Cervical facet joint dysfunction: a review

Changes in the Utilization of Cervicothoracic Injections Between 2010 and 2020

STUDY DESIGN

Descriptive epidemiologic study.

OBJECTIVE

To analyze trends and patient characteristics of those undergoing cervicothoracic transforaminal, interlaminar, and facet injections over time.

BACKGROUND

Cervicothoracic transforaminal, interlaminar, and facet injections are considered for varied spinal pathologies. Evolving literature, changing physician preferences, insurance reimbursement policies, and patient factors may influence the utilization of such injections over time.

METHODS

Patients undergoing cervicothoracic transforaminal, interlaminar, and facet injections 2010-2020 were identified in the M151Ortho PearlDiver database using Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, and West) were extracted and assessed over study intervals based on prevalence per 100,000 covered lives.

RESULTS

Cervicothoracic transforaminal, interlaminar, and facet injections were identified for 195,221 (11.3%), 951,191 (55.2%), and 575,228 (33.4%) patients, respectively. Patient characteristics for each injection type were defined. The annual number of injections performed per 100,000 covered lives decreased during the study period for transforaminal (17.1% decrease) and interlaminar (9.3% decrease) but increased for facet (3.7% increase) injections ( P <0.0001 for each). Stratifying by patient insurance type, administration of transforaminal, interlaminar, and facet injections per 100,000 covered lives was proportionally greatest for commercially insured patients (55%, 50%, and 45%, respectively), and proportionally smallest for Medicaid patients (10%, 13%, and 13%, respectively). Anesthesiology physicians performed the most injections, followed by physical medicine and rehabilitation physicians, with both provider types most frequently performing interlaminar injections, followed by facet and transforaminal injections.

CONCLUSION

Annual cervicothoracic transforaminal and interlaminar injection utilization declined by 17.1% and 9.3% from 2010 to 2020, whereas facet injection administration increased by 3.7% over the same interval. Evolving practice patterns are important to consider in characterizing the overall landscape of spine care.

Single-Photon Emission Computed Tomography (SPECT-CT) as a Predictor of Pain Generators in Patients Undergoing Anterior Cervical Discectomy and Fusion (ACDF) for Axial Cervical Pain

BACKGROUND

Axial neck pain is often associated with cervical instability, and surgical options are often reserved for patients with either neurological compromise or deformity of the spine. However, cervical facet arthropathy is often implicated with instability and the location of painful generators is often difficult to ascertain. Single-photon emission computed tomography (SPECT-CT) presents an adjunct to conventional imaging in the workup of patients with suspected facetogenic pain. We aimed to report our experience with patients undergoing anterior cervical discectomy and fusion (ACDF) guided by SPECT-CT for axial cervical pain.

METHODS

We retrospectively identified all cases undergoing ACDF that presented with axial neck pain where correlating SPECT-CT high metabolism areas were identified. Patients were treated at a tertiary care institution between January 2018 and January 2021. Patients with positive radiotracer uptake pre-operatively were compared with patients undergoing ACDF without uptake on SPECT-CT. The pre- and post-operative patients who reported neck pain at one year were compared.

RESULTS

Thirty-five patients were included in this retrospective cohort. The median pre- and post-intervention (at one-year follow-up) visual analog score (VAS) of patients undergoing ACDF without uptake on SPECT-CT was 7 and 3 (p<0.01), while the pre- and post-VAS for patients undergoing surgery with positive uptake on SPECT-CT was 8.5 and 0 (p<0.01). Improvement was significantly larger for patients undergoing SPECT-CT-guided ACDF (p=0.02). At one year after surgery, none of the assessed patients required additional surgical intervention.

CONCLUSION

This case series represents the experience of our group to date with patients undergoing SPECT-CT-guided ACDF with results suggesting potential benefit in guiding fusion.

Effectiveness of pulsed radiofrequency on the medial cervical branches for cervical facet joint pain

BACKGROUND

Cervical facet joint pain (CFP) is one of the most common causes of neck pain and headache. Persistent CFP deteriorates the quality of life of patients and reduces their productivity at work.

