Neck Solutions

The prevalence of facet joint related chronic neck pain in postsurgical and nonpostsurgical patients

From: Pain Practice. 2008 Mar;8(1):5-10

Facet (zygapophysial) joints may be clinically important sources of chronic cervical spinal pain. Previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, and reported an overall prevalence of 36% to 67% facet joint involvement in cervical spinal pain.

The reports of lumbar facet joint-involvement in postsurgery syndrome have been shown to be highly variable with prevalence ranging from 8% to 32%. To date, however, the prevalence of postsurgical facet joint-related pain in the cervical spine has not been evaluated. In light of this, the present retrospective study was conducted to assess and compare the prevalence of chronic postsurgical facet joint cervical spinal pain to nonsurgical, chronic cervical facet joint pain.

Patients presenting with chronic neck pain were studied. The procedures were performed by a single physician in an interventional pain management ambulatory surgery center. The prevalence of cervical facet joint pain in postsurgical patients was assessed and compared to nonsurgical patients.

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Biomechanical implications of degenerative joint disease in the apophyseal joints of human thoracic and lumbar vertebrae

From: American Journal of Physical Anthropology 2008 Mar 6

An experimental technique for quantifying load-sharing in cadaveric spines is used to test the hypothesis that degenerative changes in human apophyseal joints are directly related to high levels of compressive load-bearing by these joints.

About 36 cadaveric thoraco-lumbar motion segments aged 64-92 years were subjected to a compressive load of 1.5 kN. The distribution of compressive stress was measured in the intervertebral discs using a miniature pressure transducer, and stress measurements were summed over area to give the compressive force resisted by the disc. This was subtracted from the applied 1.5 kN to indicate compressive load-bearing by the apophyseal joints. The cartilage of each apophyseal joint surface was then graded for degree of degeneration. After maceration, each joint surface was scored for degenerative joint disease affecting the bone.

Results demonstrated that the apophyseal joints resisted 5-96% (mean 45%) of the applied compressive force. A significant positive correlation was demonstrated between age and cartilage degeneration, age and degenerative joint disease bone score, apophyseal joint load-bearing and bone score, and cartilage score and load-bearing. The latter correlation was strongest for load-bearing above 50%. Ordinal regression showed that the variables describing bone degenerative joint disease (marginal osteophytes, pitting, bony contour change, and eburnation) were significantly correlated with degree of cartilage degeneration.

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Strength of the cervical spine in compression and bending

From: Spine. 2007 Jul 1;32(15):1612-20

Cadaveric motion segment experiment.

Comparison of the strength in bending and compression of the human cervical spine and to investigate which structures resist bending the most.

The strength of the cervical spine when subjected to physiologically reasonable complex loading is unknown, as is the role of individual structures in resisting bending.

A total of 22 human cervical motion segments, 64 to 89 years of age, were subjected to complex loading in bending and compression. Resistance to flexion and to extension was measured in consecutive tests. Sagittal-plane movements were recorded at 50 Hz using an optical two-dimensional “MacReflex” system. Experiments were repeated 1) after surgical removal of the spinous process, 2) after removal of both apophyseal joints, and 3) after the disc vertebral body unit had been compressed to failure. Results were analyzed using t tests, analysis of variance, and linear regression. Results were compared with published data for the lumbar spine.

The elastic limit in flexion was reached at 8.5 degrees (SD, 1.7 degrees ) with a bending moment of 6.7 Nm (SD, 1.7 Nm). In extension, values were 9.5 degrees (SD, 1.6 degrees ) and 8.4 Nm (3.5 Nm), respectively. Spinous processes (and associated ligaments) provided 48% (SD, 17%) of the resistance to flexion. Apophyseal joints provided 47% (SD, 16%) of the resistance to extension. In compression, the disc vertebral body units reached the elastic limit at 1.23 kN (SD, 0.46 Nm) and their ultimate compressive strength was 2.40 kN (SD, 0.96 kN). Strength was greater in male specimens, depended on spinal level and tended to decrease with age.

