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Cervical and Thoracic Zygapophsial joint arthropathy

  1. Disease/Disorder:
    Definition

    Cervical and thoracic zygapophyseal joint arthropathy refers to degenerative changes in the zygapophyseal joints (facet joints, z-joints) in the spine and can cause pain in the neck and mid back, with referral into other regions such as the upper extremities.

    Etiology

    It results from osteoarthritis of the z-joints, and is a component of spondylosis, spondylolisthesis, trauma, and whiplash. Z-joints are considered part of the third column of the spine and usually deteriorate after the first column, involving the intervertebral disks.

    Epidemiology including risk factors and primary prevention

    In patients with localized cervical or thoracic pain, the prevalence of z-joint pain amounts to 55% and 42%, a much higher percentage than the 30% that accounts for z-joint mediated pain in the lumbar region.1 It affects females more than males, with peak prevalence in middle-aged persons. Risk factors include genetics, smoking, and data entry/management jobs, such as sedentary jobs at computer desk stations involving repetitive precision work with high level of muscular tension.2 Primary prevention is directed at modification and reduction of risk factors.

    Patho-anatomy/physiology

    Z-joints are diarthrodial joints formed by the superior articular process of one vertebrae and the inferior articular process of the vertebrae above. In the cervical spine they are oriented in a coronal oblique plane and a coronal plane in the thoracic spine. The z-joints function to limit excessive flexion, extension, sidebending, and rotation. The C2-3 z-joint is innervated by the third occipital nerve. The C3 medial branch nerve innervates the C3-4 z-joint. The remainders of the joints have a bisegmental innervation from the medial branch of the dorsal rami of the same level and the level above it.3

    Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

    In the spine, the intervertebral disc and the z-joints are the only articulations between adjacent vertebrae. They serve to stabilize and restrict excessive motion in the spine. Z-joint arthropathy is commonly seen in patients with degenerative disc disease and typically develops subsequent to it.4 Degenerative z-joint changes are similar to those seen in other joints: osteophyte formation, articular process hypertrophy, osteosclerosis, thinning of articular cartilage with subchondral cyst formation, vacuum joint phenomenon or joint effusion, and hypertrophy of the joint capsule and ligamentum flavum.5 Osteophyte formation can lead to lateral recess stenosis. Joint hypertrophy causes distortion of the articular surfaces, which can cause axial and/or referred pain.6 The articular cartilage degenerates and can progress to subchondral bone sclerosis, with degenerative cysts in advanced disease.5

    Specific secondary or associated conditions and complications

    Complications include lateral recess stenosis, which can lead to radicular symptoms. ​Z-joint arthropathy and associated ligamentum flavum hypertrophy can sometimes lead to central canal stenosis and in the neck can progress to cause cervical myelopathy.5 Synovial cysts can occur but more commonly in the lumbar spine. These cysts often cause radicular symptoms in the lumbar but not the cervical spine.7 Severe z-joint arthropathy can lead to segmental instability and joint subluxation in rare instances.

  2. Essentials of Assessment
    History

    Patients often present with unilateral neck pain that does not radiate past the shoulder, and with limited rotation and extension. The z-joints potentially affected can be identified based on specific radiating patterns from the occiput to neck and upper back, based on published referred pain maps.8 However, referred pain patterns can be non-specific and have to be interpreted with caution because intervertebral discs can produce similar patterns.9 Rotation and extension can exacerbate z-joint pain. Cervicogenic headaches can occur. ​In the thoracic spine, patients present with paravertebral pain that worsens with prolonged standing and hyperextension.

    Physical examination

    Although there are no specific signs for diagnosis, the key finding is the absence of neurological impairment (motor, sensory, reflexes) or radicular symptoms. Pain may be elicited with z-joint palpation or provocation by axial loading and side bending.2 Range of motion can be restricted in flexion, extension, and rotation. Since pain can radiate to the shoulder, shoulder examination is important. Accentuated cervical kyphosis is often seen. Evaluation of muscle tightness in the anterior and middle scalenes, trapezius, and sternocleidomastoid is recommended.

    Functional assessment

    Patients may assume a forward flexed kyphotic posture to alleviate pain and will likely have limited mobility in all planes.8 Pain may be exacerbated by going from a sitting position to standing.10 Upper cervical spine Z-joint arthropathy can limit head rotation, causing difficulty with driving, and can hinder conversations in social situations. These impairments may lead to decreased quality of life, and contribute to depression, especially in elderly patients.

    Laboratory studies

    Laboratory studies are indicated if there is suspicion of underlying cancer, rheumatologic disease, inflammatory disease, infectious process, or in cases of unexplained spine pain. In appropriate patients, Human Leukocyte Antigen-B27 (HLA-B27), Antinuclear Antibody (ANA), Rheumatoid Factor (RF), and Serum Protein Electrophoresis (SPEP) are indicated.