AIM

To investigate the effectiveness of pulsed radiofrequency (PRF) stimulation of cervical medial branches in patients with chronic CFP.

METHODS

We retrospectively included 21 consecutive patients (age = 50.9 ± 15.3 years, range 26-79 years; male: female = 8:13; pain duration = 7.7 ± 5.0 mo) with chronic CFP, defined as ≥ 4 on the numeric rating scale (NRS). We performed PRF stimulation on the cervical medial branches. The outcomes of the PRF procedure were evaluated by comparing the NRS scores for CFP before treatment and 1 and 3 mo after treatment. Successful pain relief was defined as a ≥ 50% reduction in the NRS score at 3 mo when compared with the pretreatment NRS score.

RESULTS

No patient had immediate or late adverse effects following PRF. The average NRS score for CFP decreased from 5.3 ± 1.1 at pre-treatment to 2.4 ± 0.6 at the 1 mo follow-up, and 3.1 ± 1.1 at the 3 mo follow-up. Compared to the NRS scores before PRF stimulation, those at 1 and 3 mo after PRF stimulation had significantly decreased. Eleven of the 21 patients (52.4%) reported successful pain relief 3 mo after the PRF procedure. PRF stimulation on cervical medial branches may be a useful therapeutic option to control chronic CFP.

CONCLUSION

PRF stimulation of the cervical medial branches may be used as an alternative treatment method in patients with CFP. PRF can effectively alleviate CFP, and is safe to perform.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study

BACKGROUND

A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS).

METHODS

We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated.

RESULTS

The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success.

CONCLUSION

The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

The innervation of the cervical facet joints - an anatomical and histological approach

INTRODUCTION

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings.

MATERIALS AND METHODS

Twenty-seven cervical facet joints and their innervating structures were dissected from five halves of three human neck specimens. Histologic staining was used to confirm that the samples were nervous tissues, and all samples were documented with photography.

RESULTS

Histology: Thirty-six assumed facet joint branch samples were obtained and stained. Twenty-two of these were confirmed to be nervous tissue. Therefore, 61% of the samples were identified as facet joint branches. Of all samples, 28% were not nerves. Dissection: At least one medial branch was clearly identified at each dissected cervical level. At some cervical levels, more than one medial branch was found. Anatomical differences, such as a plexus-like innervation in the high cervical region, were observed. Direct facet joint branches were also discovered. These branches originate directly from the dorsal root of the spinal nerve and were independent from medial branches during their direct pathway toward the facet joint.

CONCLUSION

Direct cervical facet joint branches were identified and a more diverse innervation pattern than previously described of the cervical facet joints was found. This article is protected by copyright. All rights reserved.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Third-degree full-thickness burns as a complication of cervical radiofrequency ablation

A 46-year-old woman underwent a cervical radiofrequency ablation (RFA) for chronic neck pain. Following the procedure, two areas surrounding the grounding pad in the lumbar region developed full thickness third-degree burns. Burn injuries following cervical RFA are rarely reported and are most often associated with cardiac and solid tumour RFA. Only one other case has been reported in literature with a similar outcome following a thoracic facet RFA. In our case, the lesion was directly from the ground pad and not from the radiofrequency electrode, which is more often the culprit. This is the first case reported in the literature of a full-thickness skin burn from a cervical RFA. Physicians should be aware of the potential for severe burns around the RF probe and ground pad as sequelae of RFA, and we caution the use of sedation during the procedure, as patients will unlikely be able to report any unusual sensation.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BACKGROUND

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.

METHODS

In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.

RESULTS

Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.

CONCLUSIONS

Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Efficacy and Long-term Effect of Radiofrequency Denervation in Patients with Clinically Diagnosed Cervical Facet Joint Pain: A Double-blind Randomized Controlled Trial

STUDY DESIGN

Multicenter double-blind randomized sham-controlled trial.

OBJECTIVE

To assess the efficacy of radiofrequency (RF) denervation of the cervical facet joints in chronic cervical facet joint pain.

