Injury or inflammation of the cervical facet can led to neck, shoulder and headache pain.
The cervical facet is a joint in the posterior aspect of the cervical spine. It functions to provide stability and guide motion.
Cervical facet pain is common in patients who have sustained a whiplash injury, trauma to the neck or undergone cervical fusion. Physical examination is typically significant for restriction in range of motion along with pain. Each joint has a distinct referral pattern illustrated below.
The Centeno-Schultz Clinic are experts at diagnosing and treating cervical facet dysfunction. Injury to the joint is not commonly detected by conventional radiographic studies. A thoough understanding of the mechanism of injury is essential.
Successful treatments include intra-articular facet injections, prolotherapy and burning of the nerves which give sensation to the affected cervical facet (radiofrequency ablation).
40 y/o female with 3 year history of left shoulder pain who had undergone left rotator cuff repair came to our office for evaluation.
She had been involved in a rear-end motor vehicle accident 3 1/2 years prior. When the drunk driver struck her car, she was looking over her shoulder.
Her pain was localized in her left lower neck and shoulder, constant in duration, 6/10 in severity and burning in character. Aggravating factors included lifting, extension and rotation . A sport’s medicine evaluation obtained a MRI of the left shoulder which was significant for a tear in the rotator cuff. Surgical repair was performed along with extensive rehabilitation. Unfortunately for this patient, her pain did not resolve.
Referred pain is pain that is perceived at a site distant from the injury’s origin. A classic example is during a heart attack when a patient may feel pain in the arm, jaw os back rather than in the chest which is the site of injury.
Facet joints are articular joints in the posterior aspect of the cervical, thoracic and lumbar spine.
The cervical facets are a common site of injury following motor vehicle injury. The C5/6 and C6/7 cervical facet joint are the most common levels injured. Each facet level has a distinct referral pattern was demonstrated below:
Injury to the C5/6 and C6/7 cervical facet typically results in pain in the lower neck and shoulder. Diagnostic injection completely resolved this patient’ s pain.
Pain can arise from many different areas. A thorough evaluation is essential which is the standard of care at the Centeno-Schultz Clinic. Not all shoulder pain originates from the shoulder.
Patient returned today who has graciously allowed me to share her history. The key is understanding what happens to cervical joints above and below the level of the fusion. The answer is OVERLOAD and acceleration of the degenerative cascade.
35 y/o female who underwent fusion of her cervical spine at multiple levels and unfortunately suffers from severe neck and headache pain.
The disc and cervical joints serve as shock absorbers. Take out the shock absorber surgically and the forces of daily living was transmitted above and below the level of the fusion. The abnormal force overload of the joint which accelerates the degenerative process. The end result all too often is pain.
At the Centeno-Schultz Clinic, we injected a small amount of contrast into the joints above her fusion. This is illustrated below. Thereafter we injected local anesthetic which significantly reduced her neck and headache pain. Patient subsequently underwent prolotherapy which has afforded her a signficant reduction in her pain and increase in her range of motion. Other regenerative therapy options include PRP and stem cell therapy.
We all take balance for granted.
Maintaining balance while standing in the stationary position relies on three major inputs:
- Joint position sense (proprioception).
- Inner ear
Balance can be maintained if two of the three inputs are intact.
Romberg test is a neurological test to assess balance. The patient stands with their feet together and hands by their sides. Patient movement is then observed first with their eyes open and then with their eyes closed. romberg test is positive when there is swaying or inability to stand erect when a patient’s eyes are closed.
A positive test, which suggests loss of proprioception, is commonly observed in patients with conditions affecting the dorsal columns of the spinal cord, conditions affecting sensory nerves( peripheral neuropathies) and injuries to the joints in the cervical spine that are rich in nerve fibers that convey joint position.
Cervical facet joint are commonly injured in motor accidents.
Cervical facet joint
They are rich in fibers that provide us with spatial information. If you sustain an injury to your neck while skiing, kite boarding or driving on the highway and have balances problems, remember the Romberg test and cervical facet damage.
Whiplash involves a range of injuries to the neck caused by or related to a sudden distortion of the neck. Typically this is associated with a rear-end motor vehicle injury.
Common symptoms include neck and shoulder pain, balance disturbances, memory loss and headaches.
Different structures may be injured and cause pain with include: cervical facets, supra and inter-spinous ligaments, the AA joint, the OA joint, transverse and alar ligaments and cervical discs. At the Centeno-Schultz Clinic treatment options include cervical facet injections, radiofrequency, autologous mesenchymal stem cell therapy, intramuscular stimulation and cervical strengthening.
A recent study by Ishikawa MD, demonstrated that a cerebrospinal leak was a common source of headaches, dizziness, visual impairment and nausea in patients who had whiplash injuries. A nuclear medicine test called radio-isotope cisternography identified a cerebrospinal leak in more than 50% of patients, most commonly in the lumbar spine. Treatment involved injection of a patients own blood into the epidural space thereby “patching” the leak. Patients had significant reduction in their symptoms following therapy.
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Pain after shoulder surgery is typically related to the operative procedure, positioning and immobilization following surgery. For some patients the “shoulder” pain unfortunately never improves despite surgery. There are several reasons for this but the major one is that the shoulder was not the cause of the pain. All to often a patient complains of shoulder pain, obtains an MRI of the shoulder which shows an abnormality and then undergoes surgery with little if any reduction in the shoulder pain.
At the Centeno-Schultz Clinic we are committed to identifying the source of a patients pain. This begins with a thorough physical examination and history. Radiographic studies are ordered when appropriate. One of the most common causes of shoulder pain is injury to a joint in the cervical spine or the cervical disc. How does this occur? It is called referred pain and the example most people are familiar with is a patient who goes to the ER with arm or jaw pain. They don’t need to see a dentist or an orthopedist, they need a cardiologist since they are having a heart attack. Referred pain is pain that is perceived at a site adjacent to or at a distance from the site of an injury’s origin.
The cervical facet is a cartilaginous joint that can be a major source of pain.
The most commomly injured facet joints are the C5/6 and C6/7 which Lord et. al., clearly demonstrated refer to the shoulder and shoulder blade.
At the Centeno-Schultz Clinic this diagnosis is established if there is significant pain relief following the injection of local anesthetic and physicologic doses of steroid into the joint. Therapy for cervical facets include stem cell therapy with regeneration of the damaged cartilage. Regenexx enables a patient to use their own stem cell to regenerate damaged tendons, ligament and cartilage.
The key is to make sure the the source of one’s pain is clearly identified and that all possible sources are considered. This is the commitement we stand by at the Centeno-Schultz Clinic.