770
REVIEW ARTICLE
Cervical Facet Joint Dysfunction: A Review
Dhiruj Kirpalani, MD, Raj Mitra, MD
ABSTRACT. Kirpalani D, Mitra R. Cervical facet joint
dysfunction: a review. Arch Phys Med Rehabil 2008;89:770-4.
Objective: To review the relevant literature on cervical
facet joint dysfunction and determine findings regarding its
anatomy, etiology, prevalence, clinical features, diagnosis,
and treatment.
Data Sources: A computer-aided search of several data-
bases was performed, including Medline (1966 to present),
Ovid (1966 to present), and the Cochrane database (1993 to
present).
Study Selection: Selected articles had the following criteria:
(1) all articles analyzed cervical facet joint pain—anatomy,
prevalence, etiology, diagnosis, treatment; (2) only full, pub-
lished articles were studied, not abstracts; and (3) all articles
were published in English.
Data Extraction: All articles were critically evaluated and
included the following categories: randomized controlled trials,
meta-analyses, uncontrolled clinical trials, uncontrolled com-
parison studies, nonquantitative systematic reviews, and liter-
ature-based reviews.
Data Synthesis: We examined 45 references that consisted
of 44 journal articles and relevant sections from 1 textbook.
Cervical facet joints have been well established in the literature
as a common nociceptive pain generator, with an estimated
prevalence that ranges from 25% to 66% of chronic axial neck
pain. No studies have reported clinical examination findings
that are diagnostic for cervical facet mediated pain.
Conclusions: Overall the literature provides very limited
information regarding the treatment of this condition, with only
radiofrequency neurotomy showing evidence of effectively
reducing pain from cervical facet joint dysfunction.
Key Words: Arthritis; Neck pain; Rehabilitation; Review
[publication type]; Whiplash injuries; Zygapophyseal joint.
© 2008 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
ERVICAL FACET JOINT dysfunction is hypothesized to
C result from trauma and/or degeneration of the cervical
facet joints. The facet (or zygapophyseal) joints have been
considered a source of spinal pain since the early 1900s.
Ghormley, as referenced in Dreyer and Dreyfuss,1 first coined
the term “facet syndrome” to describe low-back pain associated
with “sciatica.” Although facet joint dysfunction in the lumbar
spine has been well studied for decades, cervical facet joint
dysfunction has received much less attention until recently.
From the Division of Physical Medicine and Rehabilitation, Stanford University
Medical Center, Palo Alto, CA.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Raj Mitra, MD, Div of Physical Medicine and Rehabilitation,
Stanford University Medical Center, 300 Pasteur Dr, Edwards Bldg, Room R105B,
MC 5336, Stanford, CA 94305, e-mail: rmitra@stanford.edu.
0003-9993/08/8904-00825$34.00/0
doi:10.1016/j.apmr.2007.11.028
Arch Phys Med Rehabil Vol 89, April 2008
Bogduk and Marsland2 conducted one of the earliest studies on
the cervical facet joints in which diagnostic medial branch
blocks and facet joint blocks with 0.5% bupivacaine were
performed on 24 patients with undiagnosed neck pain. Com-
plete relief of pain for at least 2 hours was obtained in 17 of the
24 patients. The researchers concluded that the cervical facet
joints may be considered a source of axial neck pain. The purpose
of this article was to review the relevant literature on cervical facet
joint dysfunction and determine findings regarding its anatomy,
etiology, prevalence, clinical features, diagnosis, and treatment.
METHODS
A computer-aided search of several databases was per-
formed, including Medline (1966 to present), Ovid (1966 to
present), and the Cochrane database (1993 to present), using
the key words cervical, zygapophyseal, whiplash, neck pain,
and arthritis. In addition, we examined the references cited in
these articles for key words. Selected articles were critically
evaluated and had the following criteria: (1) all articles studied
some aspect of cervical facet joint pain—anatomy, prevalence,
etiology, diagnosis, treatment; (2) only full, published articles
were studied, not abstracts; and (3) all articles were published
in English.