SUMMARY OF BACKGROUND DATA

One randomized controlled trial showed efficacy of RF denervation in whiplash-associated disease. There are no randomized controlled trials on RF denervation in patients with chronic cervical facet joint pain.

METHODS

Patients were randomized to receive RF denervation combined with bupivacaine (intervention group) or bupivacaine alone (control group). In the intervention group, an RF thermal lesion was made at the cervical medial branches after the injection of bupivacaine. The primary outcome was measured at 6 months and consisted of pain intensity, self-reported treatment effect, improvement on the Neck Disability Index, and the use of pain medication. Duration of effect was determined using telephone interviews.

RESULTS

We included 76 patients. In the intervention group, 55.6% showed > 30% pain decrease versus 51.3% in the control group (P = 0.711); 50.0% reported success on the Patients' Global Impression of Change in the intervention group versus 41.0% (P = 0.435); the Neck Disability Index was 15.0 ± 8.7 in the intervention group compared with 16.5 ± 7.2 (P = 0.432), the need for pain medication did not differ significantly between groups (P = 0.461). The median time to end of treatment success for patients in the RF group was 42 months, compared with 12 months in the bupivacaine group (P = 0.014).

CONCLUSIONS

We did not observe significant differences between RF denervation combined with injection of local anesthesia compared with local anesthesia only at 6 months follow-up. We found a difference in the long-term effect after 6 months follow-up in favor of the RF treatment.Level of Evidence: 2.

Fluoroscopic Findings of Extra-Cervical Facet Joint Flow and Its Incidence on Cervical Facet Joint Arthrograms

Cervical facet joint (CFJ) syndrome is a common cause of neck pain. For its diagnosis and treatment, CFJ injection with arthrogram is generally performed. This study aimed to investigate the frequency of extra-CFJ flow on CFJ arthrograms during injections and its differences according to age, sex, and cervical vertebral level. We analyzed 760 CFJ arthrograms administrated to 208 patients diagnosed with CFJ syndrome. Arthrograms at each vertebral level were collected to evaluate the normal CFJ and extra-CFJ flow. The primary and secondary outcomes were frequency of extra-CFJ flow according to cervical vertebral level, age, and sex and according to pairwise cervical levels, respectively. Extra-CFJ flow at the cervical spine occurred during 179 injections, and the overall incidence was 3.3–36.2% at different cervical levels. The incidence of extra-CFJ flow at each cervical vertebral level according to age and sex was not significant. Extra-CFJ flow was the highest at C6 and C7, but there was no statistical significance. Extra-CFJ flow was higher at lower vertebral levels (C5–C7) than at upper levels (C3 and C4). Additional clinical studies and anatomical evaluations are needed to support its clinical value and enable the development of new injection techniques.

The utility of radionucleotide imaging in the surgical management of axial neck pain from cervical facet joint arthropathy

OBJECTIVE

Axial neck pain is common and often debilitating. Diagnosis of the specific pain source can be a challenge, and this confounds effective treatment. Cervical facet arthropathy is implicated in many of these cases. The diagnosis is readily made on conventional cross-sectional imaging modalities, particularly CT imaging. However, this modality falls short in determining if an osteoarthritic facet joint is truly the source of symptoms. Radionucleotide imaging presents a noninvasive radiological adjunct to conventional cross-sectional imaging in the workup of patients with suspected facetogenic pain. Herein, the authors present the patient-reported outcomes (PROs) following posterior instrumented arthrodesis of the subaxial cervical spine from a consecutive case series of patients with a diagnosis of cervical facet joint arthropathy and a concordant positive radionucleotide tracer uptake.

METHODS

The clinical case series of patients treated by the senior author at a single tertiary care institution between September 2014 and April 2018 was reviewed. Patients were selected for inclusion if their primary symptom at presentation was axial neck pain without neurological deficits and if CT imaging revealed facet arthropathy of the cervical spine. These patients underwent radionucleotide imaging in the form of a planar 99mTc methylene diphosphonate (99mTc MDP) bone scintigraphy study. Those with a finding of radionucleotide tracer uptake at a location concordant with the facet arthropathy were selected to undergo posterior cervical instrumented arthrodesis of the affected levels. PROs were recorded at the time of surgical consultation (i.e., after nonoperative treatment) and at 6 weeks, 3 months, 6 months, and 1 year following surgery. These included neck and arm pain, the Neck Disability Index (NDI) and the 12-Item Short Form Health Survey responses.

