What is Facet Disease in the Neck?
The cervical facet joints are synovial joints in the back of the spine that are contained within a fibrous capsule. Superior and inferior facet joints interact in order to allow the flexibility of the spine and are, therefore, subject to considerable wear and tear over the years through everyday movement, increasing the likelihood of facet disease in the neck. Although the facet joints themselves do not contain free nerve endings, they are innervated by mechanoreceptors, of which there are more in the cervical spine compared to the lumbar spine. This can mean that neck pain is considered more likely due to facet disease in the neck rather than the lower back.
Inflammation and degeneration of the facet joints can lead to referred pain as the joints and surrounding tissues put pressure on the spinal nerves and blood vessels of the neck. Facet joint syndrome describes axial pain due to problems of the cervical facet joints. Cause and effect are difficult to differentiate in many cases where facet joint problems coexist with disc herniation or degenerative disc disease, ligament calcification, and muscle or nerve problems in the neck.
How does facet disease in the neck cause pain?
As intervertebral discs degenerate, the space between vertebrae can become compressed, affecting facet joint mobility. Alterations in facet joint function contribute to damage to the spinal ligaments which are then unable to provide support to the facet joints and this leads to spinal instability through facet joint hypermobility. The body often responds by trying to build a larger surface area between the joints in order to provide stability. The creation of bone spurs can then cause pinched nerves and neck pain. Spinal cord compression can also occur and back surgery is often necessary in order to decompress the cervical spine.
Facet joint syndrome is often a diagnosis of exclusion, and may be overlooked in many patients, with some even told it is ‘all in the head’. Patients who had suffered whiplash were found in one review to have a 60% incidence of chronic cervical facet joint pain, with C2-C3 and C5-C6 the most frequently affected levels in the cervical spine (Barnsley, 1995). The facet joint capsule may stretch during acute trauma like whiplash leading to activation of the nociceptors in the joint capsule (Cavanaugh, 2006) and prolonged neural after-discharges. This after-effect can cause capsule damage and degeneration of the axons (nerve cells) causing chronic and persistent neck pain due to long-term nerve damage around the facet joints.
Facet Disease in the Neck Symptoms
Symptoms of facet disease in the neck are usually clustered in the back of the neck, shoulders, and upper back, in contrast to the symptoms of disc herniation. Pain-maps can help identify the root of the pain (Dwyer, 1990). Tenderness over the facet joints and paraspinal muscles, nerve abnormalities, with inflammation of the facet joints in the cervical spine point to a diagnosis of facet joint disease. 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. A review by Manchikanti (2004) concluded that the facet joints were implicated as a cause of chronic neck pain in 54-67% of patients. Some patients experience acute, unpredicatble, episodes of acute cervical facet joint pain a few times a month or year. Other symptoms include pain on extension or rotation of the neck, numbness and muscle weakness, 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.
Facet Disease in the Neck Treatment
Treatments often involve selective nerve root block of the facet joints, anti-inflammatory medication, physical therapy, and, on some occasions, surgery such as facetectomy. Beneficial treatment clearly relies on an accurate diagnosis, which is why many suffer from failed back surgery syndrome or chronic neck pain despite their physician having addressed what they thought was the cause of the patients’ symptoms. To further complicate the situation, problems in the thoracic spine and lumbar spine can cause postural issues which then affect the cervical spine, putting increased pressure on the facet joints. Without addressing the alignment issues the direct treatment of the cervical facet joints is unlikely to be fruitful in the long term. Improved diagnostic testing, using things such as selective nerve root blocks (medial branch blocks and occipital nerve blocks), has aided the correct attribution of symptoms of facet joint syndrome (Windsor, 2003). However, medial branch blocks may, unfortunately, have adverse effects on balance and lead to presyncope being experienced by some patients (Barnsley, 1993). Diagnostic nerve blocks may also allow other treatment methodologies to be attempted, such as physical therapy.
Sufferers of cervical facet joint disease are often told that the condition is psychosomatic but, whilst it is certainly true that relaxation techniques can help, this assertion is generally unfounded and can be extremely detrimental to patient health. Cognitive behavioural therapy can help to reduce stress levels and anxiety about carrying out daily activities; it should not be used in place of appropriate medical treatments however.
Medications for Facet Disease in the Neck
If there is evidence of inflammation, NSAIDs may be suggested to help with pain management, although patients should be aware of the potential side effects of NSAIDs. 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 for Facet Joint Disease in the Neck
Physical therapy is a common form of treatment for facet joint disease, with ice packs to lower inflammation, oedema, blood flow, and muscle spasm, and neck stretching exercises often helpful in relieving tight muscles. Many patients make use of neck pain relief devices such as a TENS machine which can reduce the transmission of pain signals in the affected area. Joint mobilization, gentle stretching of the muscles, and soft-tissue massage may also be included in a physical therapy treatment regime for facet joint syndrome.
If a patient does not respond to conservative treatments then back surgery may be necessary, with cervical spinal fusion a possible operation, along with facetectomy (the removal of the troublesome facet joint or part thereof). Cervical fusion surgery has a significantly lower positive outcome associated with it than does surgery to relieve radicular pain (Wiburg, 1993). 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., (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.
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.
Wiberg, J., (1992), Cervical disk defects. Results of surgical treatment of cervical vertebral radiculopathy, Tidsskr Nor Laegeforen, Vol.112, No.7, pp.876-80.
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.