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Hellinga MD, van Eerd M, Stojanovic MP, Cohen SP, de Andrès Ares J, Kallewaard JW, Van Boxem K, Van Zundert J, Niesters M. 7. Cervical facet pain: Degenerative alterations and whiplash-associated disorder. Pain Pract 2025; 25:e70005. [PMID: 39846460 PMCID: PMC11756046 DOI: 10.1111/papr.70005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2025]
Abstract
INTRODUCTION Pain from the cervical facet joints, either due to degenerative conditions or due to whiplash-related trauma, is very common in the general population. Here, we provide an overview of the literature on the diagnosis and treatment of cervical facet-related pain with special emphasis on interventional treatment techniques. METHODS A literature search on the diagnosis and treatment of cervical facet joint pain and whiplash-associated disorders (WAD) was performed using PubMed, Cochrane, and Embase databases. All relevant literature was retrieved and summarized. RESULTS Facet-related pain is typically diagnosed based on history and physical examination of the patients, combined with a diagnostic block (eg, with local anesthetic) of the medial branches innervating the joints. There is no additive value for imaging techniques to diagnose cervical facet pain, but imaging may be used for procedure planning. First-line therapy for pain treatment includes focused exercise, graded activity, and range-of-motion training. Pharmacological treatment may be considered for acute facet joint pain; however, for chronic facet joint pain, evidence for pharmacological treatment is lacking. Considering the lack of evidence for treatment with botulinum toxin, intra-articular steroid injections, or surgery, these interventions are not recommended. Diagnostic blocks are not considered a viable treatment option, though some patients may experience a prolonged analgesic effect. Long-term analgesia (>6 months) has been observed for radiofrequency treatment of the medial branches. CONCLUSIONS Cervical facet pain is diagnosed based on history, physical examination, and a diagnostic block of the medial branches innervating the painful joints. Conservative management, including exercise therapy, is the first line of treatment. When conservative management does not result in adequate improvement of pain, radiofrequency treatment of the medial branches should be considered, which often results in adequate pain relief.
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Affiliation(s)
- M. D. Hellinga
- Department of Anesthesiology and Pain ManagementLeiden University Medical CenterLeidenThe Netherlands
| | - M. van Eerd
- Department of Anesthesiology and Pain ManagementAmphia HospitalBredaThe Netherlands
| | - M. P. Stojanovic
- Department of Anesthesiology, Critical Care and Pain Medicine ServiceVA Boston Healthcare SystemBostonMassachusettsUSA
- VA Bedford Healthcare SystemBedfordMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - S. P. Cohen
- Department of Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral SciencesNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Department of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical CenterUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | | | - J. W. Kallewaard
- Anesthesiology and Pain MedicineRijnstate ZiekenhuisVelpThe Netherlands
- Anesthesiology and Pain MedicineAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - K. Van Boxem
- Department of Anesthesiology and Pain MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- Department of Anesthesiology, Intensive CareEmergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost‐LimburgLanaken/GenkBelgium
| | - J. Van Zundert
- Department of Anesthesiology and Pain MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
- Department of Anesthesiology, Intensive CareEmergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost‐LimburgLanaken/GenkBelgium
- MHeNs, Mental Health and Neuroscience Research InstituteMaastricht UniversityMaastrichtThe Netherlands
| | - M. Niesters
- Department of Anesthesiology and Pain ManagementLeiden University Medical CenterLeidenThe Netherlands
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Manchikanti L, Knezevic NN, Knezevic E, Abdi S, Sanapati MR, Soin A, Wargo BW, Navani A, Atluri S, Gharibo CG, Simopoulos TT, Kosanovic R, Abd-Elsayed A, Kaye AD, Hirsch JA. A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain. Pain Ther 2022; 12:1-48. [PMID: 36465720 PMCID: PMC9686245 DOI: 10.1007/s40122-022-00455-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. Study Design Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. Objective The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. Methods Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. Results Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. Limitations There was a paucity of literature and heterogeneity among the available studies. Conclusion This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-022-00455-0.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY USA
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL USA
- College of Medicine, University of Illinois, Chicago, IL USA
| | - Emilija Knezevic
- College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL USA
| | - Salahadin Abdi
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX USA
| | | | - Amol Soin
- Ohio Pain Clinic and Wright State University, Dayton, OH USA
| | - Bradley W. Wargo
- Interventional Pain Management, Mays & Schnapp Neurospine & Pain, Memphis, TN USA
| | - Annu Navani
- Comprehensive Spine & Sports Center and Le Reve Regenerative Wellness, Campbell, CA USA
| | | | | | - Thomas T. Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Arnold Warfield Pain Management Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA USA
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and UW Pain Clinic, Chronic Pain Medicine, Department of Anesthesiology, and University of Wisconsin School of Medicine and Public Health,, Madison, WI USA