RESULTS

A total of 11 patients were included in this retrospective case series. The average reported neck pain and NDI scores were high at baseline; 7.6 ± 2.3 and 37.1 ± 13.9 respectively. Twelve months after surgical intervention, a significant decrease in reported neck pain of -4.5 (95% CI -6.9, -2.1; p = 0.015) and a significant decrease in NDI of -20.0 (95% CI -29.4, -10.6; p = 0.014) was observed.

CONCLUSIONS

This case series represents the largest to date of patients undergoing surgical arthrodesis following a finding of facet arthropathy with a concordant positive radioisotope image study. These observations add support to a growing body of evidence that suggests the utility of radioisotope imaging for identification of a facetogenic pain generator in patients with primary axial neck pain and a finding of cervical facet arthropathy. These preliminary data should serve to promote future prospective, controlled studies on the incorporation of radionucleotide imaging into the workup of patients with suspected facetogenic pain of the cervical spine.

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught using an oblique approach to the anterior lateral capsule of the cervical facet joint. The goal is to position the electrode at the proximal location of the recurrent branch after it leaves the exiting nerve root and loops back to the cervical facet joint. The standard oblique approach to the recurrent nerve requires the testing of both motor and sensory components to verify the correct position and ensure safety so as to not damage the slightly more anterior nerve root. Bilateral lesions require the repositioning of the patient's neck. Poorly positioned electrodes can also pass anteriorly and contact the nerve root or vertebral artery. The direct posterior approach presented allows electrode positioning over a broader expanse of the facet joint without risk to the nerve root or vertebral artery. Over a four-year period, direct posterior radiofrequency ablation was performed under fluoroscopic guidance at multiple levels without neuro-stimulation testing with zero procedural neurologic events even as high as the C2 spinal segment. The direct posterior approach allows either unipolar or bipolar lesioning at multiple levels. Making a radiofrequency lesion along the larger posterior area of the facet capsule is as effective as the traditional target point closer to the nerve root but technically easier, allowing bilateral access and safety. The article will review the anatomy and innervation of the cervical facet joint and capsule, showing the diffuse nerve supply extending into the capsule of the facet joint that is more extensive than the recurrent medial sensory branches that have been the focus of radiofrequency lesioning.

Neck Pain: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

Ultrasound versus fluoroscopy-guided cervical medial branch block for the treatment of chronic cervical facet joint pain: a retrospective comparative study

OBJECTIVE

To compare the mid-term effects and advantages of the ultrasound (US)-guided with fluoroscopy(FL)-guided cervical medial branch blocks (CMBBs) for chronic cervical facet joint pain through assessment of pain relief, functional improvement, and injection efficiency.

METHODS

Patients with chronic cervical facet joint pain who received US- (n = 68) or FL-guided CMBBs (n = 58) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies, treatment effects, functional improvement, and injection efficiency of CMBBs were compared at 1, 3, and 6 months after the last injection.

RESULTS

Both the NDI and VNS scores showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), the number of injections, sex, analgesic use, and age were not independent predictors of treatment success. Compared with FL-guided CMBB, US-guided CMBB was associated with a shorter administration duration and fewer needle passes.

CONCLUSIONS

Our results suggest that, compared with FL-guided CMBBs, US-guided CMBBs require a shorter administration duration and fewer needle passes, while providing similar pain relief and functional improvements. Therefore, US-guided CMBBs can be considered as an effective alternative for the conservative management of chronic cervical facet joint pain.

