and stability to the head and neck. It connects to the thoracic spine, which is quite immobile in comparison. Problems in the thoracic spine and lumbar spine can lead to postural issues which then affect the cervical spine, putting increased pressure on the facet joints and triggering a disease-like state.
Other Influencers of Spine Pain
Often the facet joint is not the only cause of pain as any degeneration of the facet joint is intimately connected with the health of the neighbouring disc and connective tissues. Those with facet joint pain commonly have signs of disc degeneration corresponding to the affected cervical facet joint. The facet joints are surrounded by a fibrous capsule which can contain free nerve endings. The capsules are innervated by mechanoreceptors, of which there are more in the cervical spine than in the lumbar spine. This plethora of mechanoreceptors may be partly responsible for the increased intensity of pain felt in the cervical spine, as it could function as a defence against excessive movement that could lead to joint instability and joint degeneration.
Whiplash and other trauma can cause deformation of the capsule surrounding the facet joint, with this stretching effect often resulting in activation of the nociceptors in
the joint capsule (Cavanaugh, 2006). Excessive stretching of the capsule in acute trauma leads to prolonged neural after-discharges which can then lead to capsule damage and degeneration of the axons (nerve cells) in the capsules. Damage to the capsules of the facet joints during acute trauma may then result in chronic and persistent pain in the neck due to long-term nerve damage.
Spine Levels and Corresponding Pain
The C2-C3 facet joint was found by Dwyer (1990) to primarily refer pain to the back of the neck and head, whereas the C5-C6 joint refers pain to the lower and middle cervical region, the top and lateral parts of the scapula. Other facet joints such as C4-C5 also cause pain in the mid and lower cervical spine along with the top of the shoulder. The C6-C7 joint can refer pain to the top and lateral parts of the shoulder. The use of these pain maps can be beneficial in diagnosing cervical facet joint disease and isolating the problem joint.
Symptoms of Cervical Facet Joint Disease (Osteoarthritis)
Tenderness of the area over the facet joints is the most common symptom of cervical facet joint disease. This is usually a persistent tenderness accompanied by some loss of mobility and flexibility of the spinal muscle. Some patients experience episodes of acute cervical facet joint pain intermittently and unpredictably, occurring a few times a month or year. Patients may also experience pain on extension or rotation of the neck. Neurological symptoms, such as numbness and muscle weakness are also factors of cervical facet joint disease. Patients often experience headaches and neck pain, and a dull, aching, uncomfortable feeling in the back of the neck that may move, or radiate, to the shoulder and middle of the back.
Along with the facet joints, the intervertebral discs commonly cause pain in the cervical spine. As inflammation and degeneration of the facet joints puts pressure on the discs this may cause them to bulge or herniate. If a patient has a discectomy this does not always solve the problem, demonstrating that the facet joints are an independent source of pain. In general a disc herniation has symptoms such as radiating pain in the front or down the arm into the extremities. Cervical facet joint disease has a symptom profile generally isolated to the posterior spinal structures, with pain in the back of the neck, shoulders, and spine.
Other diagnoses, made incorrectly in the presence of facet joint inflammation, include deep infection, spinal muscle tears or fractures, and acute intra-abdominal problems. With facet joint pain the patient is more likely to feel higher levels of discomfort when leaning backward rather than forward. Sufferers of cervical facet joint disease may be told that the condition has a large psychosomatic element and that the pain is ‘all in their head’. It is certainly true that relaxation techniques may benefit the patient in resting the spasming muscles of the spine, but the assertion that the condition is psychological rather than physical is generally unfounded and should be treated with caution.
Diagnosis of Cervical Facet Joint Disease (Osteoarthritis)
Cervical facet joint disease has, unfortunately, frequently been overlooked by physicians when diagnosing back and neck pain. The development in the 1990s of precision diagnostic blocks, which included facet joint blocks, has positively impacted the diagnosis of cervical facet joint disease (Manchikanti, 2003) as has the development of pain maps which correlate the referred pain with specific cervical vertebrae and facet joints. The isolation of the facet joints as the site of pain, as differentiated from the occipital nerve, through tests using both nerve blocks and electrical stimulation (Windsor, 2003), means that a more precise and accurate diagnosis should be possible using modern diagnostic tools.
