Cervical spine management in patients with rheumatoid arthritis. Review of the literature

Rheumatoid arthritis of the cervical spine is a well-recognized source of neck pain. Discussion of the potential effects of various treatment interventions on the tissues of patients with rheumatoid arthritis of the cervical spine, however, has been scarce in the physical therapy literature. Physical therapists should understand the implications of this type of inflammatory arthritis when treating patients with rheumatoid arthritis. The end-stage results of the inflammatory process and the mechanical forces on the cervical spine can cause atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. The purpose of this article is to review the literature on several aspects of rheumatoid arthritis of the cervical spine: 1) pathological anatomy, 2) clinical findings, 3) surgical management, 4) management with cervical orthoses, and 5) physical therapy management.     

5. Cervical Facet Pain

More than 50% of patients presenting to a pain clinic with neck pain may suffer from facet‐related pain. The most common symptom is unilateral pain without radiation to the arm. Rotation and retroflexion are frequently painful or limited. The history should exclude risk factors for serious underlying pathology (red flags). Radiculopathy may be excluded with neurologic testing. Direct correlation between degenerative changes observed with plain radiography, computerized tomography, and magnetic resonance imaging and pain has not been proven. Conservative treatment options for cervical facet pain such as physiotherapy, manipulation, and mobilization, although supported by little evidence, are frequently applied before considering interventional treatments. Interventional pain management techniques, including intra‐articular steroid injections, medial branch blocks, and radiofrequency treatment, may be considered (0). At present, there is no evidence to support cervical intra‐articular corticosteroid injection. When applied, this should be done in the context of a study. Therapeutic repetitive medial branch blocks, with or without corticosteroid added to the local anesthetic, result in a comparable short‐term pain relief (2 B+). Radiofrequency treatment of the ramus medialis of the cervical ramus dorsalis (facet) may be considered. The evidence to support its use in the management of degenerative cervical facet joint pain is derived from observational studies (2 C+).     

Cervical spine complications in rheumatoid arthritis patients. Awareness is the key to averting serious consequences

Rheumatoid arthritis is associated with several pathologic changes in the cervical spine, including loss of articular cartilage, ligamentous destruction, and bone erosion. These changes may lead to one or a combination of complications, including atlantoaxial subluxation, cranial settling, subaxial cervical subluxation, and periodontoid pannus formation. Surgical management of these problems should focus on relieving pain, stabilizing the spine, and decompressing neural elements.     

The Prevalence of Facet Joint-Related Chronic Neck Pain in Postsurgical and Nonpostsurgical Patients: A Comparative Evaluation

Background: Facet (zygapophysial) joints may be clinically important sources of chronic cervical spinal pain. Previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, and reported an overall prevalence of 36% to 67% facet joint involvement in cervical spinal pain. The reports of lumbar facet joint‐involvement in postsurgery syndrome have been shown to be highly variable with prevalence ranging from 8% to 32%. To date, however, the prevalence of postsurgical facet joint‐related pain in the cervical spine has not been evaluated. In light of this, the present retrospective study was conducted to assess and compare the prevalence of chronic postsurgical facet joint cervical spinal pain to nonsurgical, chronic cervical facet joint pain. Methods: Patients presenting with chronic neck pain were studied. The procedures were performed by a single physician in an interventional pain management ambulatory surgery center. The prevalence of cervical facet joint pain in postsurgical patients was assessed and compared to nonsurgical patients. Results: A total of 251 patients (45 postsurgery vs. 206 nonsurgical patients) with chronic persistent neck pain were evaluated using controlled, comparative local anesthetic blocks in accordance with IASP criteria. The prevalence of the cervical facet joint pain and false‐positive rate of single blocks in postsurgical patients were 36% and 50% compared with 39% and 43% in nonsurgical patients. Conclusions: Cervical facet joints are clinically important pain generators in a significant proportion of patients with chronic persistent neck pain after surgical intervention(s). The prevalence of cervical facet joint pain was similar in both postsurgical and nonsurgical patients. ?     