RESULTS
We examined 46 references that consisted of 45 journal
articles and relevant sections from 1 textbook. The journal
articles included randomized controlled trials (RCTs), meta-
analyses, uncontrolled clinical trials, uncontrolled comparison
studies, nonquantitative systematic reviews, and literature-
based reviews.
DISCUSSION
Pathophysiology
The cervical facet joints are diarthrodial joints formed by
the articulation of the superior articular process (SAP) with
the corresponding inferior articular process of the cephalad
vertebrae. The SAP and inferior articular process arise from the
lateral mass of the vertebrae, which is formed at the junction of
the lamina and pedicle. In the upper-cervical spine the facet
joints begin with an angle approximately 45° superior to the
transverse plane and gradually assume a more vertical position
as they descend to the thoracic region.3,4
Each facet joint is surrounded by a fibrous capsule, lined by
a synovial membrane, and contains articular cartilage and me-
nisci.3,5 Cervical facet joints also contain intra-articular inclu-
sions of various shapes and sizes, which consist of fibrous
connective and adipose tissues.6 Inami et al6 studied 20 em-
balmed cadavers to investigate the composition of synovial
folds, or meniscoids, which are well-developed structures within
these inclusions. The researchers found 3 types of synovial folds
with varying amounts of fibrous and adipose tissue, suggesting
that different levels of mechanical stress are placed on these
structures and that synovial folds may play a role in cervical
facet joint pain. Kallakuri et al7 studied cadaveric human
cervical facet joint capsules and found protein gene product 9.5
in 9 of 14 capsules, substance P in 6 of 12 capsules, and
 CERVICAL FACET DYSFUNCTION, Mitra
calcitonin gene-related peptide in 7 of 12 capsules. This finding
suggests that the facet joint capsules may directly be involved
as a pain generator in the cervical spine.
The innervation of the cervical facet joints was described by
Bogduk.8 From C3-4 through C8-T1, the joints are innervated
by the medial branches of the cervical dorsal rami above and
below the joint as these branches course around the waist of the
articular pillars. The C2-3 facet joint is innervated by 2 differ-
ent branches of the C3 dorsal ramus—a medial branch called
the third occipital nerve and a separate articular branch arising
from the origin of the communicating branch or from the
communicating branch itself. The upper-cervical synovial
joints (the atlanto-occipital and atlanto-axial joints) are not
innervated by cervical dorsal rami but by branches of the C1
and C2 ventral rami.
Cervical facet joint pain results from either traumatic or
degenerative processes. Traumatic causes include fracture
and/or dislocation injuries and whiplash disorders. Facet dis-
locations or locked facet injuries occur with acute cervical
trauma, may or may not be associated with cervical facet
fracture, can be unilateral or bilateral, and are usually a surgical
emergency.3,9,10
The etiology of whiplash injuries remains controversial.
Facet joints in the cervical spine have been targeted as a
possible nociceptive pain generator. Facet joint injury has been
hypothesized to result from 2 different mechanisms during
rear-end impact: (1) excessive compression of the facet joint
and (2) excessive capsular ligament strain beyond the physio-
logic limit.11,12 Kaneoka et al13 concluded that the lower cer-
vical segments undergo extension while the upper-cervical
segments are flexed, causing the cervical spine to form an
S-shape and shifting the normal C6 axis of rotation superiorly
to C5. At the same time, the anterior ends of the adjacent
vertebral bodies separate in an abnormal fashion, and the
inferior articular process of the superior vertebrae compresses
into the SAP of the inferior vertebrae. Pearson et al12 proposed
that facet joint compression occurs during the point of maximal
extension, whereas capsular ligament strain begins during ex-
tension but peaks as the facets were returning from maximal
extension back to neutral position.
Cervical facet joint pain can also be caused by degenerative
processes such as osteoarthritis. Fletcher et al14 compared
age-related changes in 20 cadavers with no recorded history of
spinal symptoms or disease using cryomicrometry, magnetic
resonance imaging (MRI), and computed tomography (CT)
scan. The facet joints in the cadavers under 20 years of age had
uniform layers of cartilage and subarticular cortical bone, con-
sistent with the conventional anatomic description. In cadavers
over 37 years of age the articular cartilage was reduced to a
thin, discolored or microscopic layer and the meniscus was
nonexistent. The researchers concluded that age-related changes
consistent with osteoarthritis are usually found in adults after
the first 2 decades of life, but because all of the subjects in this
study were asymptomatic, the findings suggest that degenera-
tive changes are not always pathologic.
