Cervical Facet Syndrome

Neck pain arising from the cervical zygapophyseal (facet) joints, which are synovial joints lying in the posterior columns. They are innervated by the medial branches of the dorsal rami, with the C2-3 joint supplied by the third occipital nerve.

• Causes: whiplash and other neck trauma (facet joints are the source of pain in up to 50 to 60% of chronic post-whiplash neck pain), degenerative osteoarthritis, repetitive loading and poor posture, inflammatory arthritis, and rarely synovial cysts.
• Chronic neck pain has a prevalence of about 10 to 15%, with facet joints responsible for about 25 to 55% of cases.
• Pain referral patterns by level: C2-3 (occipital headache, third occipital headache, with pain at the head base), C3-4 (posterior neck), C4-5 (neck and trapezius), C5-6 (neck, shoulder and scapular), and C6-7 (posterior shoulder and interscapular).
• Natural history: most acute episodes settle within 6 to 12 weeks, but chronic whiplash related pain persists in about 20 to 40%.

• Unilateral neck pain, localised paramedian, aggravated by extension, rotation to the affected side and prolonged static postures, relieved by rest and flexion, with morning stiffness, suboccipital headaches (C2-3), and referred shoulder and interscapular pain. Arm pain below the elbow is unusual.
• Examination: paraspinal tenderness over the facet (about 1.5 to 2 cm lateral to the midline), restricted and painful extension and rotation, pain on extension rotation loading to the same side, and normal neurological examination.
• Differential diagnosis: cervical spondylosis with radiculopathy or myelopathy, disc herniation, myofascial pain, cervicogenic headache from other sources, atlantoaxial and occipitocervical disease, rotator cuff disease, thoracic outlet syndrome, vertebral artery dissection, fracture and ligamentous injury after trauma, spondyloarthritis, rheumatoid cervical disease, infection and tumour.
• Red flags: trauma with neurological deficit or midline bony tenderness, sudden severe headache with neck pain and neurological features (arterial dissection or subarachnoid haemorrhage), fever, weight loss, history of cancer, myelopathic signs, rheumatoid arthritis with neck pain (instability), and immunosuppression.
• Complications: chronic pain, headache, reduced range, disability and secondary psychological distress.

• Clinical, with neurological and shoulder examination, and screening for red flags.
• X-ray (anteroposterior, lateral and oblique, with flexion extension views if instability is suspected) shows facet hypertrophy, narrowed joints and alignment. CT or MRI shows facet arthropathy, effusions, cysts, disc disease, and excludes other causes, but findings do not predict the pain source.
• Controlled diagnostic medial branch blocks (or third occipital nerve block for C2-3) under imaging guidance with small volume local anaesthetic (bupivacaine 0.5% or lidocaine 2%, 0.3 to 0.5 mL per nerve), with at least 80% pain relief on two occasions, confirm the source. Intra articular blocks are an alternative.
• Bloods (CRP, ESR, rheumatoid serology) if inflammatory disease is suspected.

• Conservative treatment for 6 to 12 weeks: education, avoiding prolonged static postures, ergonomic adjustment, early return to normal activity (not prolonged collar use), physiotherapy (deep neck flexor and scapular strengthening, cervical range of movement, postural retraining, and manual therapy), and heat.
• Analgesia: paracetamol 1 g orally 6 hourly. Naproxen 500 mg 12 hourly (or ibuprofen 400 mg 8 hourly, or diclofenac 50 mg 8 hourly) with food for 1 to 2 weeks. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily. Muscle relaxant for spasm over 5 to 7 days (tizanidine 2 mg 8 hourly, or cyclobenzaprine 5 to 10 mg at night). Amitriptyline 10 to 25 mg at night or duloxetine 30 to 60 mg daily for chronic pain.
• Intra articular facet steroid injection (triamcinolone 10 to 20 mg or methylprednisolone 10 to 20 mg with local anaesthetic, 0.5 to 1 mL per joint, under fluoroscopy) gives short term relief for some, and the long term evidence is limited.
• Radiofrequency ablation of the medial branches after two positive controlled blocks: conventional thermal ablation at 80 degrees Celsius for 60 to 90 seconds, with 50% or more relief in about 60 to 70% of selected patients, lasting 6 to 12 months and repeatable. For C2-3 pain, third occipital nerve ablation relieves headache in about 50 to 75%. Complications: ataxia and numbness after third occipital nerve ablation, post-procedure neuritis, and infection.
• Whiplash associated disorders: early mobilisation, reassurance, analgesia and physiotherapy, and avoidance of long term collar use.
• Surgery is rarely needed for facet pain alone, and is considered for instability, deformity or neural compression.
• Special groups:
  • Elderly: lower doses and exercise based care, and avoid cyclobenzaprine.
  • Diabetes: monitor glucose after steroid injection.
  • Pregnancy: physiotherapy, ergonomic care and paracetamol. Avoid NSAIDs after 20 weeks.
  • Rheumatoid arthritis: screen for atlantoaxial instability before manipulation, and treat the inflammatory disease.
  • Anticoagulation: hold under specialist guidance for procedures.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 4 to 6 weeks and at 3 months. Refer urgently for myelopathy, trauma with neurological deficit, or suspected arterial dissection. Refer to pain medicine for chronic pain beyond 3 months and consideration of diagnostic blocks and radiofrequency ablation.