Cervical spine facet syndrome

Hi everyone, i am currently treating a patient with referred pain from the neck to shoulder region and by doing my own research via journals and books believe it could be a cause of cervical spine facet syndrome, however i am struggling to find lots of evidence to back my claim, i was wondering if anybody else knew much about cervical spine facet syndrome as it's new to me, is it a specific disorder in itself or is cervical facet syndrome a broad term eg could be a range of disc degeneration etc? any help or direction to where i could find more info on this would be very greatly appreciated.many thanks.

hi friend
good information you can get about cervical facet related pain in -physical therapy of cervical and thoracic spine by rutth grant
i think you are suspecting somatic refered pain of cervical facetal origin.
you can go a bit in depth if you read
manual of combined movements by brian r edwards.it gives treatment guidelines too

hope you ruled out all the other structures.recently i ws informed that even neurodynamic defects can cause diffuse pain presentations .
you should be careful while coming to definite diagnosis as studies are not supporting the tests that help to specify the structure causing primary cause of pain.
what i mean is there is no assurance that you could specificaly say a structure-say;disc,facet,facetal capsule,lig etc as cause of pain.

hi dear,

well, as "linbin" quoted in the previous post there are quite a few pain generators in the cervical spine; intervertebral disks, facet joints, ligaments, muscles, nerve roots.., the diagnosis of cervical facet syndrome is often one of exclusion or not considered at all.

please go through the text below, it will help you gather some info on "cervical facet syndrome"

patients with cervical facet joint syndrome often present with complaints of neck pain, headaches, and limited range of motion (ROM). the pain is described as a dull aching discomfort in the posterior neck that sometimes radiates to the shoulder or mid back regions. patients also may report a history of a previous whiplash injury to the neck.

clinical features that often, but not always, are associated with cervical facet pain include tenderness to palpation over the facet joints or paraspinal muscles, pain with cervical extension or rotation, and absent neurologic abnormalities. signs of cervical spondylosis, narrowing of the intervertebral foramina, osteophytes, and other degenerative changes equally are prevalent in people with and without neck pain.

Bogduk and Marsland studied patients with neck pain without objective neurologic signs to determine if the facet joints were the primary source of their pain (Bogduk, 1988). twenty-four consecutive patients presenting at a pain clinic with neck pain of unknown origin were entered into the study. those with lower cervical spine pain underwent C5 and C6 medial branch blocks first. if these medial branch blocks did not provide relief, then adjacent levels were blocked until the pain was relieved. those with upper cervical spine pain underwent third occipital nerve blocks, and then C3 and C4 medial branch blocks if necessary. bupivacaine was used as the blocking agent and a positive response was considered total pain relief for at least 2 hours.

fifteen patients experienced complete relief of their neck pain, and repeat blocks had the same effect. seven of these patients underwent intra-articular facet joint blocks, corresponding to the levels determined by the medial branch blocks, which also completely relieved their pain. no clinical or radiologic features corresponded with the positive responses. this finding suggests that facet joints in the cervical spine can be a significant source of neck pain and that medial branch blocks can be used as both diagnostic and therapeutic tools in the management of this type of pain.

each facet joint seems to have a particular radiation pattern upon painful stimulation. even in subjects without neck pain, stimulation of the facet joints by injecting contrast material into the joints and distending the capsule produces neck pain in a specific pattern corresponding to the specific joint.

in a study of 5 such subjects, joint pain referral patterns were mapped out. the C2-C3 facet joint refers pain to the posterior upper cervical region and head, while the C3-C4 facet joint refers pain to the posterolateral cervical region without extension into the head or shoulder. the C4-C5 joint refers pain to the posterolateral middle and lower cervical region, and to the top of the shoulder. the C5-C6 joint refers pain to the posterolateral middle and primarily lower cervical spine and the top and lateral parts of the shoulder and caudally to the spine of the scapula. the C6-C7 joint refers pain to the top and lateral parts of the shoulder and extends caudally to the inferior border of the scapula.

these pain referral maps subsequently have been used to predict the segmental origin of neck pain in 10 symptomatic patients, who were referred for radiologic evaluation of possible facet joint pain (Aprill, 1990). each of these patients was interviewed before the procedure and recorded the distribution of their pain on a diagram. these diagrams were compared with the maps previously generated from the asymptomatic subjects, and the facet joint or joints thought to be responsible for the pain patterns were predicted. afterwards, the patients underwent diagnostic facet joint nerve blocks at the predicted levels, and the pain was completely relieved in all but one patient. this result suggests that these pain referral maps may be a powerful diagnostic tool when evaluating patients with cervical pain.