Interventional pain therapy in cervical post-surgery syndrome

Fifteen percent to forty percent of patients present with persistent disabling neck pain or radicular pain after cervical spine surgery. Persistent pain after cervical surgery is called cervical post-surgery syndrome (CPSS). This review investigates the literature about interventional pain therapy for these patients. Because different interventions with different anatomical targets exist, it is important to find the possible pain source. There has to be a distinction between radicular symptoms (radicular pain or radiculopathy) or axial pain (neck pain) and between persistent pain and a new onset of pain after surgery. In the case of radicular symptoms, inadequate decompression or nerve root adherence because of perineural scarring are possible pain causes. Multiple structures in the cervical spine are able to cause neck pain. Hereby, the type of surgery and also the number of segments treated is relevant. After fusion surgery, the so-called adjacent level syndrome is a possible pain source. After arthroplasty, the load of the facet joints in the index segment increases and can cause pain. Further, degenerative alterations progress. In general, two fundamentally different therapeutic approaches for interventional pain therapy for the cervical spine exist: Treatment of facet joint pain with radiofrequency denervation or facet nerve blocks, and epidural injections either via a transforaminal or via an interlaminar approach. The literature about interventions in CPSS is limited to single studies with a small number of patients. However, some evidence exists for these procedures. Interventional pain therapies are eligible as a target-specific therapy option. However, the risk of theses procedures (especially transforaminal epidural injections) must be weighed against the benefit.

Injury mechanisms of the ligamentous cervical C2-C3 Functional Spinal Unit to complex loading modes: Finite Element study

The cervical spine sustains high rate complex loading modes during Motor Vehicle Crashes (MVCs) which may produce severe injuries accompanied with soft and/or hard tissue failure. Although previous numerical and experimental studies have provided insights on the cervical spine behavior under various loading scenarios, its response to complex impact loads and the resulting injury mechanisms are not fully understood. A validated Finite Element (FE) model of the ligamentous cervical C2-C3 Functional Spinal Unit (FSU) was utilized to assess the spinal response to six combined impact loading modes; flexion-extension combined with compression and distraction, and lateral bending and axial rotation combined with distraction. The FE model used time and rate-dependent material laws which permit assessing bone fracture and ligament failure. Spinal load-sharing, stresses in the spinal components, intradiscal pressure (IDP) change in the nucleus as well as contact pressure in the facet joints were predicted. Bone and ligaments failure occurrence and initiation instants were investigated. Results showed that spinal load-sharing varied with loading modes. Lateral bending combined with distraction was the most critical loading mode as it increased stresses and strains significantly and produced failure in most of the spinal components compared to other modes. The facet joints and surrounding cancellous bone as well as ligaments particularly the capsular (CL) and flavum (FL) ligaments were the most vulnerable structures to rapid flexion-extension, axial rotation and lateral bending combined with distraction or compression. The excessive stress and strain resulted from these loading modes produced rupture of the CL and FL ligaments and failure in the cancellous bone. The detection of failure initiation as well as fracture assessment demonstrated the vulnerability of ligaments to tensile combined loads and the major contribution of the bony structures in resisting compressive combined loads. Findings of this study may potentially assist in the development of injury prevention and treatment strategies.

Radiologic assessment of forward head posture and its relation to myofascial pain syndrome

Objective

To assess head posture using cervical spine X-rays to find out whether forward head posture is related to myofascial pain syndrome (MPS) in neck and shoulder.

Methods

Eighty-eight participants who were diagnosed with MPS in neck and shoulder were evaluated in this study. Four parameters (distance among head, cervical spines, and shoulder, and cervical angle) were measured from lateral view of cervical spine X-ray. The location and number of trigger points in the neck and shoulder and symptom duration were evaluated for each patient.

Results

Both horizontal distances between C1 vertebral body and C7 spinous process and between the earhole and C7 vertebral body were negatively correlated with cervical angle reflecting cervical lordosis (p<0.05). Younger patients had significantly (p<0.05) less cervical angle with more forward head posture. There was no relationship between MPS (presence, location, and number of trigger points) and radiologic assessments (distance parameters and the cervical angle).

