Cervical Facet Syndrome
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 dull and ill defined in character. It may be unilateral or bilateral and is thought to be the result of pathology 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. Each joint receives fibers from the dorsal ramus at the same level as the vertebra as well as fibers from the dorsal ramus of the vertebra above. This fact has clinical import in that it provides an explanation for the ill-defined nature of facet-mediated pain and explains why the dorsal nerve from the vertebra above the offending level must often also 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. Spasm of these muscles may also be present. The patient will exhibit decreased range of motion of the cervical spine and will usually complain of pain on flexion, extension, rotation, and lateral bending of the cervical spine. There will be no motor or sensory deficit unless there is coexisting radiculopathy, plexopathy, or entrapment neuropathy.
Lateral view of the cervical spine showing osteoarthritis of the apophyseal joints of the upper cervical spine. There is a resultant subluxation of C-4 on C-5. There also is degenerative disk disease present at C5-6 and C6-7. There is associated osteophyte formation at C6-7, and there is subluxation of C-5 on C-6.
If the C1-2 facet joints are involved, the pain will be 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 will be referred superiorly to the suboccipital region and inferiorly to the posterolateral neck, with pain from the C4-5 facet joints radiating to the base of the neck. Pain from the C5-6 joints is referred to the shoulders and intrascapular region, with pain from the C6-7 facet joints radiating to the supraspinous and infraspinous fossae.
The pain of cervical facet syndrome is made worse by flexion, extension, and lateral of the cervical spine.
Cervical facet syndrome is best treated with a multilmodality approach. Physical therapy including heat modalities and deep sedative massage, combined with nonsteroidal anti-inflammatory drugs and skeletal muscle relaxants, represents a reasonable starting point. The addition of cervical facet blocks is a logical next step. For symptomatic relief, blockade of the medial branch of the dorsal ramus or intra-articular injection of the facet joint with local anesthetic and steroid has been shown to be extremely effective in the treatment of cervical facet syndrome. Underlying sleep disturbance and depression are best treated with a tricyclic antidepressant compound such as nortriptyline, which can be started at a single bedtime dose of 25 mg.