Painful Intervertebral Dysfunction: Robert Maigne's Original Contribution to Headache of Cervical Origin

SYNOPSIS
Professor Robert Maigne, a French Orthopedic Medicine and Functional Rehabilitation specialist, hasput forward new concepts leading to a better understanding of common pain of spinal origin. Maigneexplains that pain in the spine is due to an intervertebral dysfunction of the mobile segment which consistsof the intervertebral disc, ligaments and the facet joints. Any benign mechanical dysfunction of the mobilesegment can induce a pain radiating in the dermatome at the same level as the vertebral problem. Maignealso described signs found in the skin (cellulalgia), in the muscles (myalgic bands) and in the bonyinsertions of tendons (tenalgia). These signs are to be found in the same dermatome, myotome andsclerotome as the spinal dysfunction. For headache of cervical origin due to painful intervertebraldysfunction, the most frequent dysfunctional mobile segment is located at the C2-C3 level. This inducespain mostly in the posterior parts of the head and cellulalgia in the C2 and C3 dermatomes. Painfultumefaction is also found over the posterior aspects of the facet joints on palpation at this level. Thesefindings are key elements for the diagnosis of painful intervertebral dysfunction. The recognition of thesesigns is changing our understanding of the role of the cervical spine in headaches. Painful intervertebraldysfunction is very frequently found in chronic daily headaches.     

A Modified Posterolateral Approach for Radiofrequency Denervation of the Medial Branch of the Cervical Segmental Nerve in Cervical Facet Joint Pain Based on Anatomical Considerations

The cervical facet joints, also called the zygapophyseal joints, are a potential source of neck pain (cervical facet joint pain). The cervical facet joints are innervated by the cervical medial branches (CMBs) of the cervical segmental nerves. Cervical facet joint pain has been shown to respond to multisegmental radiofrequency denervation of the cervical medial branches. This procedure is performed under fluoroscopic guidance. Currently, three approaches are described and used. Those three techniques of radiofrequency treatment of the CMBs, classified on the base of the needle trajectory toward the anatomical planes, are as follows: the posterolateral technique, the posterior technique, and the lateral technique. We describe the three techniques with their advantages and disadvantages. Anatomical studies providing a topographic anatomy of the course of the CMBs are reviewed. We developed a novel approach based on the observed strengths and weaknesses of the three currently used approaches and based on recent anatomical findings. With this fluoroscopic‐guided approach, there is always bone (the facet column) in front of the needle, which makes it safer, and the insertion point is easier to determine without the risk of positioning the radiofrequency needle too dorsally.     

Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies

Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain.

This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%.

The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.     

Cervical spine pain in the competitive athlete

Cervical pain is a common complaint in both the well-conditioned athlete and the weekend warrior. Some injuries are mild in nature, responding to conservative treatment, including rest, medication, physical therapy, and time. However, more serious injuries, especially those involving the cervical spine, can have devastating consequences. Having a comprehensive understanding of the evaluation and management of cervical pain and cervical spine emergencies is crucial for physicians providing coverage for organized athletic events or for those who serve as team physicians. This article reviews the common causes of cervical spine pain in the competitive athlete.     

Cervical injury in head trauma

Criteria for excluding cervical spine injury in patients who have sustained blunt head or neck trauma were prospectively studied at four hospitals in the Chicago area. The authors attempted to define a subset of these adult patients who, based on clinical criteria, could reliably be excluded from cervical spine radiography, thus avoiding unnecessary radiation and saving considerable time and money in their evaluation. Patients fell into four groups: (1) patients who were awake, alert, and had no complaint of neck pain or tenderness on physical examination; (2) patients who were awake, alert, but had complaint of neck pain or tenderness on physical examination laterally over the trapezius muscle only; (3) patients who were awake, alert, but had complaint of central neck pain or tenderness on physical examination over the cervical spine or center of the neck; and (4) patients who were not fully awake or alert, were clinically intoxicated, had other painful or distracting injuries, or had focal neurologic findings. Patients in group 4 had significantly more fractures (21/387) when compared with all other patients (7/478). Patients with central neck pain or tenderness (group 3) had significantly more fractures (7/237) than patients without pain or tenderness or with these findings limited to the trapezius area (0/236). It is clear that patients who have altered mental status, abnormal examination findings, distracting injury, or pain or tenderness over the cervical spine must have cervical spine radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Cervical Facet Arthropathy and Occipital Neuralgia: Headache Culprits

