Cervical facet syndrome

Cervical facet syndrome is a set of symptoms that include pain in the neck, head, shoulder, and proximal upper limb, radiating in a non-dermatomal pattern. The pain is mild and dull. It can be unilateral or bilateral, and is believed to be due to pathology of the facet joint.

Pain in cervical facet syndrome increases with flexion, extension, and lateral flexion of the cervical spine. It often increases in the morning after physical activity. Each facet joint receives innervation from two levels: the fibers of the dorsal branches of the corresponding and higher segments.

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Symptoms of cervical facet syndrome

Many patients with facet syndrome experience tenderness of the paravertebral muscles on deep palpation, and muscle spasm may occur. Patients demonstrate decreased range of motion in the cervical spine, often complaining of pain during flexion, extension, rotation, and lateral flexion of the cervical spine. In the absence of concomitant radiculopathy, plexopathy, or tunnel neuropathy, no motor or sensory deficits are detected.

When the facet joint is affected at the C1-2 level, the pain extends to the posterior auricular and occipital areas. When C2-3 is affected, the pain may extend to the forehead and eye area.

Pain originating from the C3-4 facet joints radiates upward to the suboccipital region and downward to the posterolateral neck, pain from the C4-5 facet joints radiates to the base of the neck, pain from the C5-6 facet joints radiates to the shoulders and interscapular region, and pain from the C6-7 facet joints radiates to the supraspinatus and infraspinatus fossae.

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Clinical characteristics of cervical facet syndrome

Cervical facet syndrome is a common cause of pain in the neck, back of the head, shoulder, and upper extremity. It is often mistaken for cervicalgia and cervical myositis. A diagnostic intra-articular facet block can confirm the diagnosis. Clinicians should exclude cervical spine disorders such as syringomyelia, which initially present with a similar appearance. Ankylosing spondylitis can also present as cervical facet syndrome and must be correctly identified to prevent joint damage and functional disability. Many pain specialists believe that cervical facet and atlanto-occipital blocks are underused in the treatment of post-whiplash cervicalgia and cervicogenic headache and should be considered when cervical epidural and occipital nerve blocks have failed to provide temporary relief of headache and neck pain syndrome.

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Diagnostics of cervical facet syndrome

By age 50, virtually all patients have some abnormalities of the cervical facet joints on x-ray. Pain specialists debated the clinical significance of such findings until the advent of computed tomography and magnetic resonance imaging (MRI) and the relationship between abnormal facet joints and the cervical nerve roots and other adjacent structures was clarified. MRI of the cervical spine should be performed in all patients suspected of having cervical facet syndrome. This expensive imaging technique can only provide a presumptive diagnosis. A diagnostic intra-articular injection of local anesthetic into the facet joint is required to confirm that the facet joint is causing the pain. If the diagnosis of cervical facet syndrome is in doubt, laboratory tests, including a complete blood count, erythrocyte sedimentation rate, antinuclear antibodies, HLA B-27, antigen testing, and biochemical testing, should be performed to exclude other causes of pain.

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Differential diagnosis

Cervical facet syndrome is a diagnosis of exclusion, confirmed by a combination of history, physical examination, radiography, MRI, and intra-articular injection into the involved facet joint. Pain syndromes that may mimic cervical facet syndrome include cervical bursitis, cervical myogenic pain syndrome, inflammatory arthritis, cervical spine blocks, and root, plexus, and nerve disorders.

Treatment of cervical facet syndrome

A multi-level approach is most effective in treating cervical facet syndrome. Heat and relaxation massage in combination with NSAIDs (eg, diclofenac, lornoxicam) and muscle relaxants (eg, tizanidine) are reasonable initial treatments. The next logical step is the use of cervical facet joint blocks, performed only under fluoroscopic guidance. For symptomatic relief, medial branch dorsal nerve blocks or intra-articular facet joint injections of local anesthetics or steroids are extremely effective. Underlying depression is best treated with tricyclic antidepressants.

Often, the cervical facet block is combined with the atlanto-occipital block when treating pain in this area. Although the atlanto-occipital joint is not a true facet joint anatomically, the technique used by pain specialists is similar to that of the facet block.

Complications and diagnostic errors

Because of the proximity of the spinal cord and nerve root exits, cervical facet block should be performed by a specialist familiar with regional anatomy and surgical pain management. Because of the proximity of the vertebral artery and the vascular structures of this region, the likelihood of intravascular injection is high, and even a small amount of local anesthetic entering the vertebral artery may cause a paroxysm. Given the close proximity of the brain and brainstem, ataxia is not uncommon due to intravascular injection of local anesthetic during cervical facet block. Many patients also complain of transient worsening of headache and cervicalgia after joint injection.

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