The cervical spine has approximately 20% of the bending strength of the lumbar spine but 45% of its compressive strength. This suggests that the neck is relatively vulnerable in bending.

Neck Movement and Muscle Activity Characteristics in Female Office Workers With Neck Pain

From: Spine. 33(5):555-563, March 1, 2008

Exploring aspects of cervical musculoskeletal function in female office workers with neck pain.

Evidence of physical characteristics that differentiate computer workers with and without neck pain is sparse. Patients with chronic neck pain demonstrate reduced motion and altered patterns of muscle control in the cervical flexor and upper trapezius muscles during specific tasks. Understanding cervical musculoskeletal function in office workers will better direct intervention and prevention strategies.

Measures included neck range of motion; superficial neck flexor muscle activity during a clinical test, the craniocerivcal flexion test; and a motor task, a unilateral muscle coordination task, to assess the activity of both the anterior and posterior neck muscles. Office workers with and without neck pain were formed into 3 groups based on their scores on the Neck Disability Index. Nonworking women without neck pain formed the control group. Surface electromyographic activity was recorded bilaterally from the sternocleidomastoid, anterior scalene, cervical extensor and upper trapezius muscles.

Workers with neck pain had reduced rotation range and increased activity of the superficial cervical flexors during the craniocervical flexion test. During the coordination task, workers with pain demonstrated greater activity in the cervical extensor muscles bilaterally. On completion of the task, the upper trapezius and dominant cervical extensor muscles and anterior scalene muscles demonstrated an inability to relax in workers with pain. In general, there was a linear relationship between the workers’ self-reported levels of pain and disability and the movement and muscle changes.

These results are consistent with those found in other cervical musculoskeletal disorders and may represent an altered muscle recruitment strategy to stabilize the head and neck. An program including neck exercises and motor reeducation may assist in the management of neck pain in office workers.

Is Your Client’s Back Pain “Rapidly Reversible”? Improving Lower Back Care at Its Foundation

From: Professional Case Management. 13(2):87-96, March/April 2008

Purpose/objectives: To convey a valuable and greatly misunderstood paradigm for evaluating and treating lower back pain and its extensive scientific evidence.

Primary practice setting(s): Lower back pain is a highly prevalent and very expensive health dilemma. But by using a paradigm called Mechanical Diagnosis and Therapy, it is now possible to identify a very large lower back pain subgroup whose pain is rapidly reversible, meaning that it can often be eliminated quickly, with return to full function using a single, patient-specific direction of simple, yet precise, end-range back exercises and some back posture modifications. This interesting subgroup includes patients with both acute and chronic lower back pain as well as both low back pain only and sciatica with neural deficits.

Findings/conclusions: This special form of clinical assessment can detect which patients are in this large, rapidly reversible subgroup and which ones are not. Of the numerous studies targeting Mechanical Diagnosis and Therapy, three have focused on patients whose persisting pain had led to recommendations of disc surgery where 50% were then found to still have a rapidly reversible disc problem with high rates of nonsurgical rapid recovery. If patients are never assessed in this way, this reversibility remains undiscovered and these patients commonly undergo potentially unnecessary surgery.

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Approach to imaging the patient with neck pain

From: Journal of Neuroimaging 2003;13:5-16

Neck pain is a common complaint of patients seeking care in the outpatient setting, and the cases seen vary widely in severity and cause. A careful history and physical exam, followed by appropriate imaging studies, are essential for the orderly workup and management of neck pain in the ambulatory patient. Available imaging studies include plain film radiography, computed tomography (CT), magnetic resonance, and CT myelography. The general considerations necessary to select the appropriate imaging study are discussed for a broad spectrum of common disorders.

A careful history is key to placing a patient in a preliminary diagnostic category for further evaluation. A patient’s occupation, postural habits, onset of pain, character of pain, and stress at work and/or home should be discussed. The patient should be questioned regarding the presence of associated symptoms, such as gait or bladder dysfunction. Certain symptom groups are suggestive or even diagnostic of certain disease processes.