A proposed etiology of facet arthritis is based on the 3-joint
complex theory. It is hypothesized that intervertebral disks
degenerate first, leading to loss of disk height and increased
load on the facet joints; these changes are thought to eventually
lead to degenerative changes. Studies have found that facet
joint arthritis is often found with disk degeneration but that disk
degeneration can frequently be found without facet arthritis. In
addition, 1 study found that it may take 20 or more years to
develop facet joint arthritis after onset of disk degenera-
tion.15,16 However, other MRI studies of the lumbar spine have
failed to show a correlation between degenerative disks and
771
facet joint arthritis and have even found evidence of facet joint
damage without disk degeneration.16,17
Prevalence
Studies have shown a wide variability in the prevalence of
cervical facet joint pain. Aprill and Bogduk18 studied responses
from 318 patients with intractable neck pain after they under-
went either single facet joint injections, provocation diskogra-
phy, or both. They estimated that the prevalence of facet joint
pain in this population was at least 25% but could be as high as
63%, had the patients who underwent only provocation dis-
kography also received facet joint injections. However, Barns-
ley et al19 described a more specific double-blind, double-block
paradigm in which the medial branches of patients with chronic
neck pain were injected using 2 local anesthetics with different
durations of action: 2% lidocaine and 0.5% bupivacaine. The
responses to the 2 injections were compared, and a patient was
considered a true positive if the duration of pain relief was
longer with the bupivacaine than the lidocaine. In this random-
ized, double-blind, controlled trial, 34 of 44 patients had longer
pain relief with bupivacaine than lidocaine (P⫽.002), leading
the researchers to conclude that the double-block paradigm was
a valid diagnostic method to identify painful cervical facet
joints. Subsequent studies20-22 using this method have esti-
mated the prevalence of cervical facet joint pain to range from
36% to 55% and have found a false-positive rate with single
diagnostic injection to be 27% to 66%. Although the double-
block paradigm has shown a higher specificity with lower
false-positive results, Lord et al23 showed that when these
patients are given a third placebo injection using normal saline,
this method yields a lower sensitivity (54%) with higher false-
negative results. In whiplash disorders, the double-block par-
adigm alone had a prevalence of 54%,24 but when adding a
placebo injection the prevalence was 50% for C2-3 facet joint
pain and 49% for lower-cervical facet joint pain (overall prev-
alence, 60% for C2-3 or below).25
Clinical Features
There have been no high quality studies that have shown that
the presence of any particular signs or symptoms is signifi-
cantly associated with cervical facet dysfunction. The clinical
presentation of cervical facet joint pain is similar to axial neck
pain of other etiologies including spinal stenosis, cervical
strain, and diskogenic pain. Cervical facet pain is often char-
acterized by axial neck pain, which may radiate suboccipitally
to the shoulders or midback. Often there is a previous history
of hyperextension injury to the neck or other trauma. Based on
studies in which joints were injected with contrast medium in
asymptomatic patients or treated with medial branch blocks in
symptomatic patients, composite maps were created showing
that each joint produces a distinct referred pain pattern.26-28
Fukui et al29 injected contrast medium into the joints of 61
symptomatic patients and subsequently performed facet dener-
vation on patients whose pain was reproduced by the injection.
During both the injection of the contrast medium and the facet
denervation, patients were asked to report if their usual pain
was reproduced and to describe the sites of their pain based on
10 regions identified by Fukui. The Fukui study findings were
similar to the results found in the previous studies on referred
pain patterns (fig 1).