    Imaging

    The primary role of imaging is to exclude other pathologies (e.g., disc disease, tumor, fracture). X-ray, magnetic resonance imaging (MRI), computerized tomography (CT), and bone scan can reveal z-joint arthropathy, even in its early stages.10 Degenerative changes seen on imaging, however, may not correlate with z-joint mediated pain, as degenerative changes are often seen in asymptomatic patients.11

    Supplemental assessment tools

    Besides the clinical reference standard, the gold standard for diagnosis utilizes diagnostic medial branch blocks (MBB).3,12 Using fluoroscopic guidance, anesthetic medication can be injected adjacent to the medial branch nerves to assess for reduction in typical pain. A reduction in pain of 50% is considered a successful block.13 To minimize false positives, a second diagnostic block is often performed with a different anesthetic (i.e., lidocaine vs. marcaine) to see if a similar relief is found.

    Early predictions of outcomes

    Local pressure pain, defined as pain when applying pressure of at least 4 kg, is a predictor of success with radiofrequency ablation (RFA).13 Ninety percent of patients who have successful pain relief with initial RFA have been shown to report satisfactory pain relief for eight to twelve months on subsequent RFAs.14

    Environmental

    Patients with obesity and scoliosis are at higher risk for osteoarthritis.15 Sedentary jobs at computer desk stations and those involving repetitive precision work with high level of muscular tension can be occupational risks.

    Social role and social support system

    Chronic neck pain can contribute to missed work and disability. Biopsychosocial variables such as self-esteem, coping mechanisms, support at home and in the community, and workplace satisfaction come into play. Lack of social support in the work environment appears to have an effect.15 Psychological factors such as avoidance behavior and catastrophizing are not related to neck pain, in contrast to patients with low back symptoms.3

    Professional Issues

    Z-joint mediated pain can be mimicked by malingerers and patients with secondary gain, given that it is a diagnosis of exclusion with no absolute findings.

  3. Rehabilitation Management and Treatments
    Available or current treatment guidelines

    Conservative treatment is recommended initially for both acute and chronic z-joint pain. Physical therapy has been shown to have a better outcome than a home exercise program, and is the best choice when choosing conservative treatment.15 The focus is on posture correction, range of motion, muscular strengthening, and activity modification. Manipulation and mobilization via chiropractic treatment and osteopathic manipulation has a positive short-term effect on pain relief.16 Medications such as NSAIDs and topical agents are employed at all stages of the disease with variable results. A multidisciplinary approach should be employed, with minimally invasive interventional techniques for patients not responding to conservative treatment. RFA of the medial branch can be considered after a 50% relief of pain is demonstrated with a diagnostic anesthetic MBB. There is limited evidence regarding intra-articular z-joint corticosteroid injections and corticosteroid medial branch injections.2

    At different disease stages
    • New onset/acute
      • Initial management is focused on medical and rehabilitation treatment. This includes NSAIDs, topical agents, ice/heat, physical therapy, chiropractic interventions, and home exercise. The primary goal is risk factor modification, postural training, activity modification, and mobilization. Early z-joint injections are sometimes performed for very painful presentations and may aid in participation in therapy.10
    • Subacute
      • If symptoms have been present for more than three months and have failed conservative treatment, interventional methods are often indicated. Intra-articular (IA) corticosteroid injection into the affected joints are often employed, however definitive efficacy studies are lacking. Short-term relief leads to employing diagnostic MBB with local anesthetic. The addition of corticosteroid to local anesthetic has not been shown to provide a better outcome and is not recommended as first-line interventional therapy.17 If the anesthetic MBB results in 50% reduction of pain, definitive RFA can be performed.13 Retrospective analysis shows that initial RFA has a mean duration of 12.5 months in the cervical spine.14 There are no comparative studies between IA injections and RFA.18 The focus from a functional perspective is still on restoring range of motion and strengthening postural muscles.
    • Chronic
      • In the chronic phase, if RFA has yielded positive results it can be repeated every six months. On subsequent RFA, more than 90% of patients reported satisfactory pain relief with 8-12 months of pain relief.14 Therapeutic joint injections can be performed 4-6 times per year. If a patient has failed conservative and interventional management, their treatment becomes quite difficult. Occasionally transcutaneous electrical nerve stimulation (TENS) units might prove helpful in addition to acupuncture, medications such as Pregabalin or Duloxetine, or biopsychosocial treatments.
    Coordination of care

    The physiatrist's role is to coordinate multidisciplinary treatment approach. This includes physical therapy and home exercise programs, environmental modifications, nutrition, medications, manipulation, interventional techniques and addressing psychological factors. Cognitive behavioral therapy shows improvement in somatic, behavioral, and cognitive symptoms but only a small effect on pain.2

    Patient & family education

    Patient and family education should be focused on risk factor reduction and modification, including smoking cessation, weight loss, postural mechanics, ergonomic adjustment, and home exercise program.

