This 48-year-old male football coach presents with a four-month history of neck pain. He descried a minor ‘whiplash’ injury when he headed a ball. While this was only mildly uncomfortable at the time, his neck has remained painful since. His symptoms are slowly deteriorating and were waking him from sleep at times. The pain is clearly related to activity (and improved by rest). On examination he has a mildly restricted, but age-appropriate, cervical range of motion. His pain is reproduced by cervical extension, extension and right-sided rotation as well as by palpation over the mid-cervical spine in the midline.
A lateral x-ray image shows a loss of the normal cervical lordosis and spondylosis which is more pronounced in the mid-cervical spine. SPECT CT was then performed. These images showed intense uptake involving the left C3-4 facet joint. The CT imaging showed significant associated morphological changes at this level including joint space narrowing, subchondral cystic change, sclerosis and osteophytosis. There was less pronounced increased signal more inferiorly with mild uptake at two other levels.
Given that this man’s pain was becoming worse, and didn’t respond to observation, analgesics and physiotherapy, a decision was made to trial a guided steroid injection into his left C3-4 facet joint. Immediately following the injection, while the local anaesthetic was active, his pain was substantially better. Over the next few days his pain further improved. Within a week he was able to stop taking oral analgesics and continue physiotherapy. At six-month follow-up he only had mild, occasional cervical discomfort with activity and was happy with his symptoms.
It is common for patients over the age of 30 years to have asymptomatic ‘incidental findings’ on imaging studies. Loss of disc height, marginal osteophytes and facet joint arthropathy are all common and are frequently not associated with any symptoms. For this reason, these imaging findings need to be interpreted with caution and considered in relation to the patient’s presenting complaint. In this case SPECT has been used to attempt to define the symptomatic anatomical structure (but only after a failure of less invasive treatments). This modality can be useful as it both defines the bony anatomy and gives information about metabolic activity. As illustrated in this case there was substantial increased signal associated with the symptomatic region. Unfortunately, the increased signal does not always mean that this is the case of the patient’s symptoms. A diagnostic local anaesthetic (and or steroid injection) can also be used to help confirm the cause of the patient’s symptoms. If the structure is indeed the cause of the patient’s pain one would expect a substantial (but transient) improvement in their symptoms following the injection of local anaesthetic.
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