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    Zygapophyseal joint pain

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    23 views4 pages

    Zygapophyseal Joint Pain

    Uploaded by

    Marco Peroli

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    © All Rights Reserved
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    Cervical Zygapophyseal Joint Pain Patterns Il: A Clinical Evaluation CHARLES APRILL, MD,* ANTHONY DWYER MB, BS, FRACS, + and NIKOLAI BOGDUK MB, BS, PhD+ To test the predictive value of segmental pain charts, ten patients with suspected cervical zygapophyseal pain were studied, Their pain distribution was recorded on a body diagram, and using pain charts derived from studies ‘on normal volunteers, predictions were made by two observers of the segmental location of the symptom: joint. Correct predictions were made in all nine patients who were shown tohave symptomatic joints onthe basis of diagnostic joint blocks. The results vindicate the accu- racy of pain charts for predicting the segmental location of symptomatic joints in patients with cervical joint pain. [Key words: neck pain, cervical zygapophyseal joints, Teferred pain] tention as possible causes of neck pain.2“¢*#* However, 10 date, the only means of establishing a diagnosis of cervical _ygapophyseal joint pein have been diagnostic blocks of the putatively symptomatic joints; but these blocks require spectiized facil- ties and skill that are not generally available. Furthermore, because ~zygapophyseal joint blocks are invasive, it isnot atractve to suggest ‘hata patients wih neck pain should undergo this procedure. Whats required is some clinical noninvasive screening test that can either establish the diagnosis or, inthe Fist instance, atleast predict which patients would be likely to respond to confirmatory locks. ‘A recent study has shown that physical examination by a well- ‘qualified manipulative therapist can be as accurate as radiologically controlled diagnostic Blocks in the diagnosis of cervical zygapophyseal joint pain,” but the skills involved require considerable training, and the services ofa suitably skilled manipulative therapist are not universally available. A simpler diagnostic test would be desirable. To this end, we have sought to determine whether the distribution ofa patient's neck Pain might be indicative of is origin In the preceding study,” we determined the distribution of pain that ‘occurs following noxious stimulation of selected cervical zygapophy- seal joints in normal volunters. We found that reasonably distinct pattems of pain-referal were associated with given joints, However, for ethical and logistic reasons, observations could be made only in a small numberof volunteers. Consequently, the study did not provide a measure of biologic variation that, in principle, might affect the reliability ofthe refered pain charts we constructed. To overcome this limitation by increasing the numberof volunteers and observations was D== (oF THE cervical zygapophyseal joints are attracting From *Diagnostic Imaging, New Oreans, Louisiana; the {Department of Ortopacdic Sergey. Universi of Colorado Heh Scenes Cone, Dente, Colorado; ad he Faculty of Medicine, Universty of Newest, Newcalsy ppared by « Project Grant from the National Health and Medical Research (Coun of Australia ad a Research Grant from the Ausalan Asocaion of Maseuloskeltal Medieine. ‘Submited for publiation December 1, 1989 impractical because ofthe lack of suitably qualified volunters. There- fore, we undertook instead to tet the elibiltyof our pain chats by a clinical tal ‘The principle adopted was that if the pin paterns reported in normal Yolunters were not characteristic, their us in a clinical setting would fail topredictthe segmental origin cervical zyenpophyseal Conversely, notwithstanding the limited number of observations on ‘which hey were based, ithe psi pattems could comet idemtiy the source of neck pai, thee validity would be vindicated. If so, recogni- tionof pain pattems could be advocated asa diagnostic aid inthe clinical assessment of neck pai METHODS “The study was conducted on ten consecutive patents refered io a radiology ‘practice for investigation of putative zypapophyseal pain, All patients complained of neck pain and various pattems of refered pain tothe head, chest, shoulders, or upper limb. None had neurologic signs or prior evidence of cervical fracture, tumor, or inflammatory disease. The paint selected for study were ones thought likely to have cervical joint cisease by their refering physician. In Seven ofthe patents this decision was Based largely onthe elimination of disc disease as a diagnosis. Patients 3 and 10 had previously undergone anterior cervical fusion from C4 to C7; leaving the zygapo- piyseal joints asthe mos likely source of tee perssting pin, Patients 4and Thad fusions at C5-6, C6-7, and C5-6, respectively. Patents 1, 5, and 9 had undergone negative provocation discography at C3~4 t0 65-6, C45 to C67, and C5-6 to C7-TI, respestively. In the remaining thre patient the referring physicians had suspected cervical hse joint pain onthe asi ofthe focal, posterior location of and had referred the patients for evaluation ofthis diagnosis before investigating the cervical intervenebral diss, Before investigation, the radiologist (CA) interviewed each patient, and recorded the distribution oftheir pain on a body diagram, By comparing the distribution of pain withthe putatively characteristic segmental pattems established in normal volunteers (Figure 1), he decided what joint o joints would be responsible forthe patent's pain and recorded is decison ‘The efteria adopted for pain stemming from particular segmental levels were: ‘C2-3: pain located inthe upper cervical region and extendingat least nto the occiput. Extension fuer into the bead: toward the eat, vertex, forehead, or eye (as reported in clinical studies of C2-3 pain?) wes regarded s confirmatory but not essential. ‘C3-4: pain located over the posterolateral cervical region, extend- ing cranially a5 far a5 the suboccptal region, but not intruding substantially into the oecipital region, and extending caudally over the posterolateral aspect of the neck without entering the region of the Shoulder girdle, following, more or less the course of the levator seapulae muscle. (C4-S: pain located overa more or less triangular area with two ides «consisting ofthe posterior midine and posterolateral border ofthe neck anda baserunning parallel to the spine ofthe seapula, but somewhat CERVICAL ZYGAPOPHYSEAL JOINT PAIN PATTERNS II Fig. Amapol the characteristic areas of painreferred from cervical zygapophyseal joins of C2-3 to C6~7, Taken from Dwyer etal.” above it, more or les in the same horizontal plane asthe lateral third of the clavicle. (C5-6: pain in a triangular, mantle-ike distribution with an apex ireted tothe midcervieal region posteriorly and the main area draping. ‘over the top, front, and back of the shoulder girdle, with a base coinciding withthe spine of the scapula. ‘C5-T: pain over a more or less quadrangular area covering the supraspinous and infraspinous fossae. ‘C5=1 pain. was distinguished from that of C5-6 by its extensi ‘below the spine of the scapula. C36 pain was characterized by its Tateral extension over the shoulder and ts extension as fara the spine of the scapula, and was distinguished from C45 pain in that the later reached only the upper extent of the shoulder girdle. C34 pain was distinguished from C45 pain by its lesser caudal extension into the shoulder girdle and its greater cranial extension towards the occiput. ‘The hallmark of C2-3 pain was its extension over the occiput, which

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