OUTLINE

GENERAL MEDICAL BACKGROUND

1. DEFINITION
Cervical Facet Syndrome is a degenerative condition marked by stiffness and pain in the
cervical region (neck) of the spine.

2. EPIDEMIOLOGY
● The prevalence of cervical facet joint-mediated pain in patients with complaints of neck
pain ranges from 36% to 60%.
● 52% have only one symptomatic joint.
● Patients that have two or more consecutive joints that are symptomatic are rare.
● Prevalence of Chronic Traumatic Zygapophyseal joint pain is 54-64%.
● 58-88% complain of headaches
● 50-53% prevalence of C2-C3 zygapophyseal joint pain whose chief complaint is
posterior headaches after whiplash injury

3. ETIOLOGY
Cervical facet syndrome has only one symptomatic joint, rarely two or more consecutive
joints symptomatic. Traumatic injuries such as whiplash from MVA induce cervical
zygapophyseal joint pain. Non-traumatic factors such as disc degeneration, arthritic
changes, repetitive stress injuries, genetic factors, and improper biomechanics may
cause the irritation of the cervical zygapophyseal joint.

4. CLASSIFICATION
● Axial pain

5. PATHOPHYSIOLOGY
● Facet syndrome can be caused by trauma. Abnormal postures can overload spinal
tissues, including the facet joints, and cause inflammation and pain in these joints. More
commonly, degenerative changes in the cervical spine can lead to abnormal stress and
strain. This results in increased loads on the facet joints.
● Zygapophyseal joint fractures, intra-articular hemorrhage and capsular tears.

6. CLINICAL MANIFESTATIONS
● Neck pain
● Headaches
● Limited range of motion (ROM)
● The pain is described as a dull, aching discomfort in the posterior neck that sometimes
radiates to the shoulder or mid back regions.
● Traumatic upper zygapophyseal joint involvement at C2-C3 joint is likely to cause
unilateral occipital headaches
● Unilateral paramedian neck pain is more painful than any associated headaches
 ● Site of pain according to involved zygapophyseal joint site:
○ C1 to 2 AND C2 to 3 = Occiput
○ C3 to 4 AND C4 to 5 = Posterior neck
○ C5 to C6 = Supraspinatus fossa of the scapula
○ C6 to 7 = Scapula
○ C1 to 2, C2 to 3, C3 to 4 AND C4 to 5 = FACE
○ C3 to 4, C4 to 5. AND C5 to 6 = HEAD
(Each joint can produce unilateral or bilateral symptoms)

7. COMPLICATIONS

Cervical Facet Syndrome will mostly likely result to:

● Additional complications that can arise from facet arthropathy include headaches
(particularly with C1-2 and C2-3 joints), degenerative spondylolisthesis, facet joint cyst
and neuroforaminal stenosis, which can result in cervical radiculopathy. Inflammatory
autoimmune arthritis, infection or local inflammation, like synovitis or pseudogout, can
also affect the facet joints.
● There is a lot of damage of the cartilage, bone and supporting ligaments in the affected
facet joint(s) so the patient has recurrent episodes of dislocation of the facet joints. This
causes recurrent spasm of the nearby muscles and the neck or lower back is stiff and
painful.

8. DIAGNOSIS
● History and Physical Examination
○ Report a history of preceding trauma, in the absence of precipitating events,
symptoms can start spontaneously and gradually or explosively. If referral
symptoms are present, pt’s chief complaint is primarily axial pain associated with
nondescript upper limb symptoms.
● Diagnostic Imaging (Radiography, CT scan)
● Factors:
○ Exacerbating factors: prolonged sitting, coughing, sneezing or lifting
○ Alleviating factors: lying supine with head support, palpation over the cervical
spinous processes of the involved level can elicit pain.

9. DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS OF CERVICAL FACET SYNDROME AND CERVICAL NERVE

ROOT LESION, AND THORACIC OUTLET SYNDROME

Signs and Facet Syndrome Cervical Nerve Thoracic Outlet

Symptoms Root Syndrome

Pain referral Possible Yes Possible

Pain on Yes (often without Yes with increased No
hyperextension and increased referral of symptoms
rotation symptoms)

Spine stiffness Yes Possible Possible

Paresthesia No Yes Possible

Reflexes Not affected May be affected May be affected

Muscle spasm Yes Yes Yes

Tension tests May or may not be Positive May be positive

positive

Pallor and coolness No No Possible

Muscle weakness No Possible Not early (later small

hand muscles)

Muscle fatigue and No No Possible

cramps

10. PROGNOSIS
● Because facet joint syndrome develops with age, there is no way to “cure” it with non-
surgical treatments. However, the vast majority of people are able to manage their
symptoms without surgery for many years.
● Aspirin, Ibuprofen, Naproxen, Diclofenac, and other similar anti-inflammatories will help
for a few years.
● Finally, RFA (or radiofrequency ablation) can also be used to manage pain for up to 12
months.

MEDICAL/ SURGICAL/ PHARMACOLOGICAL MANAGEMENT

1. MEDICAL
● Diagnostic zygapophyseal joint blocks use CT imaging to confirm the suspected
symptomatic joint and perform via intraarticular injection of local anesthetic.
Anesthetizing the medial branches innervating the suspected joint enables the doctor to
determine if the suspected joint is the symptomatic structure or not. The pain may be
relieved or not.
○ Therapeutic zygapophyseal joint injections are appropriate for those who have
not improved from pharmacologic and physical modalities. Medications used are
local anaesthetics or steroids to reduce inflammation, nerve irritation and pain.
● Percutaneous Radiofrequency Ablation Medial Branch Neurotomy is indicated if the pain
is alleviated by the medial branch blocks. The RFA needle is inserted to numb the nerve
of the symptomatic joint. With more local anesthetic, the radiofrequency current is turned
 on. This generates heat to create a small, precise burn over the portion of the nerve that
transmits pain. The burn takes 90 seconds, and multiple nerves can be burned at the
same time.

2. SURGICAL
● N/A
3. PHARMACOLOGICAL
● Acute stage- Nonsteroidal anti-inflammatory drugs or NSAIDS and opiate

OTHER HEALTHCARE MANAGEMENT

● Surgery - If conservative treatment fails or if your neurological signs and symptoms —

such as weakness in your arms or legs — worsen, you might need surgery to create
more room for your spinal cord and nerve roots. Surgery might involve:
○ Removing herniated disks or bone spurs.
○ Removing part of a vertebra
○ Fusing a segment of the neck using bone graft and hardware.

PT EXAMINATION, EVALUATION AND DIAGNOSIS

1. POINTS OF EMPHASIS ON EXAMINATION

The examiner must conduct a detailed examination. History taking especially on the past
medical history, details of the accident, family history, employment,etc. Understanding
the mechanism of the injury and running a thorough screening process can help rule out
spinal cord injury, plexopathy, or traumatic brain injury.

● Patients’ chief complaints may vary from neck pain to occipital headaches hence
the physical examination must be thorough to determine if the condition is a
musculoskeletal involvement or a systemic one.
● If the patient pinpoints a localized spot as the source of pain, the clinician might
as well suspect zygapophyseal joint injury.
● Inspection should include checking of the changes in posture in response to the
injury (cervical kyphosis or the loss of normal lordotic curvature).
● Palpation is done over the cervical region. Focal tenderness over the joint upon
palpation may have underlying joint problems. Assess also for the tonicity of the
anterior/middle scalenes, trapezius, sternocleidomastoid and other neck
muscles.
● Cervical range of motion restrictions (specifically in flexion, extension, and
rotation) must be assessed. Increased focal suboccipital pain exacerbated with
45 degrees of cervical flexion and sequential axial rotation suggests a
zygapophyseal joint affectation.
● Diagnostic imaging can be obtained. Imaging includes but is not limited to X-
Rays, MRI, and CT scan. This is to exclude other pathologies (i.e., disc disease,
 tumor, fracture,spinal cord injury, plexopathy, or traumatic brain injury)

2. PROBLEM LIST
● Pain referral
● Mm spasm
● Pain on extension and rotation

3. PT DIAGNOSIS
● Report a history of preceding trauma, in the absence of precipitating events,
symptoms can start spontaneously and gradually or explosively. If referral
symptoms are present, the patient's chief complaint is primarily axial pain
associated with nondescript upper limb symptoms.
● Exacerbating factors: prolonged sitting, coughing, sneezing or lifting.
● Alleviating factors: lying supine with head support; thorough neuromuscular
examination should be performed to exclude myelopathy or radiculopathy.
Palpation over the cervical spinous process of the involved level can elicit pain.