| | - Alan D. Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSUHSC, Shreveport, LA USA
| | - Joshua A. Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
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The Association Between Sleep Disturbance and Health Outcomes in Chronic Whiplash-Associated Disorders: A Series of Mediation Analyses. Clin J Pain 2022; 38:612-619. [PMID: 36037089 DOI: 10.1097/ajp.0000000000001066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the association between sleep disturbance and clinical features of chronic whiplash-associated disorders. We also aimed to use a bootstrapped mediation analysis approach to systematically examine both direct and indirect pathways by which sleep disturbance may affect chronic pain and functional status. METHODS One hundred and sixty-five people (63% female) with chronic whiplash-associated disorders and not taking medications for sleep disturbance completed questionnaires evaluating sleep disturbance, pain intensity, pain interference, disability, physical and mental health quality of life, stress, anxiety, depression, pain catastrophizing, and posttraumatic stress severity. RESULTS Greater sleep disturbance was associated with increased duration of symptoms, higher levels of pain and disability, higher levels of emotional distress and pain catastrophizing, and functional impairment (reduced health-related quality of life). Mediation analyses demonstrated that sleep disturbance influenced chronic pain intensity and interference through both direct and indirect associations inclusive of stress, anxiety and pain catastrophizing. Similarly, sleep disturbance was associated with higher levels of disability and poor health-related quality of life, both directly and also through its negative association with pain intensity and interference. DISCUSSION Sleep disturbance in chronic WAD was associated with worse health outcomes and demonstrated both direct and indirect effects on both chronic pain and function.
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Engel A, King W, Schneider BJ, Duszynski B, Bogduk N. The Effectiveness of Cervical Medial Branch Thermal Radiofrequency Neurotomy Stratified by Selection Criteria: A Systematic Review of the Literature. PAIN MEDICINE 2020; 21:2726-2737. [DOI: 10.1093/pm/pnaa219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Objective
To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria.
Design
Comprehensive systematic review.
Methods
A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.
Outcome Measures
The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief.
Results
Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used.
Conclusions
Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.
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Affiliation(s)
- Andrew Engel
- Affordable Pain Management, Chicago, Illinois, USA
| | - Wade King
- Mayo Multidisciplinary Pain Clinic, Mayo Private Hospital, Taree, NSW, Australia
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | | | - Nikolai Bogduk
- University of Newcastle, Faculty of Health and Medicine, Newcastle, Australia
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Smith AC, Albin SR, Abbott R, Crawford RJ, Hoggarth MA, Wasielewski M, Elliott JM. Confirming the geography of fatty infiltration in the deep cervical extensor muscles in whiplash recovery. Sci Rep 2020; 10:11471. [PMID: 32651447 PMCID: PMC7351986 DOI: 10.1038/s41598-020-68452-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/22/2020] [Indexed: 02/08/2023] Open
Abstract
Previous preliminary work mapped the distribution of neck muscle fat infiltration (MFI) in the deep cervical extensor muscles (multifidus and semispinalis cervicis) in a small cohort of participants with chronic whiplash associated disorders (WAD), recovered, and healthy controls. While MFI was reported to be concentrated in the medial portion of the muscles in all participants, the magnitude was significantly greater in those with chronic WAD. This study aims to confirm these results in a prospective fashion with a larger cohort and compare the findings across a population of patients with varying levels of WAD-related disability one-year following the motor vehicle collision. Sixty-one participants enrolled in a longitudinal study: Recovered (n = 25), Mild (n = 26) and Severe WAD (n = 10) were studied using Fat/Water magnetic resonance imaging, 12-months post injury. Bilateral measures of MFI in four quartiles (Q1–Q4; medial to lateral) at cervical levels C4 through C7 were included. A linear mixed model was performed, controlling for covariates (age, sex, body mass index), examining interaction effects, and comparing MFI distribution between groups. The recovered group had significantly less MFI in Q1 compared to the two symptomatic groups. Group differences were not found in the more lateral quartiles. Results at 12 months are consistent with the preliminary study, indicating that MFI is spatially concentrated in the medial portions of the deep cervical extensors regardless of WAD recovery, but the magnitude of MFI in the medial portions of the muscles is significantly larger in those with severe chronic WAD.
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Affiliation(s)
- Andrew C Smith
- School of Physical Therapy, Regis University, Denver, CO, USA
| | | | - Rebecca Abbott
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Mechanical Engineering, Northwestern University, Evanston, IL, USA
| | | | - Mark A Hoggarth
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA
| | - Marie Wasielewski
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James M Elliott
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Faculty of Medicine and Health, The Northern Sydney Local Health District, The Kolling Institute, The University of Sydney, St. Leonards, NSW, 2065, Australia.
