Cervical Facet Syndrome

THE CLINICAL SYNDROME

• Pain that radiates in a manner that is not dermatomal can be a sign of cervical facet syndrome, which is a collection of symptoms that can affect the neck, head, shoulders, and proximal parts of the upper extremities.

• The discomfort is not really sharp and is rather mild.

• A pathological process of the facet joint is assumed to be the cause of this condition, which can manifest itself unilaterally or bilaterally.

• The pain caused by cervical facet syndrome can be made worse by flexing or extending the neck, as well as by bending the cervical spine laterally.

• It is common for the symptoms to be worse in the morning after engaging in strenuous activity.

• Each facet joint receives innervation from two different levels of the spinal column; it receives fibers from the dorsal ramus at the relevant vertebral level as well as from the vertebra above it.

• This pattern explains why the dorsal nerve from the vertebra above the problematic level must frequently be blocked in order to provide total pain relief.

• It also explains the ill-defined nature of pain that is mediated through the facet joints.

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SIGNS AND SYMPTOMS

• The majority of patients who have cervical facet syndrome experience pain to deep probing of the cervical paraspinous musculature.
• There may also be spasm present in the affected muscles.
• Patients typically complain of pain during flexion, extension, rotation, and lateral bending of the cervical spine.
• Patients also show a decreased range of motion in the cervical spine. If the patient does not also have concurrent radiculopathy, plexopathy, or entrapment neuropathy, then there is no motor or sensory loss present.
• When the C1-2 facet joints are affected, pain is felt in the posterior auricular and occipital regions of the head. If the facet joints at C2-3 are affected, the discomfort may spread to the area around the eyes and the forehead.
• The pain that originates from the C3-4 facet joints is referred inferiorly to the posterolateral neck and superiorly to the suboccipital area, while the pain that originates from the C4-5 facet joints radiates all the way down to the base of the neck.
• Discomfort in the facet joints between the cervical spine's C5 and C6 segments is said to radiate to the shoulders and interscapular area, whereas pain in the facet joints between the cervical spine's C6-7 segments is said to radiate to the supraspinous and infraspinous fossae.

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TESTING

• Plain radiographs of the cervical spine reveal abnormalities in almost all people by the time they reach their fifth decade of life. These abnormalities involve the facet joints.

• Pain specialists have been debating the clinical significance of these findings for a long time, but it wasn't until the advent of computed tomography scanning and magnetic resonance imaging (MRI) that the relationship between these abnormal facet joints and the cervical nerve roots and other structures in the surrounding area was clearly understood.

• Any patient in whom cervical facet syndrome is even a remote possibility ought to have a magnetic resonance imaging (MRI) exam of the cervical spine. However, only a provisional diagnosis may be offered based on the information obtained from this very advanced imaging technique.

• It is necessary to perform a diagnostic intraarticular injection of a local anesthetic into a particular facet joint in order to demonstrate that one of the patient's facet joints is the source of their discomfort.

• Screening laboratory tests including a complete blood count, erythrocyte sedimentation rate, anti-nuclear antibody testing, human leukocyte antigen (HLA)-B27 antigen screening, and automated blood chemistry should be performed to rule out other potential causes of the patient's pain if the diagnosis of cervical facet syndrome is in question.

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DIFFERENTIAL DIAGNOSIS

• Cervical facet syndrome is a diagnosis of exclusion that is supported by a combination of clinical history, physical examination, radiography, MRI, and intraarticular injection of the suspicious facet joint in question.
• This is because cervical facet syndrome cannot be caused by any other condition.
• Pain syndromes such as cervicalgia, cervical bursitis, cervical fibromyositis, inflammatory arthritis, and conditions affecting the cervical spinal cord, roots, plexus, and nerves can all have symptoms that are similar to those of cervical facet syndrome.

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TREATMENT

• The multidisciplinary approach is the most effective way to treat cervical facet syndrome.
• It is normal to begin with physical therapy that consists of heat modalities and deep sedative massage, along with nonsteroidal anti-inflammatory medications and skeletal muscle relaxants. The next obvious step is to include cervical facet blocks in the treatment plan.
• Blockade of the medial branch of the dorsal ramus or intraarticular injection of the facet joint with local anesthetic and steroid is a very successful treatment for relieving the symptoms of facet joint syndrome.
• Patients who have experienced good, but temporary relief of their pain following facet block with local anesthetic and steroid should be considered for radiofrequency lesioning of the medial branches of the affected facet joints.
• This treatment option should be considered in patients who have experienced radiofrequency lesioning of the medial branches of the affected facet joints.
• Beginning treatment with a tricyclic antidepressant like nortriptyline, which can be taken as a single 25-mg dose before going to bed, is the most effective way to treat underlying sleep disturbances as well as depression.
• When treating pain in this region, an atlanto-occipital block and a cervical facet block are frequently used in conjunction with one another.
• The atlantooccipital joint is not a true facet joint in the anatomical sense; rather, the technique is equivalent to the facet joint block that is often employed by pain practitioners and may be seen as such because to the similarities between the two.

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COMPLICATIONS AND PITFALLS

• Because of its location so close to the spinal cord and exiting nerve roots, the cervical facet block should only be performed by those who are well-versed in the anatomy of the region and have prior experience with various interventional methods of pain management.

• Because of its close proximity to the vertebral artery and the highly vascular nature of this region, the risk of intravascular injection is significant.

• Seizures can be brought on by the injection of even a very tiny dose of local anesthetic into the vertebral artery.

• After a cervical facet block, ataxia caused by vascular absorption of the local anesthetic is not an unusual complication. This is due to the close proximity of the brain and brainstem to the cervical spine.

• After receiving an injection into the joint, a number of patients report that they experience a temporary worsening of their headache and cervicalgia symptoms.

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