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Disease/ Disorder


Cervical and thoracic zygapophyseal joint arthropathy refers to degenerative changes in the facet joints (zygapophyseal joints, z-joints) of the spine which may result in facet-mediated head, neck, and back pain.


It results from osteoarthritis of the facet joints, and it is a component of spondylosis, spondylolisthesis, trauma, and whiplash. Facet joints are considered part of the third, or posterior column of the spine, and usually deteriorate after the first, or anterior column, involving the intervertebral disks. The facet joints are often referred to as part of the “posterior elements”.

Epidemiology including risk factors and primary prevention

In patients with localized cervical or thoracic pain, the prevalence of facet joint pain amounts to 36-67% and 34-48%, respectively. This is in comparison to lumbar facet-mediated pain, which only accounts for 16-41% of lower back pain.1 The prevalence increases to 50-60% in trauma-induced chronic pain, including whiplash.2 In addition, 70% of cervicogenic headaches, which are seen in 4.1% of the population, result from C2-C3 facet joint arthropathy.3 Peak prevalence is in middle-aged individuals. Risk factors include genetics, major depression, and sedentary occupations that involve repetitive precision work with high level of muscular tension, such as data entry/management jobs.4 Primary prevention is directed at modification and reduction of risk factors. There are no studies to date addressing race, sex, or morbidity/mortality of facet-joint mediated pain. Facet tropism is the angular asymmetry between left and right facet joint orientation; it has recently been a target of investigation as a possible risk factor able to be correlated with chronic spine pain.5,6,7


Facet 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; in the thoracic spine, they are in a coronal plane. The facet joints function to limit excessive flexion, extension, side-bending, and axial rotation. The C2-3 facet joint is innervated by the third occipital nerve and a separate articular branch of the posterior ramus of C3. The C3 medial branch nerve innervates the C3-4 facet joint. The remainder of the joints have a bisegmental innervation from the medial branch of the dorsal rami of the same level and the level above it.8

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

The intervertebral disc and the facet joints are the only articulations between adjacent vertebrae. They serve to stabilize and restrict excessive motion in the spine. Facet joint arthropathy is commonly seen in patients with degenerative disc disease and typically develops subsequent to it.9 Degenerative facet 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.10 Joint hypertrophy causes distortion of the articular surfaces which can cause axial and/or referred pain.11

Specific secondary or associated conditions and complications

Complications include lateral recess stenosis, which may cause radicular symptoms. Facet joint arthropathy and associated ligamentum flavum hypertrophy can lead to central canal stenosis and subsequently result in myelopathy.10 Synovial cysts, while more common in the lumbar spine, can form in the cervical/thoracic joint, and may result in radicular symptoms.12 In rare instances, severe facet joint arthropathy can lead to segmental instability and joint subluxation. There have been many cases of intraspinal synovial cyst communicating with the C1-C2 facet joints and subarachnoid space associated with rheumatoid atlantoaxial instability and associated myelopathic symptoms.13 Whiplash injuries can result in chronic neck pain and headaches; frequently this pain is referred from facet joints, especially C2-3, injury.3

Essentials of Assessment


There are no symptoms unique to facet-mediated neck pain. Patients may present with non-specific symptoms which include deep/achy pain localized to paravertebral region (unilateral or bilateral) that may be exaggerated by hyperextension, twisting, side bending and torsional loads. Rarely is the pain axial or central. Patients may also report headaches or morning neck stiffness. Facet arthropathy pain is largely progressive, except when caused by trauma or whiplash injuries.14  Chronic whiplash associated disorders have a complex presentation involving physical and psychological factors. A substantial number of patients with chronic whiplash associated disorder have persistent pain generated from cervical facet joints.15,16Patients may present with specific referral patterns to the occiput, neck, and upper back which may correlate to specific facet joints. Published pain maps identify these common referral areas, however they are very non-specific in terms of pathology and are substantially variable in spinal level overlap.17 These findings should be interpreted with caution as other pathologies such as discogenic pain can produce similar pain patterns.18

Physical examination

Facet-mediated neck pain is largely a diagnosis of exclusion. There are no specific signs or special examination maneuvers/movements to aide in the diagnosis. Diagnosis is often guided by the absence signs that may suggest alternate etiologies, such as neurological impairment or radicular symptoms.4 Numerous quality studies consistently fail to demonstrate a correlation between the popularized “facet loading” maneuver (pain upon extension and ipsilateral rotation) and facet mediated pain.14 The only physical exam finding that appears to consistently correlate with facet arthropathy, and later successful treatment, is paraspinal tenderness, which has been shown to distinguish facet pain from discogeninc back pain.14 Manual spine examination, when used in conjunction with paraspinal tenderness, may also be a useful clinical tool.19 Additional examination findings may include: range of motion restrictions (specifically in flexion, extension, and rotation), cervical kyphosis (loss of normal lordotic curvature), and hypertonicity of anterior/middle scalenes, trapezius, and sternocleidomastoid.