To our knowledge, there are no physical examination ma-
neuvers that are specific for the diagnosis of cervical facet joint
dysfunction. Jull et al30 compared the accuracy of manual
diagnosis by a trained manipulative therapist to radiologically
controlled diagnostic nerve blocks on 20 patients. Based on
Arch Phys Med Rehabil Vol 89, April 2008
772 CERVICAL FACET DYSFUNCTION, Mitra
Fig 1. Main referred pain distributions for the zygapophyseal joints
from C0-1 to C7-T1 and the dorsal rami from C3 to C7. Reprinted
with permission from the International Association for the Study of
Pain.29
criteria such as abnormal end-feel or resistance at the extremes
of the range of motion and abnormal quality of resistance to
motion, the manipulative therapist correctly identified all 15
patients with symptomatic joints, as well as the 5 patients who
were asymptomatic. The findings of the above study are limited
by the fact that only 1 therapist evaluated all of the patients, so
interrater reliability could not be assessed. In addition, the
physical examination maneuvers (abnormal end-feel or resis-
tance) was not fully described.
King et al31 attempted to reproduce the results from Jull’s
study by comparing the clinical assessment of 173 patients as
described by Jull versus diagnostic medial branch blocks using
the double-block paradigm described earlier with 2 local anes-
thetics of different duration (ie, 2% lidocaine vs 0.5% bupiv-
acaine). This study found that sensitivity was .89 and specific-
ity was .47 for these manual diagnostic techniques and
therefore refutes the results of the Jull study that showed 100%
sensitivity and specificity. The results of this study, however,
should be viewed with caution because only 1 clinician exam-
ined the patients, only those patients with positive clinical
findings were given the diagnostic blocks, and neither the
clinicians nor patients involved were blinded to the results of
the clinical examination (appendix 1).32
Diagnostic Workup
There are a variety of different tests used to aid in the
diagnosis of cervical facet joint pain. Workup often begins with
plain radiographs, which are a good screen for detecting insta-
bility, gross fractures, abnormal lesions, and osteoarthritis. If
radiographs are ordered, they should include flexion and/or
extension views to detect any abnormal vertebral motion or
spinal instability, as well as a trauma and/or open mouth view
to rule out a dens fracture. Advanced imaging such as CT or
MRI can also be used to diagnose causes of cervical facet joint
pain. Advanced imaging can detect a greater number of abnor-
malities compared with plain radiographs, but studies have
shown that such abnormalities can also be found in asymptom-
atic patients.33 Degenerative changes of the facets, unconver-
tebral joints, and foramina were found in 75% of asymptomatic
patients in the seventh decade of life. An MRI study34 found
cervical spine degenerative changes in 14% of asymptomatic
patients under the age of 40 years and 28% of such patients
over the age of 40 years. Therefore, findings on imaging studies
must be correlated with a patient’s history and physical exam-
ination findings before being considered clinically significant.
Arch Phys Med Rehabil Vol 89, April 2008
Single-photon emission computed tomography (SPECT) is a
nuclear imaging technique that can also be used to aid in
diagnosis, particularly in assessing the degree of active inflam-
mation within the joints. Although no study recommends using
SPECT in the routine diagnostic workup of facet dysfunction,
some studies35-37 using this imaging modality in the lumbar
facet joints have suggested that SPECT may help determine
which patients are good candidates for intra-articular facet joint
injections. Dolan et al36 compared the response to lumbar facet
injections in 22 SPECT-positive patients with a control group
of 36 SPECT-negative patients. It was found that the SPECT-
positive patients had statistically significant improvements in
visual analog scale, McGill Pain Questionnaire, and Present
Pain Intensity scores at 1 month follow-up. Pneumaticos et al37
performed a similar study comparing the response to lumbar
facet injections in 15 patients who were SPECT positive versus
32 patients who were either SPECT negative or did not un-
dergo SPECT before the injection. Patients who received a
facet injection in the setting of a positive SPECT scan were
more likely to have significant improvement in pain and func-
tion scores at 1 and 3 months follow-up. In addition, the
number of facets injected was reduced in the SPECT-positive
patients, and therefore the cost was reduced from $2191 to
$1865 a patient. To our knowledge, no studies exist that eval-
uate SPECT in diagnosing cervical facet joint dysfunction or in
predicting the response to cervical facet joint injections.