Cervicogenic headache (CH) is pain referred from the neck. Two common causes are cervical facet arthropathy and occipital neuralgia. Clinical diagnosis is difficult because of the overlying features between primary headaches such as migraine, tension-type headache, and CH. Interventional pain physicians have focused on supporting the clinical diagnosis of CH with confirmatory blocks. The treatment of cervical facet arthropathy as the source of CH is best approached with a multidimensional plan focusing on physical therapy and/or manual therapy. The effective management of occipital neuralgia remains challenging, but both injections and neuromodulation are promising options.     

Cervical SNAGs: a biomechanical analysis

A sustained natural apophyseal glide (SNAG) is a mobilization technique commonly used in the treatment of painful movement restrictions of the cervical spine. In the manual therapy literature, the biological basis and empirical efficacy of cervical SNAGs have received scant attention. In particular, an examination of their potential biological basis in order to stimulate informed discussion seems overdue. This paper discusses the likely biomechanical effects of both the accessory and physiological movement components of a unilateral cervical SNAG applied ipsilateral to the side of pain when treating painfully restricted cervical rotation. The use of flexion and extension SNAGS, and rotation SNAGS performed contralateral to the side of pain are not considered. Although a cervical SNAG may clinically be able to resolve painfully restricted cervical spine movement, it is difficult to explain biomechanically why a technique which first distracts (opens) and then compresses (closes) the zygapophyseal joint ipsilateral to the side of pain, and perhaps slightly distracts the uncovertebral cleft, would be superior to a technique which distracts the articular surfaces with both accessory and physiological movement components. Therefore, the reported clinical efficacy of cervical SNAGs cannot be explained purely on the basis of the resultant biomechanical effects in the cervical spine.     

Facet joint pain and the role of neural blockade in its management

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.     

Cervical facet joint dysfunction: a review

Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review.

Objective

To review the relevant literature on cervical facet joint dysfunction and determine findings regarding its anatomy, etiology, prevalence, clinical features, diagnosis, and treatment.

Data Sources

A computer-aided search of several databases was performed, including Medline (1966 to present), Ovid (1966 to present), and the Cochrane database (1993 to present).

Study Selection

Selected articles had the following criteria: (1) all articles analyzed cervical facet joint pain—anatomy, prevalence, etiology, diagnosis, treatment; (2) only full, published articles were studied, not abstracts; and (3) all articles were published in English.

Data Extraction

All articles were critically evaluated and included the following categories: randomized controlled trials, meta-analyses, uncontrolled clinical trials, uncontrolled comparison studies, nonquantitative systematic reviews, and literature-based reviews.

Data Synthesis

We examined 45 references that consisted of 44 journal articles and relevant sections from 1 textbook. Cervical facet joints have been well established in the literature as a common nociceptive pain generator, with an estimated prevalence that ranges from 25% to 66% of chronic axial neck pain. No studies have reported clinical examination findings that are diagnostic for cervical facet mediated pain.

Conclusions

Overall the literature provides very limited information regarding the treatment of this condition, with only radiofrequency neurotomy showing evidence of effectively reducing pain from cervical facet joint dysfunction.     