PT DIAGNOSIS, PLAN OF CARE AND INTERVENTIONS

1. PLAN OF CARE GOALS

● It would be to remodel the patient’s lifestyle and improve it as well. We can achieve that
goal by advising him or her to exercise regularly, such as neck strengthening and
stretching to avoid recurrence of the cervical joint pain.
● Letting the patient be knowledgeable about his or her proper posture and body
mechanics when doing activity. Also, to avoid activities that are known to aggravate the
facet joints. Any twisting of the spine has the potential for injury. A few of the known
causes are:
○ Golf
○ Over-extending
○ Leaning backward
● Lastly, educating the patient on what to do to alleviate the pain caused by cervical facet
syndrome.

2. INTERVENTIONS
a. MODALITIES
● Superficial cryotherapy such as with ice application is preferred to
superficial heat. Cryotherapy for 20 minutes, 3-4x per day to cause
vasoconstriction and decrease the release of pain and inflammatory
mediators.
b. EXERCISES/MANAGEMENT
■ Soft tissue mobilization and massage can help break muscular guarding
or splinting, but should not be the mainstay of treatment. Soft cervical
collars can be worn for a short period of time, up to 72 hours after the
initial injury. These are used for comfort, especially when sleeping.
 ■ The restorative phase encompasses stabilization and functional
restoration by normalizing the range of motion, soft tissue length, and
biomechanical deficits, and strengthening the spinal musculature.
Transition to this phase begins after there is a reduction in pain caused by
the acute injury. Restoration of cervical spine motion helps achieve a
balanced posture that decreases strain of the injured joints and also
allows optimal strengthening to occur. Cervicothoracic stabilization
addresses flexibility, posture reeducation, and strengthening, all of which
reduce pain, improve function, and prevent recurrent injury.

c. PT EDUCATION/ HOME EXERCISES

■ Explaining the problem or their associated impairment to the patient
■ Diplomatic approach
■ Therapist gives advice/instructions or cues about the patient’s posture
and placement of his/her body.
■ Patient is discharged to a home exercise maintenance program

References:
● DePalma, MJ, Gasper, JJ, et.al. Common Neck Problems. In Braddom’s Physical
Medicine & Rehabilitation. (5th ed.; pp. 687-710). Elsevier Saunder: Philadelphia, PA
● Spinal Injections & Radiofrequency Ablation (RFA). Virginia Spine Institute. Retrieved
from https://www.spinemd.com/how-we-treat/non-surgical/additional-treatments/radio
frequency-ablation/. Date Retrieved: September 22, 2020.
● Cervical Facet Syndrome. Retrieved from https://redefinehealthcare.com/cervical-facet-
syndrome/. Date Retrieved: September 22, 2020.
● Facet Joint Syndrome. Physiopedia. Retrieved from https://www.physio-pedia.com/
Facet_Joint_Syndrome Date Retrieved: September 22, 2020
● Facet Joint Block. RadiologyInfo.org. Retrieved from https://www.radiologyinfo.org/en/
info.cfm?pg=facet-joint-block Date Retrieved: September 22, 2020
● Saravanakumar K, Harvey A. Lumbar Zygapophyseal (Facet) Joint Pain. Rev Pain.
2008;2(1):8-13. doi:10.1177/204946370800200103. Date Retrieved: September 22,
2020
● Parker, L. (2020). Treatment Options for Facet Joint Disorders. Spine-health Retrieved
from https://www.spine-health.com/conditions/arthritis/treatment-options-facet-joint-
disorders Date Retrieved: September 22, 2020
● Facet Joint Injury. Retrieved from https://www.autoaccident.com/facet-joint-injury.html
Date Retrieved: September 22, 2020
● Nance, PW & Adcock, EM (2017) Facet Mediated Pain. https://now.aapmr.org/facet-
mediated-pain/ Retrieved from Date Retrieved: September 22, 2020
● Everett C, Bauernfeind M, et.al (2012). Cervical and Thoracic Zygapophyseal joint
arthropathy. Retrieved from https://now.aapmr.org/cervical-and-thoracic-zygapophsial-
joint-arthropathy/. Date Retrieved: September 23, 2020