Treatment
Conservative management of cervical facet joint dysfunction
and other mechanical neck disorders usually involves a trial of
analgesic and anti-inflammatory medications, physical therapy
(PT), various modalities (eg, heat and/or ice, massage, trans-
cutaneous electric nerve stimulation, traction, orthoses), and
spinal manipulation or mobilization. Based on our review, no
studies were found that specifically evaluated these treatment
options in relation to cervical facet joint dysfunction. With regard
to specific treatment of this condition, only intra-articular facet
injections and radiofrequency (RF) neurotomy were identified.
Injections. Therapeutic cervical facet joint injections with
corticosteroids may be performed under fluoroscopic guidance,
either directly into the synovial joint (intra-articular block) or
over the medial branch of the dorsal rami above and below the
affected joint (medial branch block). Both injections accom-
plish the same goal of blocking pain impulses originating from
the facet joint. Based on anatomic studies it has been suggested
that medial branch blocks have the same specificity as intra-
articular blocks, but no studies comparing these 2 types of
injections in the cervical spine exists.2,8 Intra-articular blocks
carry the theoretic risk of placing the needle into the epidural
space, intervertebral foramen, or vertebral artery.2,38 Barnsley
et al39 performed a randomized, double-blind trial in 41 pa-
tients with chronic neck pain, comparing the effect of intra-
articular injections with betamethasone versus 0.5% bupiva-
caine. Less than half of the patients reported pain relief for
more than 1 week, and less than 20% had pain relief for more
than 1 month, irrespective of the treatment received. Based on
these results, the researchers concluded that intra-articular cor-
ticosteroid injections were ineffective in the treatment of cer-
vical facet joint pain.
Additional uncontrolled studies have further investigated the
efficacy of cervical intra-articular facet joint injections. Slip-
man et al40 performed a retrospective study on 18 patients with
chronic daily headache who received C2-3 joint injections and
found that 61% had fewer than 3 headaches a week. Kim et al41
performed intra-articular injections with a mixture of 1% lido-
caine and triamcinolone on 60 patients with complaints of C5-6
 CERVICAL FACET DYSFUNCTION, Mitra
and C6-7 facet joint pain associated with myofascial pain
syndrome (MPS), herniated nucleus pulposus (HNP), or whip-
lash-associated disorders (WAD). Patients with cervical facet
joint pain in the HNP group had significantly longer pain relief
than those in the MPS and WAD groups. Although both of
these studies concluded that intra-articular cervical facet joint
injections were effective, their results have a great potential for
selection bias and false-positives because they were not RCTs.
RF neurotomy. The purpose of RF neurotomy is to ablate
the medial branches of the dorsal rami at high temperatures and
provide longer pain relief than simple nerve or intra-articular
blocks. The procedure involves first positioning a needle elec-
trode over the nerve at its corresponding bony anatomy and
performing sensory and motor stimulations to ensure proper
needle placement. Then the nerve is injected with local anes-
thetic, radiographs are taken, and several overlapping lesions of
the nerve are performed at 80° to 82°C for 1 minute each.42
Lord et al43 performed a randomized, double-blind, controlled
trial on 24 patients with chronic cervical facet joint pain.44 The
patients were assigned to the active treatment group (n⫽12)
and received RF neurotomy at 80°C for 60 to 90 seconds or to
the control group (n⫽12) and underwent the same procedure at
37°C. Six patients in the control group and 3 patients in the
active treatment group returned to their accustomed pain level
immediately after the procedure. By 27 weeks, 1 patient in the
control group and 7 in the active treatment group remained free
of pain. The median time to return to at least 50% of the
preprocedure level was 263 days in the active treatment group
and 8 days in the control group. Lord concluded that RF
neurotomy can provide lasting, complete relief in a moderate
number of patients for several months to almost a year.
Stovner et al45 conducted a randomized, double-blind study
with RF on 12 patients with cervicogenic headache in which 6
patients each were assigned to either an active treatment group
or a sham treatment group. Overall, both groups had significant
improvement in their pain at 1 month, but at 3 months the
active treatment group had better improvement than the sham
group. By 6 months both groups had similar results, and at 24
months the sham group was actually better on most variables.