After taking a thorough case history, including medications, previous trauma, operations, symptom severity, onset, and frequency, the physician may use x-rays, MRI, or CT scans to observe if there are any clear structural issues that are causing the pain. A pain map may be used in order to establish the likely site of facet joint disease as it corresponds with sites of referred pain.
Those with lower cervical spine pain may be assessed using C5 and C6 medial branch blocks first. If these injections do not provide relief then the adjacent levels are blocked until the source of the pain is discovered. Upper cervical spine patients may have third occipital nerve blocks and then C3 and C4 medial branch blocks if necessary to relieve the pain. Bogduk (1988) conducted such research and determined that the administration of Bupivacaine could provide relief for at least 2 hours, and often a lot longer for those with specific facet joint problems as the source of the pain, although results vary between studies.
Radiographs and Range of Motion
Radiographs of the neck in a neutral, flexed, and extended position along with the patient’s range of motion and history of trauma should be used as key diagnostic tools for assessing the presence of cervical facet joint disease. In general the horizontal movement of one vertebral body on the next should not exceed 3.5mm, although a young, flexible, athlete may have more laxity to their ligaments and fall outside these measurements.
Treatment of Cervical Facet Joint Disease (Osteoarthritis)
The same tools that are used for diagnosing cervical facet joint disease are often useful for treating the disease as well. Diagnostic blocks of the facet joints can provide temporary pain relief for a patient and allow other treatment methodologies to be attempted. Intra-articular facet joint injections can provide shorter term relief (2hrs or so), and longer lasting relief from the pain associated with cervical facet joint disease (Dory, 1983). However, the evidence varies significantly between numerous studies, making the use of intra-articular facet joint injections a variable and uncommon treatment in these cases (Fairbank, 1981, Roy, 1988). Medial branch blocks appear beneficial for both diagnosing and providing pain relief for patients with cervical facet joint disease, and are the strategy of choice when attempting to locate the source of the problem prior to surgical intervention due to the lack of false positives obtained during these studies and the relative localized effect of the injected material (Windsor, 2009). Medial branch blocks may, unfortunately, have adverse effects though, with balance problems and presyncope experienced by some patients Barnsley (1993).
If there is evidence of inflammation, through blood biomarkers, or scans of the tissues then the use of NSAIDs may be suggested to help with pain management. NSAIDs can reduce cyclooxygenase activity and prostaglandin synthesis, along with leukotriene synthesis, neutrophil aggregation, and other pathological mechanisms. Unfortunately, there are some side-effects associated with the use of NSAIDs, particularly if used long-term.
Alternative anti-inflammatories and analgesics may also be useful for those with cervical facet joint disease, as are natural sedatives and muscle relaxants. Pharmaceutical muscle relaxants such as baclofen may help those with cervical facet joint disease and, if neuropathic pain is experienced then medications such as amitryptyline and doxepin may be prescribed. Antiseizure medications (gabapentin, carbamazepine, and divalproex and others) are also indicated for use in neuropathic pain.
Physical Therapy Treatment
Physical therapy is frequently used in the rehabilitation and management of patients experiencing pain as a result of facet joint degeneration and trauma. Treatment may take the form of ice packs to reduce inflammation, blood flow, and oedema. Muscle spasm may also be reduced through the application of ice. A TENS machine may be helpful to those suffering from neck pain due to cervical facet joint disease as it can also prevent muscle spasm and reduce the transmission of pain signals in the area. Other forms of physical therapy include joint mobilization, gentle stretching of the muscles, and soft-tissue massage. Strengthening of the muscles should be carefully supervised so as to avoid straining and the creation of further problems.