Conclusion

Forward head posture and reduced cervical lordosis were seen more in younger patients with spontaneous neck pain. However, these abnormalities did not correlate with the location or the number of MPS. Further studies are needed to delineate the mechanism of neck pain in patients with forward head posture.

Transforaminal versus intra-articular facet corticosteroid injections for the treatment of cervical radiculopathy: a randomized, double-blind, controlled study

BACKGROUND AND PURPOSE

Transforaminal corticosteroid injections can be performed in the management of cervical radiculopathy but carry the risk of catastrophic complications. This study compares the efficacy of transforaminal and facet corticosteroid injections at 4 weeks' follow-up.

MATERIALS AND METHODS

We randomly assigned 56 subjects to receive CT-guided transforaminal (15 men, 13 women; mean age, 52 years; range, 28-72 years) or facet (8 men, 20 women; mean, 44 years; range, 26-60 years) injections. The primary outcome was pain severity rated on a Visual Analog Scale (0-100). Secondary outcomes were the Neck Disability Index and the Medication Quantitative Scale.

RESULTS

In the intention-to-treat and as-treated analyses, for a mean baseline score, facet injections demonstrated a significant pain score reduction of 45.3% (95% CI, 21.4-69.2) and 37.0% (95% CI, 9.2-64.7), while transforaminal injections showed a nonsignificant pain score reduction of 9.8% (95% CI, +11.5-31.2) and 17.8% (95% CI, +6.6-42.2). While facet injections demonstrated an improvement in the Neck Disability Index score of 24.3% (95% CI, +2.9-51.5) and 20.7% (95% CI, +6.2-47.6) as opposed to transforaminal injections of 9.6% (95% CI, +15.2-34.4) and 12.8% (95% CI, +11.2-36.7), the results were not statistically significant. Noninferiority of facet to transforaminal injections was demonstrated for baseline pain scores of ≤60, while noninferiority analysis was inconclusive for baseline pain scores of ≥80 and for the Neck Disability Index. Neither intervention showed a significant medication-intake score reduction with time.

CONCLUSIONS

Facet injections are effective for the treatment of cervical radiculopathy and represent a valid and safer alternative to transforaminal injections.

The prostaglandin E2 receptor, EP2, is upregulated in the dorsal root ganglion after painful cervical facet joint injury in the rat

STUDY DESIGN

This study implemented immunohistochemistry to assay prostaglandin E2 (PGE2) receptor EP2 expression in the dorsal root ganglion (DRG) of rats after painful cervical facet joint injury.

OBJECTIVE

To identify if inflammatory cascades are induced in association with cervical facet joint distraction-induced pain by investigating the time course of EP2 expression in the DRG.

SUMMARY OF BACKGROUND DATA

The cervical facet joint is a common source of neck pain, and nonphysiological stretch of the facet capsular ligament can initiate pain from the facet joint via mechanical injury. PGE2 levels are elevated in painful inflamed and arthritic joints, and PGE2 sensitizes joint afferents to mechanical stimulation. Although in vitro studies suggest that the EP2 receptor subtype contributes to painful joint disease, the EP2 response has not been investigated for any association with painful mechanical joint injury.

METHODS

Separate groups of male Holtzman rats underwent either a painful cervical facet joint distraction injury or sham procedure. Bilateral forepaw mechanical allodynia was assessed, and immunohistochemical techniques were used to quantify EP2 expression in the DRG at days 1 and 7.

RESULTS

Facet joint distraction induced mechanical allodynia that was significant (P < 0.024) at all time points. Painful joint injury also significantly elevated total EP2 expression in the DRG at day 1 (P = 0.009), which was maintained at day 7 (P < 0.001). Neuronal expression of EP2 in the DRG was only increased over sham levels at day 1 (P = 0.013).

CONCLUSION

Painful cervical facet joint distraction induces an immediate and sustained increase of EP2 expression in the DRG, implicating peripheral inflammation in the initiation and maintenance of facet joint pain. The transient increase in neuronal EP2 suggests, as in other painful joint conditions, that after joint injury nonneuronal cells may migrate to the DRG, some of which likely express EP2.