Morphologic Evaluation of Cervical and Lumbar Facet Joints: Intra‐Articular Facet Block Considerations

Study Design: Needle orientations for lumbar and cervical facet injection were measured in cadavers and compared with facet angles measured on magnetic resonance images (MRIs). Objectives: To establish facet orientation relative to clinical procedures of a facet joint block in the cervical and lumbar spine. Methods: Needle orientation angles were measured from 20 unembalmed human cadaveric specimens (13 cervical and 7 lumbar). Spinal needles were inserted into the midpoints of the facet joint spaces from C3 to C7 and L1 to L5. Needle trajectories were measured with an optical tracking system. For comparison, facet angles from 100 clinical MRIs of lumbar spines were also measured. Facet orientations on MRIs were measured at their intersection with the transverse plane, and angles were quantified using image analysis software. Results: Typical angles for insertion of the needle into the cervical facets were oriented closer to the coronal plane, whereas insertion angles for lumbar needles were oriented closer to the sagittal plane. Relative to the sagittal plane, the mean cervical angle was 72 degrees and the mean lumbar angle was 33 degrees. The insertion points of the cervical facets were a mean of 29 mm from the midsagittal plane compared with a mean of 22 mm for the lumbar facets. MRI‐based facet joint angles correlated poorly with actual injection angles, which were overestimated 5 to 23 degrees, depending on the lumbar level. Conclusions: Knowledge of the quantitative anatomy of the facets may help improve clinical diagnosis and treatment. These data also may aid in constructing more realistic computer simulations.     

Unilateral septic arthritis of a lumbar facet joint secondary to acupuncture treatment--a case report

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.     

Cervical Manipulation and Vertebral Artery Injury: A Literature Review

Abstract

Understanding the risks and benefits of manipulation of the cervical spine is essential in developing effective and safe intervention strategies for patients with cervical spine pain. A review of the literature was performed to assess the effectiveness, benefits, and risks as well as the prudence of performing manipulation to the cervical spine as it relates to vertebral artery injury.     

Cervical Spine pain as a presenting complaint in metastatic pancreatic cancer: a case report

A 48 year-old female presented to her primary care physician with a two-month history of neck pain with negative cervical spine x-rays. During that office visit, the patient was noted to be tachycardic with EKG revealing ST depressions, which led to hospital admission. Acute coronary syndrome was ruled out, however, persistent neck pain warranted inpatient MRI of the cervical spine, which revealed a cervical spine lesion. Extensive investigation and biopsy ultimately confirmed stage IV pancreatic adenocarcinoma with metastases to the bone, liver, and likely lung. In the literature, the findings of a primary metastatic site being bone is rare with only a few case reports showing vertebral or sternal metastasis as the first clinical manifestation of pancreatic cancer. The uniqueness of this case lies in the only presenting complaint being cervical spine pain in the setting of extensive metastases to the liver, bone, and likely lung.     

Phrenic Nerve Injury After Radiofrequency Denervation of the Cervical Medial Branches

Radiofrequency denervation of the cervical medial branches is a possible treatment for chronic cervical facet pain syndrome when conservative management has failed. According to the literature, complications after radiofrequency denervation of the cervical medial branches are rare. We report a case of possible phrenic nerve injury after ipsilateral radiofrequency denervation of the cervical medial branches following a posterolateral approach.     

Screening of patients suitable for diagnostic cervical facet joint blocks--a role for physiotherapists

The cervical facet joint is a prevalent source of pain in patients with chronic cervical spine pain. Patients with persistent, disabling neck pain, are increasingly being referred for diagnostic facet joint blocks, with the aim of assessing their suitability for interventional procedures such as radiofrequency neurotomy (RFN). A positive response to the block is an indicator of more substantive benefits from RFN. Physiotherapists and medical practitioners are challenged to make appropriate referrals for diagnostic facet joint blocks. This lack of selection contributes to lengthy wait-lists, unnecessary invasive procedures for those who have a negative response and significant costs to the health care system. Physiotherapists use manual examination to identify the facet joint as the primary source of a patient's pain but its diagnostic accuracy and reliability is variable. It is reasoned that a combination of findings of a physical, manual and psychological assessment may better indicate that a patient will respond positively or negatively to a diagnostic facet joint block. Clinical prediction guides (CPG) allow practitioners to use the results of the patient history, self-report measures and physical examination toward optimal diagnostic and therapeutic decisions. It is proposed that the development and validation of a CPG may aid in the appropriate selection of patients for this diagnostic procedure.