Functional assessment

Patients may assume a forward flexed kyphotic posture to alleviate pain and will likely have limited mobility in all planes.17 Pain may be exacerbated by going from a sitting to standing position.20 Upper cervical spine facet 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 can contribute to depression.

Laboratory studies

Laboratory studies are indicated if there is suspicion of underlying cancer, rheumatologic disease, inflammatory disease, and infectious process, as well as in cases of unexplained spinal pain. In appropriate patients, Human Leukocyte Antigen-B27, Antinuclear Antibody, Rheumatoid Factor, and Serum Protein Electrophoresis, Thyroid and Parathyroid, and Vitamin D levels are indicated.


The primary role of imaging is to exclude spondylolysis, spondylolisthesis, and tumor. X-ray, magnetic resonance imaging (MRI), computerized tomography (CT), and bone scan can reveal facet arthropathy, even in its early stages.20 Degenerative changes seen on imaging, however, lack predictive value for corresponding facet joint mediated pain, as degenerative changes are often seen in asymptomatic patients.21 Imaging may help to exclude facet joint arthropathy, as multiple radiological studies have demonstrated that disc degeneration almost always precedes facet joint degeneration, especially in older adults.14 It is common to order spine X-ray and MRI or CT prior to performing a spine procedure.

Supplemental assessment tools

In addition to the clinical reference standard, the gold standard for diagnosis utilizes diagnostic medial branch blocks (MBB).1,8,22 Using fluoroscopic guidance, anesthetic medication can be injected adjacent to the medial branch nerves to assess for pain reduction. Clinically, a reduction in pain of 50% is considered a successful block; however, an 80% pain reduction it typically used in studies.23 Pain reduction following MBB is not only diagnostically useful, but also correlates  response to further treatments such as medial branch radiofrequency ablation24,25. To minimize false positives, which can be as high as 58% in the thoracic spine and 27-63% in the cervical spine, a second diagnostic block is recommended with a different anesthetic (i.e., lidocaine vs. bupivacaine) in order to evaluate if pain relief is reproduced and commensurate with the known duration of the chose anesthetic.14 Compared to single blocks, the use of double blocks is associated with higher radiofrequency ablation (RFA) success rates which is attributed to the increased rate of false-negative diagnostic blocks and elimination of placebo responders.14 MBBs may not be efficacious in patients with aberrant innervation of facet joints and when branches of the primary posterior ramus innervate other pain–generating structures (i.e. back muscles).

Early predictions of outcomes

Local pressure pain, defined as pain when applying pressure of at least 4 kg, is a predictor of RFA success.23 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 with subsequent RFAs.26


Patients with obesity and scoliosis are at higher risk for osteoarthritis.21 Sedentary jobs at computer desk stations and those involving repetitive precision work with high level of muscular tension can be occupational risks.4  Other risk factors include leg length discrepancy, lower limb injuries, weakness or deformities that cause asymmetric forces across facet joints; this may be true more for lumbar facet joints.

Social role and social support system

Chronic neck pain can contribute to missed work and disability. Biopsychosocial variables such as self-esteem, coping mechanisms, home and community support network, and workplace satisfaction come into play. Cognitive behavioral therapy shows improvement in somatic, behavioral, and cognitive symptoms but only a small effect on pain.4 Lack of social support in the work environment also appears to have an effect.27 In contrast to patients with low back pain, psychological factors such as avoidance behavior and catastrophizing have not appeared to share the same association8 Although the evidence for a relationship between neck pain and the aforementioned psychological factors is lacking, there is growing evidence to support a similar relationship.16,28

Rehabilitation Management and Treatments

Available or current treatment guidelines

Conservative treatment is recommended initially for both acute and chronic facet joint pain. Exercise therapy, including physical therapy, has the strongest evidence for efficacy compared to all other non-interventional treatments.14 Physical therapy has been shown to have a better outcome than a home exercise program, and is the best choice when choosing conservative treatment; though, there is a financial cost to this27 Treatment focus is on posture correction, range of motion, muscular strengthening, and activity modification. Acupuncture, manipulation, and mobilization via chiropractic treatment and osteopathic manipulation has a positive short-term effect on pain relief,29 but when compared to sham, other non-interventional treatments, or physical exercise, the results are inconclusive.14

Medications such as NSAIDs are beneficial for neck and back pain, but have associated adverse effects, especially in in elderly patients; caution should be used specifically in patients with a history of gastrointestinal, renal, and/or cardiovascular problems. Topical agents including NSAIDs and lidocaine are a great option with few systemic side effects since less than 10% is absorbed systemically. Transcutaneous electrical nerve stimulation (TENS) units may be considered as an alternate treatment modality. A multidisciplinary approach should be employed, with minimally invasive interventional techniques offered to patients not responding to conservative treatment. RFA of the medial branch can be considered after a successful diagnostic anesthetic MBB(s). Alternative treatments such as hyaluronic acid injections, platelet rich plasma, and stem cell injections into non-lumbar facet joints have not been studied.14 There is a lack of evidence for arthrodesis and surgery for spondylosis or facet-mediated pain. Surgery can, however, be indicated in patients with symptomatic instability of the spine.