Acute pain with limited motion, especially in a younger person, is likely to follow trauma or a persistent new activity. Often, the neck muscles are tender in these patients. Middle-aged patients may present with recurrent or persistent pain, sometimes accompanied by tingling in the arms or fingers and/or pectoral pain from an affected C6 nerve root. Extension or lateral gaze may aggravate the pain. This constellation of symptoms, usually without history of trauma, suggests cervical degenerative arthritis or cervical spondylosis. Rheumatoid arthritis of the cervical spine usually occurs after a decade of peripheral joint disease and is characterized by severe neck pain followed by arm pain and progressive radiculopathy or myelopathy.

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Prevalence of cervicogenic headache: Vågå study of headache epidemiology

From: Acta Neurologica Scandinavica Volume 117 Issue 3 Page 173-180, March 2008

OBJECTIVES: To describe the prevalence and various clinical characteristics of cervicogenic headache in the population at large.

METHODS: Cervicogenic headache was searched for in Vågå, Norway, where 1838 18 to 65-year-old citizens, i.e. 88.6% of this age group, underwent an interview/clinical examination. The Cervicogenic Headache International Study Group criteria include: (I) unilaterality of head pain, (II) reduction, range of movement, neck, (III/IV) ipsilateral shoulder/arm discomfort, (V/VI) mechanical provocation of similar pain, objectively or subjectively.

RESULTS: A prevalence of 4.1% was found. In 41 cases with the highest number of cervicogenic headache criteria (’core’ cases), there was a male preponderance (F/M: 0.71). While cervicogenic traits (mechanical precipitation etc.) were frequently present in cervicogenic headache, ‘migraine traits’, like nausea, vomiting, and throbbing seemed to be rarely present. In 97% of the cases, pain exacerbations began in the neck/occipital region.

CONCLUSIONS: Cervicogenic headache may be one of the three large, recurrent headaches. In this series, there was no female preponderance. Nuchal onset of pain is a characteristic trait of cervicogenic headache.

Pharmacological enhancement of disc diffusion and differentiation of healthy, ageing and degenerated discs : Results from in-vivo serial post-contrast MRI studies in 365 human lumbar discs.

From: European Spine Journal 2008 Mar 21

Degenerative disc disease is still a poorly understood phenomenon because of the lack of availability of precise definition of healthy, ageing and degenerated discs. Decreased nutrition is the final common pathway for degenerative disc disease and the status of the endplate plays a crucial role in controlling the extent of diffusion, which is the only source of nutrition. The vascular channels in the subchondral plate have muscarinic receptors but the possibility of enhancing diffusion pharmacologically by dilation of these vessels has not been probed. Although it is well accepted that endplate damage will affect diffusion and thereby nutrition, there is no described method to quantify the extent of endplate damage. Precise definitions with an objective method of differentiating healthy, ageing and degenerated discs on the basis of anatomical integrity of the disc and physiological basis of altered nutrition will be useful. This information is an urgent necessity for better understanding of degenerative disc disease and also strategizing prevention and treatment.

Seven hundred and thirty endplates of 365 lumbar discs from 73 individuals (26 healthy volunteers and 47 patients) with age ranging from 10-64 years were evaluated by pre-contrast and 10 min, 2, 4, 6 and 12 h post contrast MRI after IV injection of 0.3 mmol/kg of Gadodiamide. End plates were classified according to the extent of damage into six grades and an incremental score was given for each category. A total endplate score was derived by adding the endplate score of the two endplates for each concerned disc. The enhancement percentage for each time period, the time for peak enhancement (T-max) and the time intensity curve (TIC) over 12 h were used to study and compare the diffusion characteristics. The differences in pattern of diffusion were obvious visually at 4 h which was categorized into five patterns-Pattern A representing normal diffusion to Pattern E representing a total abnormality in diffusion. Degeneration was classified according to Pfirrmann’s grading and this was correlated to the total endplate score and the alterations in diffusion patterns. The relationship of total endplate score on the increase in degenerative disc disease was evaluated by a logistic curve and the cut point for severe degenerative disc disease was found by ROC curve.

