Anatomy & Background
The neck or cervical spine can be divided into three separate areas, each of which performs a different function due to the orientation of the joints between the vertebral. The upper cervical spine (C1,C2) are primarily built for rotation. The middle and lower cervical spine (C3-C7) are responsible for flexing, extension, side bending and remaining rotation or turning.
The greatest amount of movement occurs at cervical vertebra C5-C6, but the levels of C4-C5 and C6-C7 have almost as much. This movement produces more stress on these areas of the spine, thus the greatest amount of degeneration of the cervical spine occurs here.
Spinal and Facet Joints
Aside from the upper cervical spine (C1,C2 ) all other cervical vertebral levels consist of three joints. There is one joint consisting of the intervertebral discs which connect the bodies of the vertebra. There are also two posterior and lateral joints with one on each side called facet joints. The facet joints provide support, stability and facilitate motion of the cervical spine.
Facet joints are synovial joints, which have a smooth shiny contact surfaces called articular cartilage. The articular cartilage allows the bones to slide freely over each other with reduced friction and stress. Each joint is also surrounded by a protective sleeve called a capsule, and is lubricated by synovial fluid. The facet joints can become irritated and inflamed producing pain and dysfunction.
Common conditions of the facet joints include spondylosis, osteoarthritis of the spine, facet joint inflammation, degenerative joint disease of the spine and facet arthropathy.
Degenerative joint disease
Arthritis is a noninfectious progressive disorder of the joints. The normal articular joint cartilage is smooth, white, and translucent. In early arthritis or joint degeneration, the cartilage becomes yellow and opaque with localized areas of softening and roughening of the surfaces. As degeneration progresses, the soft areas become cracked and worn, exposing bone under the cartilage. Eventually, osteophytes (spurs of new bone) covered by cartilage form at the edge of the joint. As mechanical wear increases, the cartilage cells are unable to repair themselves. This wearing can become painful with loss of motion and function at that particular level.
The majority of degenerative joint disease is the result of mechanical instabilities, aging or changes within the joint.
Degenerative Joint Disease is a common cause of cervical neck pain. The cervical facet joints like other synovial joints of the body are susceptible to wear and tear, degeneration, inflammation and arthritic changes. Inflammation and degenerative changes of the facet joints may result in pain, loss of motion, irritation of the nerve of the joint and if bad enough encroachment or pinching of the nerve exiting the spinal column. Common causes of facet joint irritation include the following:
- Degeneration, arthritic changes or general wear-and-tear of the joint over time.
- Disc degeneration may cause a loss of height between vertebra placing a greater compression force on the posterior facet joints increasing and accelerating wear-and-tear on these joints.
- Backward motions can produce compression on the facet joints which can lead to degenerative and eventual arthritic changes.
- A sudden fall or trauma, such as a motor vehicle accident, can result in a facet joint irritation, increasing and accelerating wear-and-tear of joints.
- Genetic factors can contribute to the likelihood of degenerative joint disease.
- Repetitive stress injuries such as lifting or carrying heavy loads can cause facet joint irritation and degenerative joint disease.
The symptoms of degenerative joint disease will depend on the location of the joint and what structures it effects. Symptoms can vary from mild to severe and may mimic the symptoms of a disc problem:
- Pain in the neck or radicular to the shoulder blade and arm.
- Pain and tenderness localized at the level of the facet joint that is involved.
- Muscle spasms and changes in posture in response to the injury.
- A loss of motion, an inability to bend backward, move sideways to the effected side, or turning the head.
- Sitting, turning the head or looking up can be difficult if the irritation is severe enough.
- Loss of the normal cervical curvature.
- Development of entrapment, radiating pain and stenotic like symptoms.
- Stiffness in the joints following a period of rest.
- Pain with excess activity and relief with rest.
- Localized swelling at the joint level may be present.
Treating Degenerative Joint Disease
Treatment of degenerative joint disease or injury will depend on the severity of the condition. When treating acute back problems
- Rest. Avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backwards, etc).
- Anti-inflammatory drugs and other pain medications.
- Apply ice in acute cases to the neck or cervical spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Moist heat may be helpful to reduce pain and improve feeling of stiffness.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative joint disease and improve joint mobility, spinal alignment, posture, and range of motion.
- A neck collar may be necessary to reduce stress on the facet joints, muscles and cervical spine.
- Steroidal medication to reduced inflammation in moderate to severe conditions.
- Facet Joint injections directly to the involved joint.
- Physical Therapy to reduce inflammation, restore joint function, improve motion, and return full function.
In mild cases patients often found that rest, ice and medication were enough to reduce the pain. Physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe Cases
If the problem persists, consult with your health care provider. Your physician should perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine and soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
- CT scans which can give a cross section view of the spinal structures
Medications to consider
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with facet joint irritation.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective your physician my prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
- Muscle Relaxers to reduce acute muscle spasm.
- Injections such as facet injections, nerve blocks or epidural injections. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Conditions
In the case of conditions that do not respond to conservative care surgery may be indicated. If you continue to experience some of the following symptoms
- Increase in radiating or radicular pain
- Pain or nerve irritation that is getting worse
- Associated disc involvement
If symptoms the degenerative joint changes may have compromised the nerves that exit from the intervertebral foramen. This can result in nerve root entrapment causing radicular pain, weakness, and stenotic like symptoms. In this case surgery may be indicated to release entrapment and remove the degenerative changes that are compromising the nerve.
Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
- Caudal Epidural Injections
- Facet Joint Injections
- Interlaminar Caudal Epidural Steroid Injections
- Medial Branch Blocks
- Selective Nerve Root Blocks
Surgical Procedures to reduce the affects of degeneration on pain producing structures of the spine.
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Laser Facet Rhizotomy
- Facet Thermal Ablation
- Radiofrequency Ablation