Cervical Facet Dysfunction

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Cervical Facet Dysfunction

When patients present with neck pain with or without headache, cervicogenic causes need to be considered. It has been postulated that the pathophysiology of a cervicogenic headache relates to a neurological link that exists between the sensory fibers of the trigeminal nerve and the upper three cervical nerves. These nerves converge to form the trigeminocervical nucleus and create the anatomical basis whereby any musculoskeletal structure innervated by the C1 to C3 spinal nerves may be a source of a cervicogenic headache.

Musculoskeletal structures innervated by the C1 to C3 spinal nerves include:

• The atlanto-occipital joints and their ligaments
• The atlanto-axial (C1-C2) joints and their ligaments
• The C2-C3 and the C3-C4 facet joints
• The C2-C3 intervertebral disc
• The suboccipital, upper cervical, trapezius, and sternocleidomastoid muscles

Involvement of the cervical facet joints can lead to localized neck pain or cause pain referral to the head, particularly the occiput, neck, shoulder, and periscapular regions. Whilst these joints are likely to be impacted by trauma such as “whiplash” injury, involvement can arise without the patient being able to recall a precipitating event. The cervical spine is also a region prone to the development of osteoarthritis, either secondary to a significant trauma or due to microtraumas that have accumulated over a lifetime. The location of referred pain may assist in determining the level and side of involvement. The following list provides a guide for the pain referral region of each of the cervical spine levels:

• Occ-C1: Occiput
• C1-C2: Occiput, vertex, periorbital, and periauricular
• C2-C3: Occiput, periorbital, temporal, and frontal
• C3-C4: Upper and lateral neck
• C4-C5: Lateral neck from the base of the occiput to the base of the shoulder
• C5-C6: Lower neck and across the shoulder to the acromion
• C6-C7: Base of the neck, across the shoulder, and the periscapular

It is suggested that the C2-C3 facet joint is the most frequent source of a cervicogenic headache. The C1-C2 joint is considered the second most common source. In whiplash injuries, the C2-C3 spinal level is the most frequent dysfunctional spinal segment causing a cervicogenic headache. Convergence of the nerves in the trigeminocervical nucleus explains why functional disturbances of the upper cervical spine can lead to temporal or frontal head pain.

However, the convergence of the nerves in the trigeminocervical nucleus also explains the reverse situation. Pain originating from the first trigeminal branch can be experienced in the neck, as often seen in migraine patients.

Cervicogenic headaches can arise from a single trauma but may also occur as a result of repeated microtrauma, postural strain, and poor ergonomics.

Causes

• Sprain injury to the cervical region (e.g., Whiplash injury)
• Prolonged incorrect posture (e.g., non-ergonomic workstation or poor head support during sleep)
• Impact injury to the head or neck

• Gradual or sudden onset of well-localized neck pain with or without stiffness
• Pain that may spread to include the head, shoulder, and arm
• Pain that is typically sharp or ‘stabbing’ but can also be a dull ache
• Pain that is brought on or aggravated by neck movement?

• Reduced cervical range of motion
• Tenderness on palpation over the affected facet joints
• Possible hypertonicity and tenderness of local musculature
• A loss of intersegmental joint mobility
• Possible reproduction or exacerbation of pain during the Cervical Compression test
• Possible reproduction or exacerbation of pain during the Cervical Distraction test

• Plain radiography to assess for cervical postural abnormalities, bone, and joint pathology
• CT or MRI when a fracture or spinal canal compromise is suspected

The following are examples of “red flags” for patients presenting with neck pain:

• Presence of upper motor neuron signs
• History of a significant injury
• Worsening radiculopathy signs and symptoms
• Bilateral upper extremity symptoms
• Severe pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Deformity
• Significant loss of range of motion
• Significant neurological impairment
• Severe tenderness on palpation or severe pain during examination procedures
• Leg pain arising after a prolonged period of immobility or bed rest
• Nuchal rigidity
• A positive Lhermitte’s Sign

If any “red flags” are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Posture
Below are some examples of prolonged incorrect posture that the patient should avoid:

• Avoid looking down for too long (e.g., prolonged use of smart devices or knitting).
• Avoid looking up for too long (e.g., painting a ceiling).
• Avoid prolonged neck rotation (e.g., sitting beside someone you are talking to rather than in front of them).
• Avoid falling asleep in a seated position (e.g., in an armchair while watching television).

Ice or Heat?
Some practitioners advocate using moist heat in the subacute or chronic phase. However, we have found that patients often benefit from the continued application of ice to reduce discomfort and manage inflammation.

Myofascial Pain Syndrome Causing Neck Pain and Headache
In patients presenting with neck pain, suboccipital pain, and headache, a complete clinical examination should include an evaluation for the presence of myofascial trigger points (TrPs) as either the primary cause of the pain or as a concomitant condition. The primary muscle to evaluate is the upper and lower components of the trapezius muscle.