Cervical Degenerative Facet Disease

Cervical Degenerative Facet Disease Overview

The cervical facets differ from the lumbar facets in many ways. First, the lumbar facets carry less than 10% of the entire weight of the lower back but the cervical facets, because of their larger size; carry over 30% of the cervical spine weight. The facet’s larger surface area and greater weight carrying capacity cause these facets to be subjected to greater forces. These forces can cause destructive wear and tear and result in typical arthritis.

Anatomy

The facets are a true diarthrodial joints. This means the facet is really a classic joint that we think of like a knee, hip or shoulder joint. This joint complex consists of two smooth bony surfaces each covered with a very slippery coating called hyaline cartilage where they touch. The joint itself is held together with a tough fibrous outer sack called the capsule. The capsule literally pulls the joint surfaces together and prevents extreme motion by acting like a checkrein ligament. The inside of the capsule is lined with a slim layer of cells called the synovium. These cells produce a very thin, slippery liquid called synovial fluid, which lubricates these joints.

If a pressure transducer probe is inserted into any diarthrodial joint, you would find that the joint itself is under negative pressure or suction. This negative pressure is one of the protective forces that hold the joint together. This is not dissimilar to the suction that holds the bottom of a wet glass onto a glass coffee table. Removing the glass takes some force to break the vacuum between the table and the glass. When the glass finally releases, a slight “pop” is heard when the suction bond is broken. This is the same pop that is produced with a chiropractic adjustment.

Abnormal wear of the cartilaginous surfaces can occur under many circumstances. Degenerative disc disease can cause abnormal motion to the facets. Injury to the ligaments that hold the joint together (including the capsule) causes abnormal wear. Simple genetics can cause wear of the facets. This wear destroys the suction bond that holds the joint together.

Facet Function

Mechanically, the intact facet has three purposes. The first purpose is to guide the spine in specific directions of motion. Facets, depending upon how they are anatomically angled, allow flexion/extension, lateral bending and rotation. These joints also demonstrate coupled motions. That is, strict lateral bending will also cause rotation of the vertebra.

The second purpose of the facet is to bear weight. Approximately 30% of the weight of the head is transmitted into the shoulders through the facets (the other 70% is transmitted through the discs). The amount of weight bearing percentage changes with bending the head forwards vs. backwards and side to side. Backwards bending (extension) produces increased load and therefore pressure to be placed on the facets. Patients with facet pain normally will have increased neck pain with this motion.

The last function of the bilateral facets is that of a doorstop. The upper facets are angled backwards and “hook into” the lower facets of the vertebra below. This link prevents the upper vertebra from sliding forward on the lower vertebra (I like to call this the doorstop mechanism). When the facets wear out, this link is broken and the upper vertebra can abnormally slide forward on the lower vertebra (degenerative spondylolisthesis or anterolisthesis). This shifting can be painless or produce instability pain along with possible nerve and spinal cord impingement.

(Click to Enlarge Image) Lateral X-Ray of the neck with a forward bend (flexion). Note the vertebra slipping forward. The black arrows point to the forward slide and forward angulation of the vertebra.

(Click to Enlarge Image) This patient developed unilateral (one-sided) arthritis of the facet of C1-2. Black arrow points to the arthritic facet and the white arrow points to the normal facet. She has pain with rotation of the head and rotation is limited. This X-ray is called an open mouth odontoid as it is taken through an open mouth to visualize the C1-2 facet joints.

(Click to Enlarge Image) This view shows the opposite side view of mild degenerative facet disease. The large arrow points to the degenerative facet and the small arrow to a normal facet.

Are you suffering from symptoms of cervical degenerative facet disease?

Would you like to consult with Dr. Corenman about your condition?
You can set up a long distance consultation to discuss your
current X-rays and/or MRIs for a clinical case review.

REQUEST A SECOND OPINION

(Please keep reading below for more information on this condition.)

Symptoms of Cervical Degenerative Facet Disease

Facet degeneration or arthrosis causes four potential symptoms; neck pain, headaches, arm pain from foraminal stenosis (compression of the nerve root) and instability pain (degenerative spondylolysthesis with potential spinal cord compression).

Local neck pain is probably the most common symptom of facet pain. When the cartilaginous surfaces wear off and bone to bone contact is the result, deep dull local bone ache is common. Sharp pain with movement occurs when neck motion overloads these surfaces. Stiffness and joint noises (clicking and popping) typically occur. This pain can radiate into the shoulders.

The upper cervical joints (C2-3 and C3-4) can cause headaches along with local pain due to their proximity to two particular nerves; the greater occipital nerve-C2 and the lesser occipital nerve- C3 (AKA greater auricular nerve). The greater occipital nerve originates from C2 and radiates up over the skull to end at the forehead. The lesser occipital nerve originates from C3 and radiates around the ear to the temple. These two nerves can cause suboccipital headaches (headaches that originate from the base of the skull and radiate to their respective terminus). Interestingly, the C2-3 and C3-4 facets do not have to have significant degenerative appearances on MRI or CT scan to cause this type of pain.

Facets develop bone spurs when they become arthritic. These bone spurs can grow into the foramen and compress the spinal nerve (pinched nerves). This in turn will cause pain that radiates down the distribution of the nerve. Each nerve has a specific route of pain that will be produced. If the C3 nerve is involved, pain will radiate from the base of the skull around the ear and terminate at the temple. If the C7 nerve is involved, pain will radiate from the shoulder into the middle of the hand. This condition is covered more thoroughly in the foraminal stenosis section on this website.

Many times, arthritic facets will not be painful even with advanced arthritis. However, the wear of the facets will allow some increased play in the “doorstop mechanism”. This sloppiness can allow a forward slip of one vertebra on the other and will increase the strain on the disc. This, in turn can lead to annular tears of the disc, which then starts the degenerative cascade of degenerative disc disease. In addition, the wear of the facets can allow a forward slip of the vertebra above on the vertebra below leading to a degenerative spondylolisthesis. This shifting can cause local neck instability pain or can cause intermittent compression of the nerve roots or even spinal cord compression.

Treatment of Cervical Degenerative Facet Disease

Treatment of facet disease depends upon the symptoms, the biomechanics and the source of pain. There are many individuals that have facet disease without pain. The reason for the lack of pain in some individuals while others have incapacitating pain is a Nobel Prize winning answer.

Simple facet pain responds to many therapies including chiropractic, physical therapy, massage and even acupuncture. For more advanced pain that fails these treatments, injection therapy in the form of facet blocks or medial branch blocks (see website under injections for more information) can be effective.

Rhizolysis (the burning of the small sensory nerves that innervate the joint through a small needle) can be very effective in the right hands under the right circumstances.

Finally, surgery can be very effective. If a pinched nerve develops from facet arthritis, a posterior foraminotomy can be effective (as long as there is also no anterior bone spur off the uncovertebral joint). For instability from a degenerative spondylolisthesis or from severe pain due to a very arthritic facet, fusion is required. Artificial discs will not work in this circumstance.

To discuss cervical degenerative facet disease in more detail, please contact the office of Dr. Donald Corenman, spine specialist and neck doctor offering diagnostic and surgical second opinions to patients in the USA and around the world.

Related Content

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Submit your review
First Name, Last Initial:
Email:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel

Cervical Degenerative Facet Disease