Facet Disease Surgery
As a last resort, cervical fusion may be considered as a treatment option. Conservative treatment for neck and back pain is the usual course of action in most patients’ cases. Cervical fusion surgery has a significantly lower positive outcome associated with it than does surgery to relieve radicular pain (Wiburg, 1993, Williams, 1968). Another surgical option is the use of percutaneous radiofrequency neurotomy. This procedure denervates the facet joint through coagulation of the medial branch of the dorsal ramus. The nerve is not destroyed because the medial branch cell bodies remain intact in the dorsal root ganglion. The procedure does prevent the pain signals transmitting along the nerve to the dorsal root ganglion until the nerve grows back within 6-9 months (in most cases). At this point the neurotomy can be repeated as it is an effective method of pain relief in most (c70%) sufferers of whiplash-induced cervical facet joint disease (McDonald, 1999). Multiple procedures can provide effect treatment for many years without the need for surgery.
Barnsley, L., Lord, S., Bogduk, N., (1993), Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain, Pain, Vol.55, No.1, pp.99-106.
Barnsley, L., Lord, S.M., Wallis, B.J., Bogduk, N., (1994), Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints, N Engl J Med, Vol.330, No.15, pp.1047-50.
Barnsley, L., Lord, S.M., Wallis, B.J., Bogduk, N., (1995), The prevalence of chronic cervical zygapophysial joint pain after whiplash, Spine, Vol.20, No.1, pp.20-5; discussion 26.
Bogduk, N., Marsland, A., (1988), The cervical zygapophysial joints as a source of neck pain, Spine, Vol.13, No.6, pp.610-7.
Cavanaugh, J.M., Lu, Y., Chen, C., Kallakuri, S., (2006), Pain Generation in Lumbar and Cervical Facet Joints, The Journal of Bone and Joint Surgery (American), Vol.88, pp.63-67.
Dory, M.A., (1983), Arthrography of the cervical facet joints, Radiology, Vol.148.\No.2, pp.379-82.
Dwyer, A., Aprill, C., Bogduk, N., (1990), Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers, Spine, Vol.15, No.6, pp.453-7.
Fairbank, J.C., Park, W.M., McCall, I.W., O’Brien, J.P., (1981), Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes, Spine, Vol.6, No.6, pp.598-605.
Ghormley, R., (1933), Low back pain with special reference to the articular facets with presentation of an operative procedure, JAMA, Vol.101, pp.1773-7.
Manchikanti, L., Staats, P.S., Singh, V., Schultz, D.M., Vilims, B.D., Jasper, J.F., Kloth, D.S., Trescot, A.M., Hansen, H.C., Falasca, T.D., Racz, G.B., Deer, T., Burton, A.W., Helm, S., Lou, L., Bakhit, C.E., Dunbar, E.E., Atluri, S.L., Calodney, A.K., Hassenbusch, S., Feler, C.A., (2003), Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain, Pain Physician, Vol.6, pp.3–80.
Manchikanti, L., Boswell, M.V., Singh, V., Pampati, V., Damron, K.S., Beyer, C.D., (2004), Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions, BMC Musculoskelet Disord, Vol.5, p.15.
Roy, D.F., Fleury, J., Fontaine, S.B., Dussault, R.G., (1988), Clinical evaluation of cervical facet joint infiltration, Can Assoc Radiol J., Vol.39, No.2, pp.118-20.
Wiberg, J., (1992), Cervical disk defects. Results of surgical treatment of cervical vertebral radiculopathy, Tidsskr Nor Laegeforen, Vol.112, No.7, pp.876-80.
Williams, J.L., Allen, M.B. Jr., Harkess, J.W., (1968), Late results of cervical discectomy and interbody fusion: some factors influencing the results, J Bone Joint Surg Am, Vol.50, No.2, pp.277-86.
Windsor, R.E., Nagula, D., Storm, S., Overton, A., Jahnke, S., (2003), Electrical stimulation induced cervical medial branch referral patterns, Pain Physician, Vol.6, No.4, pp.411-8.