2: Cervical Facet Arthropathy

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CHAPTER 2

Cervical Facet Arthropathy

Ted A. Lennard, MD

Synonyms

Facet joint arthritis

Apophyseal joint pain

Spondylosis

Z-joint pain

Zygapophyseal joint pain

Posterior element disorder

ICD-9 Codes

715.1  Osteoarthrosis, localized, primary

715.2  Osteoarthrosis, localized, secondary

719.4  Pain in joint

721.0  Cervical spondylosis without myelopathy

723.1  Cervicalgia

723.3  Cervicobrachial syndrome

723.9  Unspecified musculoskeletal disorders and symptoms referable to neck

847.0  Neck: atlanto-occipital (joints), atlantoaxial (joints), whiplash injury

ICD-10 Codes

M43.02  Cervical spondylosis

M54.2   Cervicalgia

S13.4 Neck: Sprain of atlanto-axial (joints), sprain of atlanto-occipital (joints), whiplash injury

Definition

Cervical facet joints are located in the posterior portion of the cervical spine (Fig. 2.1). These paired synovial joints allow mobility and provide stability to the head and neck. Each of these joints is innervated by the medial branch of the posterior primary ramus [13]. Cervical facet arthropathy refers to any acquired, degenerative, or traumatic process that affects the normal function of the facet joints in the cervical region, often resulting in a source of neck pain and cervicogenic headaches. It may be a primary source of pain (e.g., after a whiplash injury) but often is secondary to a degenerative or injured cervical disc, fracture, or ligamentous injury. Common causes of cervical facet pain include acceleration-deceleration cervical injuries (whiplash), a sudden torque motion to the head and neck with extension and rotation, and a cervical compression force. In some cases, simply looking upward may cause facet pain. The cervical facet joints may also become painful in conjunction with a cervical disc herniation, after a cervical discectomy or fusion, or after a cervical compression fracture.

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FIGURE 2.1 Lateral fluoroscopic view of the right C2-3 zygapophyseal joint with the needle tip inside the joint. (From Dreyfuss P, Kaplan M, Dreyer SJ. Zygapophyseal joint injection techniques in the spinal axis. In Lennard TA, ed. Pain Procedures in Clinical Practice, 3rd ed. Philadelphia, Elsevier/Saunders, 2011: 373.)

Cervical facet arthrosis appears to increase with age and occurs more commonly in the upper cervical spine. In cadaveric studies, the prevalence of cervical arthrosis was greatest for the C4-C5 level, followed by the C3-C4 level [4]. The C6-C7 level was least involved. Abnormal findings within the cervical facet joints appear to be independent of race and gender [5].

Symptoms

Patients typically complain of generalized posterior neck and suboccipital pain but may present with localized tenderness over the posterolateral aspect of the neck. Pain provoked with cervical extension and axial rotation is common. These joints may refer pain anywhere from the midthoracic spine to the cranium and often in the suboccipital region [68]. Neurologic symptoms, such as sensory complaints and muscle weakness in the upper limbs, are not expected in patients with primary cervical facet pain. Concomitant nerve root or cord injury is more likely if these symptoms are present.

Physical Examination

The essential element of the examination is manual palpation of the spinal segments and elicitation of reproducible pain over the involved joints [9]. Localized point tenderness over the cervical paraspinal muscles is common and is precipitated by excessive cervical lordosis, causing abnormal joint forces. The fluidity of motion of the involved spinal area–cervical region may suggest extension pain with relief on flexion. Patients may present with loss of cervical motion and paraspinal spasms. Unless cervical disc or nerve root disease is also present, the findings of the neurologic examination are otherwise typically normal.

Functional Limitations

Cervical extension and rotation, overhead lifting, and overhead reaching may be difficult when the cervical spine is involved. This may interfere with activities such as bathing, grooming, and driving.

Diagnostic Studies

Fluoroscopically guided intra-articular arthrography confirmed that anesthetic injections are the “gold standard” for diagnosis (Fig. 2.2) [1013]. Abnormalities detected on radiography, computed tomography, or magnetic resonance imaging have not been shown to correlate with facet joint pain. A single-photon emission computed tomographic scan can be used in refractory cases of suspected cervical facet disorders to rule out underlying bone processes that may mimic facet pain (e.g., spondylolysis, infection, tumor) [14

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