A 48-year-old male, ex-professional player presented with an insidious onset of left sided neck and posterior shoulder pain. This had been present for approximately six months and had been getting worse. He recalled several episodes of neck pain during his playing career but nothing that had been associated with time-loss or an ongoing need for treatment.
On examination there was a mild, generalised restriction in cervical movements. Cervical extension and left sided rotation provoked his symptoms. There was not significant focal tenderness of note. He had a normal upper limb neurological examination.
An x-ray series of the cervical spine is relatively unremarkable (showing only age-appropriate changes). The most significant (radiological) finding on the MRI scan is marked left sided, C3-C4 facet joint arthrosis with associated para-articular marrow oedema. There is also mild, multilevel disc bulging and annular tears without high-grade foraminal or canal stenosis. A CT scan (conducted at the time of a guided injection) further demonstrated severe narrowing of the left C3-4 facet joint with the majority of the facet joint being fused. The inferior aspect of the facet remains patent and was associated with small erosions.
Given that the symptoms had been quite longstanding, and progressively worsening, a decision was made to trial a guided injection. This was intended as both a diagnostic and therapeutic procedure. Under CT guidance a mixture of steroid and local anaesthetic was injected into the facet joint. The pre-procedure pain score was 6/10 while the post-procedure pain score was 1/10. There has been a substantial improvement in the patient’s pain. It has been approximately four months since the injection, and he remains relatively pain-free. He has participated in some regular physiotherapy-led training of his deep cervical flexors.
Neck pain is a common complaint with a reported lifetime prevalence of up to 71%. The pain may come from a wide range of anatomical sites including the intervertebral discs, facet joints, atlanto-axial and atlanto-occipital joints, ligaments, fascia, muscles and nerve roots. Pathology involving these structures can cause neck pain, pain in the upper extremities and can cause headaches. It can be hard to determine which site is the primary cause of a patient’s pain, however in most cases the exact cause of the pain is not essential as effective treatment can be ‘empirical’. The zygapophyseal (facet) joints may be implicated in up to 50% of cases.
When a patient’s pain is more significant and/or is refractory to treatment it can be helpful to try to identify the pain-generating structure. As this case illustrated a guided injection can be a good diagnostic tool. There is good data to support the role of diagnostic injections with two systematic reviews showing strong evidence for the diagnostic accuracy of cervical facet joint blocks. The efficacy of steroid injections for providing longer term symptomatic relief is less clear. Available evidence regarding the long- term therapeutic benefits of intraarticular facet joint injections is limited. Medial branch blocks and radiofrequency neurotomy of the medial branches appears to be better supported by the literature.
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