Stovner concluded that RF denervation was not an effective
treatment in cervicogenic headache. The results of this study
are limited by the small sample size (n⫽12), inclusion criteria
based on clinical features and not on diagnostic medial branch
blocks, and results that lack statistical significance.
Although RF denervation has been established as a treatment
option of cervical facet joint pain, the application of heat up to
80° to 85°C (thermal RF) carries the potential risk of neuritis
from coagulation of the dorsal root ganglion and spinal insta-
bility from denervation of the multifidus muscle,46 as well as
inadvertent ablation of the spinal nerve root and paralysis.
Pulsed RF is a newer method in which RF energy is applied to
the nerve at a pulsed time cycle of 2⫻2ms/s but at temperatures
not exceeding 42°C. Mikeladze et al46 retrospectively studied
114 patients at a pain management clinic with chronic cervical
and lumbar facet joint pain. In 68 (⬇60%) of the 114 patients,
the procedure was successful and lasted 3.93⫾1.86 months.
The outcome was not significantly different in the cervical
versus lumbar spine. Mikeladze concluded that pulsed RF is a
safe and useful therapeutic procedure for facet joint pain, but
its effect has a much shorter duration than continuous RF
(⬇4mo for pulsed RF vs up to 1 year with continuous RF).
They postulated that pulsed RF is less effective than thermal
RF because pulsed RF interrupts signals only in unmyelinated
C fibers, leaving the myelinated delta fibers functional to
transmit pain signals. Their study results, however, are limited
by lack of control subjects and inclusion criteria based on only
773
single diagnostic medial branch blocks, creating the possibility
of more false-positive subjects.
Surgery. No studies were found that specifically evaluated
the surgical management of cervical facet joint dysfunction.
CONCLUSIONS
Cervical facet joints have been well established in the liter-
ature as a common source of axial neck pain, with an estimated
prevalence that ranges from 25% to 66%. The diarthrodial
joints are formed by bony articulation of the SAP and inferior
articular process, surrounded by a fibrous capsule; they contain
articular cartilage and menisci and are innervated by the medial
branches of the dorsal rami. Pain from the cervical facet joints
can originate from traumatic hyperextension injuries such as
whiplash or degenerative processes such as osteoarthritis.
The clinical features of this condition are similar to other
causes of axial neck pain, and the differential diagnosis in-
cludes cervical strain, spinal stenosis, and diskogenic pain. The
diagnostic workup usually begins with plain radiographs to rule
out fracture or instability, but advanced imaging such as CT or
MRI can be useful if the diagnosis is uncertain. Some studies
of patients with lumbar facet pain suggest that SPECT can be
used to predict which patients are good candidates for intra-
articular facet joint injections; there are no high quality SPECT
scan studies involving cervical facet dysfunction.
Limited evidence exists concerning treatment of cervical
facet joint dysfunction. Therapeutic cervical facet injections
can be performed through intra-articular blocks or medial
branch blocks. Limited studies on intra-articular blocks give
conflicting evidence regarding their effectiveness; there were
no studies found on the long-term efficacy of medial branch
blocks alone. RF neurotomy through a continuous or pulsed
approach has been shown through limited studies to provide
lasting pain relief from cervical facet joint dysfunction for
several months. No studies were found that analyzed the effi-
cacy of conservative management in cervical facet dysfunction
(medications, PT, modalities, spinal manipulation or mobiliza-
tion).1
APPENDIX 1: DIFFERENTIAL DIAGNOSIS32
Disk herniation
Unconvertebral joint hypertrophy
Muscular strain or sprain
Myofascial pain syndromes
Fibromyalgia
Primary tumor or metastatic disease
Neuralgic amyotrophy (ie, Parsonage-Turner syndrome)
Polymyalgia rheumatica
Polymyositis
Thoracic outlet syndrome
Shoulder-related pain syndromes (eg, rotator cuff tendinitis,
subacromial bursitis, adhesive capsulitis)
Spinal cord injury
Syringomyelia
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