facet joint pain referral patterns also have been documented in OA joint and the lateral AA joint. Dreyfuss studied 5 asymptomatic subjects and injected the right AA joint and the left OA joint in each participant with contrast medium to distend the capsule (Dreyfuss, 1994). the resultant pain referral patterns for the AA joints were similar and located posterior and lateral to the C1-2 segments. the patterns for the OA joints were variable and extended from the vertex of the skull to the C5 segment. perceived pain also was greater with the OA injections compared to the AA injections. pain referral patterns also have been documented in symptomatic patients and correspond well to those obtained from asymptomatic subjects (Star, 1992).

more recently, Fukui et al have created pain referral patterns from the OA facet joint to the C7-T1 joint (Fukui, 1996). Fukui et al studied 61 patients with neck pain and stimulated the painful joints by the following 2 methods: injection of contrast medium into the joints and electrical stimulation of the medial branches. two separate pain referral maps were constructed, and the facet joints and their corresponding medial branches correlated relatively well.

in 2003, Windsor et al electrically stimulated the medial branches of the C3-C8 posterior primary rami with or without the third occipital nerve in 9 subjects (Windsor, 2003). this study demonstrated that the medial branch and third occipital nerve, when stimulated individually, have a separate and distinct referral pattern from the facet joint referral patterns previously mentioned. these medial branch referral maps may provide additional insight when evaluating patients with suboccipital, cervical, or shoulder girdle pain.

physical therapy

Kibler et al have defined 3 phases of rehabilitation.

acute phase
the goals of the first phase are to reduce pain and inflammation, and increase the pain-free ROM. ice is indicated during the acute phase to decrease blood flow and subsequent hemorrhage into the injured tissues, as well as reducing local edema. application of ice also can reduce muscle spasm. therapeutic modalities such as ultrasound and electrical stimulation may also reduce painful muscle spasms as well. manual therapy, joint mobilization, soft tissue massage, and muscle stretching often are helpful. passive range of motion (PROM) and then active range of motion (AROM) exercises in a pain-free range should be initiated in this phase. finally, strengthening should begin with isometric exercises and progress to isotonic as tolerated.

recovery phase
patients should transition into the recovery phase of rehabilitation when they are nearly pain free. the goals of this phase are to eliminate pain and further increase ROM, strength, and neuromuscular control. manual therapy with soft tissue massage and mobilization still may be required, but emphasis is placed on improving strength, flexibility, and neuromuscular control.

maintenance phase
Patients are ready for the final phase of rehabilitation after they have achieved full and pain-free ROM, and a significant improvement in strength. The goals of the maintenance phase are to balance strength and flexibility, and to increase endurance.

cheers,

thomas

I read physiotherapy book in Thailand.

When patient has severe pain use mobilisation around that joint . you can adjusted force to spine it started grade 1-3. following use manual traction and have home program for patient (correct posture(chin in with pillow and chin in no pillow)and isometric ex's of neck muscle). At this time don't use stretching because it have pain when stretching.

About 3-5 days, if patient feel good but have numbness use mobilize nerve. and you can use mobilize spine T6-T7 for patient because it relax nerve. I have been use this method. It appears good for patient after treatment.

:rolleyes: Don't forget correct posture it's important for patient.

Whilst it would be very nice to be able to determine whether facet joint pathology is present, from memory studies have shown that we are able to localise the source of pain in the cervical spine about 20 percent of the time with manual examination (which is pretty poor).

That said i do believe we are able to locate the specific segment which is pathological with manual examination, although i believe that is also under debate.

My opinion is, whether it is facet or disc or something else, it wont really change the way you should treat your patient. Assess the deep cervical flexors, deep extensors, lifestyle, scapular, posture and somatosensory dysfunction : address any impairments noted in the above and also treat with manual therapy over the pathological segment.

I guess what i am saying is that the diagnosis of facet joint pathology does not guide what treatment you will choose, but rather impairments such as a craniocervical flexion test of 22mmhg would suggest that retraining should be part of the treatment.

That said to know whether facet joint pathology is present may aid in estabilishing a liklelihood of the effectiveness of a physio program, although there would have to be some studies looking into this also.