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Influence of Psychological Variables on the Diagnosis of Facet Joint Involvement in Chronic Spinal Pain

From: Pain Physician 2008; 11:145-160

Facet or zygapophysial joint pain is one of the common conditions responsible for chronic spinal pain. Controlled diagnostic blocks are considered the only means of reliable diagnosis of facet joint pain, due to the inability of physical examination, clinical symptoms, radiologic evaluation, and nerve conduction studies to provide a reliable diagnosis. The prevalence of facet joint pain has been established to be 15% to 45% of patients with low back pain, 39% to 67% of patients with neck pain, and 34% to 48% of patients with thoracic pain. However, using only a single block, false-positive rates of 27% to 63% in the cervical spine, 42% to 58% in the thoracic spine, and 17% to 50% in the lumbar spine have been reported.

While there are multiple reasons for false-positive results, psychological variables may also contribute to false-positive results. A lack of influence of psychological factors on the validity of controlled diagnostic local anesthetic blocks of lumbar facet joints has been demonstrated. However, no such studies have been performed in the thoracic or cervical spine.

Objective: To study the influence of psychopathology (depression, generalized anxiety disorder, and somatization individually or in combinations of multiple psychopathologic conditions) on the ability of controlled, comparative local anesthetic blocks to accurately identify facet joint pain and false-positive rates with a single block.

Methods: Four hundred thirty-eight patients undergoing controlled, comparative local anesthetic blocks were included in the study. Patients were allocated based on their psychological profiles — each diagnostic group or combination was divided into distinct categories. Primary groups consisted of patients with major depression, generalized anxiety disorder, and somatization disorder. Combination groups consisted of 4 categories based on multiple combinations. All the patients were treated with controlled, comparative local anesthetic blocks either with 1% lidocaine or 1% lidocaine and 0.25% bupivacaine. A positive response was defined as at least an 80% reduction in pain and the ability to perform previously painful movements with appropriate relief with 2 separate local anesthetics.

Results: The prevalence of facet joint pain in chronic spinal pain ranged from 25% to 40% in patients without psychopathology, whereas it ranged from 28% to 43% in patients with a positive diagnosis of major depression, generalized anxiety disorder, and somatization disorder, respectively, compared to 23% to 39% in patients with a negative diagnosis. Regional facet joint pain prevalence and false-positive rates were higher in the cervical region in patients with major depression. In the lumbar and thoracic regions, no significant differences were noted. Conclusion: This study demonstrated that, based on patient psychopathology, there were no significant differences among the patients either in terms of prevalence or false-positive rates in the lumbar and thoracic regions. A higher prevalence and lower false-positive rates in the cervical region were established in patients with major depression.

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Effectiveness of an educational and physical programme in reducing headache, neck and shoulder pain: a workplace controlled trial.

From: Cephalalgia. 2008 Mar 3

This study was an 8-month controlled trial to evaluate the effectiveness of a workplace educational and physical programme in reducing headache and neck and shoulder pain.

Central registry office employees (n = 192; study group) and 192 peripheral registry office and central tax office employees (controls) in the city of Turin, Italy were given diaries for the daily recording of pain episodes. After 2 months, the study group only began the educational and physical programme.

The primary end-point was the change in frequency of headache and neck and shoulder pain expressed as the number of days per month with pain, and as the proportion of subjects with a >/= 50% reduction of frequency (responder rate). The number of days of analgesic drug consumption was also recorded. Diaries completed for the whole 8 months were available for 169 subjects in the study group and 175 controls.

The baseline frequency of headache (days per month) was 5.87 and 6.30 in the study group and in controls; frequency of neck and shoulder pain was 7.12 and 7.79, respectively. Mean treatment effects [days per month, 95% confidence interval (CI)] on comparing the last 2 months vs. baseline were: headache frequency -2.45 (-3.48, -1.43); frequency of neck pain -2.62 (-4.09, -1.16); responder rates (odds ratio, 95% CI) 5.51 (2.75, 11) for headache, 3.10 (1.65, 5.81) for neck and shoulder pain, and 3.08 (1.06, 8.90) for days with analgesic drug consumption.

The study suggests that an educational and physical programme reduces headache and neck and shoulder pain in a working community.