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November 2019 Letter to the Editor-in-Chief. J Orthop Sports Phys Ther 2019; 49:866-867. [PMID: 31672118 DOI: 10.2519/jospt.2019.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Letter to the Editor-in-Chief of JOSPT as follows: "The Whole Pie? Maybe-But Let's Compare Apples With Apples" with Authors' Response J Orthop Sports Phys Ther 2019;49(11):866-867. doi:10.2519/jospt.2019.0202.
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Psychological Manifestations and Chronic Pain in Whiplash-Associated Disorder Mechanisms: The Whole Pie, Please. J Orthop Sports Phys Ther 2019; 49:118-121. [PMID: 30819055 DOI: 10.2519/jospt.2019.0603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the last decade, as the biopsychosocial model of patient health care has expanded, there has been an increased focus on the influence of psychological manifestations on patient symptoms and health-related outcomes. This Viewpoint explores the scientific underpinnings of psychological manifestations in chronic whiplash-associated disorders (WADs)-where opinions vary widely concerning the reason for persistent symptoms and nonrecovery. It also provides an epidemiological and scientific foundation for the management of chronic WAD, incorporating the spectrum of the biopsychosocial model. J Orthop Sports Phys Ther 2019;49(3):118-121. doi:10.2519/jospt.2019.0603.
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Abstract
Synopsis The development of persistent symptoms following whiplash injury from a motor vehicle collision is common and contributes substantially to societal and personal costs. The popular Quebec Task Force classification system of whiplash-associated disorders (WADs) was meant to function as a prognostic and intervention decision aid, but its usefulness has been questioned. Emerging evidence highlights the heterogeneity of WAD by demonstrating physical and psychological impairments that are unique to those who develop persistent symptoms. These impairments are not recognized in the Quebec Task Force classification system. The purpose of this clinical commentary is to describe an integrated model that focuses on how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic WAD. The model has been developed through more than 20 years of work in the field, consultation with experts, in-depth synthesis of existing evidence, and new evidence from the authors' own research programs. A subtheme is that a point of convergence currently exists between the psychological, physiological, and social determinants of health literature that can further explain the complex presentation of WAD. The new model is proposed to orient future research toward more interdisciplinary efforts across nontraditional fields, including data scientists and consumers, to clarify the WAD condition. J Orthop Sports Phys Ther 2017;47(7):462-471. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7455.
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The Physiological Basis of Cervical Facet-Mediated Persistent Pain: Basic Science and Clinical Challenges. J Orthop Sports Phys Ther 2017. [PMID: 28622486 DOI: 10.2519/jospt.2017.7255] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Synopsis Chronic neck pain is a common condition and a primary clinical symptom of whiplash and other spinal injuries. Loading-induced neck injuries produce abnormal kinematics between the vertebrae, with the potential to injure facet joints and the afferent fibers that innervate the specific joint tissues, including the capsular ligament. Mechanoreceptive and nociceptive afferents that innervate the facet have their peripheral terminals in the capsule, cell bodies in the dorsal root ganglia, and terminal processes in the spinal cord. As such, biomechanical loading of these afferents can initiate nociceptive signaling in the peripheral and central nervous systems. Their activation depends on the local mechanical environment of the joint and encodes the neural processes that initiate pain and lead to its persistence. This commentary reviews the complex anatomical, biomechanical, and physiological consequences of facet-mediated whiplash injury and pain. The clinical presentation of facet-mediated pain is complex in its sensory and emotional components. Yet, human studies are limited in their ability to elucidate the physiological mechanisms by which abnormal facet loading leads to pain. Over the past decade, however, in vivo models of cervical facet injury that reproduce clinical pain symptoms have been developed and used to define the complicated and multifaceted electrophysiological, inflammatory, and nociceptive signaling cascades that are involved in the pathophysiology of whiplash facet pain. Integrating the whiplash-like mechanics in vivo and in vitro allows transmission of pathophysiological mechanisms across scales, with the hope of informing clinical management. Yet, despite these advances, many challenges remain. This commentary further describes and highlights such challenges. J Orthop Sports Phys Ther 2017;47(7):450-461. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7255.
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Abstract
Rapid advances in the basic, clinical, and behavioral sciences are molding developments in conservative management of musculoskeletal disorders. Curiously, there seems to be discord developing between approaches to the assessment and management of patients, depending on whether they present with an extremity or spinal disorder. This viewpoint will comment on examples of differences emerging in some current practices. The aim is not to present a scientific treatise about underpinning sciences and evidence-based practice or to comment on what is correct or incorrect. Rather, the aim is to stimulate thought on the seeming discord in clinical practice, with respect to both the clinical evaluation of, as well as management approaches to, extremity and spinal disorders. J Orthop Sports Phys Ther 2016;46(11):938-941. doi:10.2519/jospt.2016.0610.
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