Abstract
Cervical facet syndrome is a constellation of symptoms consisting of neck, head, shoulder, and proximal upper extremity pain that radiates in a nondermatomal pattern. The pain is ill defined and dull. It may be unilateral or bilateral and is thought to be the result of a pathologic process of the facet joint. The pain of cervical facet syndrome is exacerbated by flexion, extension, and lateral bending of the cervical spine. It is often worse in the morning after physical activity. Each facet joint receives innervation from two spinal levels; it receives fibers from the dorsal ramus at the corresponding vertebral level and from the vertebra above. This pattern explains the ill-defined nature of facet-mediated pain and explains why the dorsal nerve from the vertebra above the offending level must often be blocked to provide complete pain relief. Most patients with cervical facet syndrome have tenderness to deep palpation of the cervical paraspinous musculature; muscle spasm may also be present. Patients exhibit decreased range of motion of the cervical spine and usually complain of pain on flexion, extension, rotation, and lateral bending of the cervical spine. No motor or sensory deficit is present unless the patient has coexisting radiculopathy, plexopathy, or entrapment neuropathy.
Keywords
cervical facet syndrome, facet joint, medial branch, facet block, medial branch block, cervicalgia, cervical nerve roots, cervical radiculopathy
ICD-10 CODE M47.812
The Clinical Syndrome
Cervical facet syndrome is a constellation of symptoms consisting of neck, head, shoulder, and proximal upper extremity pain that radiates in a nondermatomal pattern. The pain is ill defined and dull. It may be unilateral or bilateral and is thought to be the result of a pathologic process of the facet joint. The pain of cervical facet syndrome is exacerbated by flexion, extension, and lateral bending of the cervical spine. It is often worse in the morning after physical activity. Each facet joint receives innervation from two spinal levels; it receives fibers from the dorsal ramus at the corresponding vertebral level and from the vertebra above. This pattern explains the ill-defined nature of facet-mediated pain and explains why the dorsal nerve from the vertebra above the offending level must often be blocked to provide complete pain relief.
Signs and Symptoms
Most patients with cervical facet syndrome have tenderness to deep palpation of the cervical paraspinous musculature; muscle spasm may also be present. Patients exhibit decreased range of motion of the cervical spine and usually complain of pain on flexion, extension, rotation, and lateral bending of the cervical spine ( Fig. 15.1 ). No motor or sensory deficit is present unless the patient has coexisting radiculopathy, plexopathy, or entrapment neuropathy.
If the C1-2 facet joints are involved, the pain is referred to the posterior auricular and occipital region. If the C2-3 facet joints are involved, the pain may radiate to the forehead and eyes. Pain emanating from the C3-4 facet joints is referred superiorly to the suboccipital region and inferiorly to the posterolateral neck, and pain from the C4-5 facet joints radiates to the base of the neck. Pain from the C5-6 facet joints is referred to the shoulders and interscapular region, and pain from the C6-7 facet joints radiates to the supraspinous and infraspinous fossae ( Fig. 15.2 ).
Testing
By the fifth decade of life, almost all individuals exhibit some abnormality of the facet joints of the cervical spine on plain radiographs ( Fig. 15.3 ). The clinical significance of these findings has long been debated by pain specialists, but it was not 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 surrounding structures was clearly understood. MRI of the cervical spine should be performed in all patients suspected of suffering from cervical facet syndrome. However, any data gleaned from this sophisticated imaging technique can provide only a presumptive diagnosis. To prove that a specific facet joint is contributing to the patient’s pain, a diagnostic intraarticular injection of that joint with local anesthetic is required. If the diagnosis of cervical facet syndrome is in doubt, screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, antinuclear antibody testing, human leukocyte antigen (HLA)-B27 antigen screening, and automated blood chemistry should be performed to rule out other causes of the patient’s pain.