    Emerging/unique Interventions

    Patients' response to treatment can be measured by the visual analog scale or numerical rating scale, and the McGill Pain Questionnaire, Neck Disability Index, and Pain Disability Questionnaire.

    Translation into practice: practice "pearls"/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

    Conservative measures such as medications and therapy then local joint injections are the mainstay of treatment. If symptoms progress beyond three months, interventional diagnostic methods such as MBB can be employed. If these blocks are successful, RFA can provide longer-lasting pain relief.

  4. Cutting edge/emerging and unique concepts and practice
    Cutting edge concepts and practice

    Pulsed RFA (rather than continuous) consists of smaller amounts of current at a lower temperature compared to thermal ablation. This is considered a safer alternative, although the risks are minimal when thermal ablation is performed correctly. Cooled RFA in the thoracic spine is a promising technique, providing large lesions that compensate for the anatomic variability in the region.19 With proper technique and fluoroscopic confirmation of needle placement, risks can be minimized.

  5. Gaps in the evidence-based knowledge
    Gaps in the evidence-based knowledge

    There is limited research regarding the efficacy of conservative treatments such as physical therapy, manipulation, chiropractic adjustment, traction units, or acupuncture. Insurance companies are now denying z-joint injections, citing lack of evidence. Also, evidence behind thoracic interventions is limited because they are infrequently performed. Disagreement exists whether one diagnostic medial branch block is considered sufficient vs. two. Further research is needed to establish evidence-based guidelines regarding the diagnosis and treatment of z-joint arthropathy and when to perform interventions.

    References
    1. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. May 28 2004;5:15.
    2. van Eerd M, Patijn J, Lataster A, et al. 5. Cervical facet pain. Pain Pract. Mar-Apr 2010;10(2):113-123.
    3. Bogduk N, McGuirk B. Acute neck pain: natural history. In: Bogduk N, McGuirk B, eds. Management of Acute and Chronic Neck Pain: An Evidence-based Approach. Philadelphia, PA: Elsevier; 2006:31-34.
    4. Butler D, Trafimow JH, Andersson GB, McNeill TW, Huckman MS. Discs degenerate before facets. Spine (Phila Pa 1976). Feb 1990;15(2):111-113.
    5. van den Hauwe L. Pathology of the Posterior Elements. In: van Goethem J, van den Hauwe L, Parizel P, eds. Spinal Imaging: Diagnostic Imaging of the Spine and Spinal Cord. New York, NY: Springer; 2007:157-172.
    6. Carrera GF. Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology. Dec 1980;137(3):665-667.
    7. Stoodley MA, Jones NR, Scott G. Cervical and thoracic juxtafacet cysts causing neurologic deficits. Spine (Phila Pa 1976). Apr 15 2000;25(8):970-973.
    8. Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Spine (Phila Pa 1976). Jun 1990;15(6):458-461.
    9. Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine (Phila Pa 1976). Jun 1 2000;25(11):1382-1389.
    10. Fenton D, Czervionke L. Facet Joint Injection and Medial Branch Block. In: Fenton D, Czervionke L, eds. Image-Guided Spine Intervention. Philadelphia, PA: Saunders; 2003:9-51.
    11. Friedenberg ZB, Miller WT. Degenerative Disc Disease Of The Cervical Spine. J Bone Joint Surg Am. Sep 1963;45:1171-1178.
    12. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. Jul-Aug 2009;12(4):699-802.
    13. Cohen SP, Bajwa ZH, Kraemer JJ, et al. Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis. Reg Anesth Pain Med. Nov-Dec 2007;32(6):495-503.
    14. Husted DS, Orton D, Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for cervical facet joint pain. J Spinal Disord Tech. Aug 2008;21(6):406-408.
    15. Cote P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S60-74.
    16. Schellingerhout JM, Verhagen AP, Heymans MW, et al. Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation therapy, physiotherapy, or usual care? Pain. Oct 31 2008;139(3):670-680.
    17. Manchikanti L, Singh V, Falco FJ, Cash KM, Fellows B. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine (Phila Pa 1976). Aug 1 2008;33(17):1813-1820.
    18. Falco FJ, Erhart S, Wargo BW, et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. Mar-Apr 2009;12(2):323-344.
    19. van Kleef M, Stolker RJ, Lataster A, Geurts J, Benzon HT, Mekhail N. 10. Thoracic pain. Pain Pract. Jul-Aug 2010;10(4):327-338.
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