Prevalence of migraine headaches in the Romany population in Spain: sociodemographic factors, lifestyle and co-morbidity

PURPOSE

To compare the prevalence of migraine headaches in the Romany population with the prevalence in the general Spanish population and to describe its association with demographic and clinical risk factors.

METHOD

A cross-sectional study using data from the 2006 Spanish National Health Survey (n = 16,079) and the National Health Survey in the Romany Population (n = 993). Inclusion criteria were migraine headache diagnosed by a neurologist, suffered over the preceding 2 weeks that reduced work or leisure activity by half a day or more.

RESULTS

The prevalence of migraine in the Romany population (29.4%, 95% confidence interval [CI] = 26.48-32.53) was significantly higher than in the general Spanish population (12.52%, 95% CI = 11.85-13.22). Females (odds ratio [OR] = 1.56, 95% CI = 1.10-2.21), those ≤40 years old (OR = 4.17, 95% CI = 1.78-9.62), those sleeping ≤8 hours/day or less (OR = 1.85, 95% CI = 1.32-2.59), those with body mass index >30 kg/m(2) (OR = 1.75, 95% CI = 1.15-2.65), those suffering from osteoarthritis (OR = 2.59, 95% CI = 1.54-4.36), and those suffering from allergy (OR = 1.69, CI = 1.05-2.71) were associated with higher incidence of migraines. Romanies with migraines reported worse self-perceived health status (OR = 2.11, 95% CI = 1.41-3.15) and higher incidence of depression (OR = 2.09 95% CI = 1.32-3.30) than those without.

DISCUSSION

Prevalence of migraines is greater in the Romany living in Spain than in the general Spanish population.

IMPLICATION

Public health systems should focus prevention campaigns specifically on this population and concentrate on those factors that are potentially modifiable.

Cervical facet-mediated pain

The cervical zygapophyseal joints, or facet joints, have long been implicated as a source of neck pain. This article examines the epidemiology of pain arising from these joints and relevant anatomy and histology. An emphasis on clinical findings, examination, and imaging are presented, as well as a focus on whiplash-associated pain.

Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study

STUDY DESIGN

Cross-sectional epidemiological study.

OBJECTIVE

To determine the 1-year prevalence of neck pain and low back pain in the Spanish population and their association with sociodemographic and lifestyle habits, self-reported health status and comorbidity with other chronic disorders.

SUMMARY OF BACKGROUND DATA

No recent population-based epidemiological studies have estimated the prevalence of neck and low back pain in Spain.

METHODS

We analyzed data obtained from adults aged 16 years or older (n = 29,478) who participated in the 2006 Spanish National Health Survey, an ongoing, home-based personal interview which examines a nation-wide representative sample of civilian noninstitutionalized population residing in main family dwellings (household) of Spain. We analyzed prevalence data of neck and low back pain and their relationship with socio-demographic characteristics (sex, age, marital status, educational level, occupational status, or monetary income), self-perceived health status, lifestyle habits (smoking habit, alcohol consumption, sleep habit, physical exercise, or obesity), and the presence of concomitant chronic diseases or symptoms.

RESULTS

The 1-year prevalence was 19.5% (95% CI: 18.9-20.1) for neck pain and 19.9% (95% CI: 19.3-20.5) for low back pain. Both neck pain and low back pain were higher among female (26.4% and 24.5%) than male (12.3% and 15.1%). Subjects in the 31 to 50 years group were 1.5 times (95% CI: 1.3-1.8) more likely to report low back pain than participants in the 16 to 30 years group. Individuals reporting neck or low back pain showed worse self-reported health status (OR: 4.9, 95% CI: 4.5-5.3 for neck pain; OR: 4.7, 95% CI: 4.3-5.1 for low back pain) and were more likely to complain of depression (OR: 4.3, 95% CI: 3.9-4.7 or OR: 3.6, 95% CI: 3.3-3.9, respectively). Further, a strong association between neck and low back pain was found (OR: 15.6, 95% CI: 14.2-17.1). Finally, neck pain and low back pain were also associated with several other chronic conditions, particularly arthrosis (OR: 6.5, 95% CI: 6.0-7.0), and headaches (OR: 4.3, 95% CI: 3.9-4.8) for neck pain, and both arthrosis (OR: 5.7, 95% CI: 5.3-6.2), and osteoporosis (OR: 6.3, 95% CI: 5.6-7.2), for low back pain.