 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 facet joint injections are sometimes performed for very painful presentations and may aid in participation in therapy.20 Muscle relaxants, including cyclobenzaprine, are effective agents for acute neck and back pain.14


  • If symptoms have been present for more than three months and have not responded to conservative treatment, interventional methods are often indicated, as detailed above. These interventions include intra-articular corticosteroid injections and RFA following diagnostic MBB. The addition of corticosteroid to local anesthetic for MBB has not been shown to provide a better outcome and is not recommended as first-line interventional therapy.30 Currently, RFA is the standard of care for facetogenic pain.25 Analysis shows that initial cervical spine RFA provides pain relief for an average of 7 to 9 months, and up to a year in some patients, in approximately 60% of patients.14 Pain relief greater than 3 months is an indication for repeating RFA.26,31 RFA typically is more efficacious for cervical compared to lumbar facets, largely because cervical nerve anatomy patterns facilitate better electrode placement and subsequent RFA success.14 Thoracic RFA is comparatively more difficult due to anatomic innervation variants, ribs on fluoroscopy, and more complicated electrode placement.33 There is growing evidence that both intra-articular thoracic facet joint steroid injection and therapeutic thoracic MBB are useful treatment options for managing thoracic facet joint pain.34 For facet injections, only 1cc of volume is typically injected under fluoroscopic guidance; there is a potential risk of damaging the joint capsule with facet injections.


  • 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.26,31 Therapeutic intra-articular facet joint injections, while less commonly used due to poor efficacy, can be performed 4 times per year. If a patient has failed conservative and interventional management, their treatment becomes quite difficult. A recent review of 21 RTCs and 5 observational studies assessing for the best evidence and effectiveness of management of spinal facet joint pain, the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy.32

The three main reasons for treatment failures are misdiagnosis, poor selection of patients for treatment, and technical failures. Depression, opioid use, radiation of pain to the occiput, previous back surgery, and a greater number of affected vertebral levels were associated with treatment failure of spinal facet pain. In addition, RFA of the C2-C3 level is also associated with a lower success rate compared to RFA of lower levels.14 Psychiatric comorbidity appears to be a risk factor for diminished pain relief after a MBB injection.1

Coordination of care

The physiatrist’s role is to coordinate a multidisciplinary approach to treatment. This includes physical therapy and home exercise programs, environmental modifications, nutrition, medications, manipulation, interventional techniques and addressing psychological factors.

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 programs. Over the long-term, low-impact aerobic exercise has been shown to improve function.

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. The use of ultrasound is currently under investigation for cervical MBBs.35, 36

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

Conservative measures, such as medications and therapy followed by 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.

Cutting Edge/ Emerging and Unique Concepts and Practice

Pulsed, rather than continuous RFA, consists of smaller amounts of current at a lower temperature compared to thermal ablation and has been used in thoracic spine.37 This is considered a safer alternative, although the risks are minimal when thermal ablation is performed correctly.

Cooled RFA has been compared to traditional RFA in lumbar facets and shown comparable outcomes but has not been compared in cervical or thoracic spine regions.38 Cooled RFA and Pulsed RFA in the thoracic spine are promising techniques. Cooled RFA creates larger lesions than traditional RFA that compensate for the anatomic variability in the region.39, 40 With proper technique and fluoroscopic confirmation of needle placement, risks can be minimized. 

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, and acupuncture. The lack of a true placebo for nerve blocks has limited researchers’ ability to perform placebo-controlled trials, thereby restricting the concrete evidence needed for verifying the diagnostic accuracy and treatment efficacy of this procedure.1 Evidence behind thoracic interventions is also limited because they are infrequently performed. Further research is needed to establish evidence-based guidelines regarding the diagnosis and treatment of facet joint arthropathy and appropriate indications for interventions.41


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Original Version of the Topic:

Thiru M. Annaswamy, MD, MA, Kinjal Parikh, DO. Cervical and Thoracic Zygapophsial joint arthropathy. 12/28/2012.

Previous Revision(s) of the Topic:

Clifford Everett, MD, MPH, Mark Bauernfeind, MD, David Essaff, DO. Cervical and Thoracic Zygapophsial joint arthropathy. 8/17/2016.

Author Disclosure

Casey A. Murphy, MD
Nothing to Disclose

Allen Degges, MD
Nothing to Disclose