CONCLUSION

This Spanish population-based survey showed that neck and low back pain are prevalent and highly associated between them, more frequent in female (particularly neck pain) and associated to worse self-reported health status. Individuals with neck and low back pain were more likely than those without pain to have depression and other painful conditions, including headache and osteoporosis.

Image-guided facet joint injection

Chronic spine pain poses a peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features and nonspecific radiological findings. Facet joint injection is an interventional pain management tool for facet-related spinal pain that can be effectively administered by a radiologist. This technique is the gold standard for identifying facet joints as the source of spinal pain. The major indications for facet injections include strong clinical suspicion of the facet syndrome, focal tenderness over the facet joints, low back pain with normal radiological findings, post-laminectomy syndrome with no evidence of arachnoiditis or recurrent disc disease, and persistent low back pain after spinal fusion. The contraindications are more ancillary, with none being absolute. Like any synovial joint degeneration, inflammation and injury can lead to pain on motion, initiating a vicious cycle of physical deconditioning, irritation of facet innervations and muscle spasm. Image-guided injection of local anesthetic and steroid into or around the facet joint aims to break this vicious cycle and thereby provide pain relief. This outpatient procedure has high diagnostic accuracy, safety and reproducibility but the therapeutic outcome is variable.

Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash

Cervicogenic headache (CEH) is a well-recognized syndrome. Proposed diagnostic criteria differentiate CEH from migraine and tension-type headache (TTH) in most of the cases. The best differentiating factors include side-locked unilateral pain irradiating from the back and evidence of neck involvement--attacks may be precipitated by digital pressure over trigger spots in the cervical/nuchal areas or sustained awkward neck positions. Migrainous traits may be present in some cases. Cervical lesions are not necessarily seen, and most common cervical lesions do not produce CEH. Whiplash may occasionally induce headaches. This is suspected when the pain onset and the whiplash trauma are close in time. Whiplash-related headaches tend to be short-lasting, admitting mostly a TTH or a CEH-like phenotype. Neuroimaging abnormalities are not necessarily expected in CEH. Whiplash patients must undergo cervical imaging mostly in connection with the trauma, as no abnormalities are pathognomonic in chronic cases.

Radiofrequency neurotomy for the treatment of therapy-resistant neck pain after ventral cervical operations

OBJECTIVE

The objective of this study was to determine if radiofrequency neurotomy is effective for patients with postoperative neck pain after cervical spine operations.

DESIGN

The study design used was a retrospective practice audit.

SETTING

Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 2.5 years.

INTERVENTIONS

Patients with persistent postsurgical neck pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). If pain recurred, diagnostic medial branch blocks were performed. Patients with at least 80% relief following both the therapeutic and the diagnostic block underwent radiofrequency neurotomy. Positive treatment response was defined for at least 50% reduction of pain or sufficiently satisfaction of the patient.

RESULTS

Two hundred forty-two operations were performed, 125 of which were artificial disc operations, 66 were stand alone cages, and 51 were fusions with cage and plate. Two patients were lost to follow-up. Persistent neck pain occurred in 31% of the patients. The prevalence of zygapophysial pain after surgery was 13.2%. These 32 patients were treated with radiofrequency neurotomy because of recurrent neck pain. The average follow-up time was 15 months. A significant pain reduction was achieved in 59.4%. Significantly, after a double-level operation, more patients suffered persisting neck pain (P=0.002) compared with all patients being operated.

CONCLUSIONS

Zygapophysial joints are a possible source of postoperative pain after anterior cervical spine surgery. Persistent and therapy-resistant neck pain occurs more often in patients after double-level operation. Radiofrequency neurotomy can provide an effective treatment for persistent neck pain after ventral cervical spine surgery.