Cervical Facet Syndrome?

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hart
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October 13, 2011 at 6:52 am

Post count: 34

#4993

Hi Dr. Corenman:

Thanks for all the insight re: T-spine herniation. I think things are going pretty nicely with the T-spine.

I have a new problem now. 6 week history of occipital headache, pain and limited ROM on rotation and lateral flexion of neck. No specific trauma. I have none of the typical red flag signs/symptoms. I think this pain may be at the C2-C3 facet joint bilaterally. (I have had some help in figuring this out from my physio.) I got this MRI yesterday. The study was read as normal except for a small disc protrusion at C5-C6.

I am not sure the best way to communicate these studies. I tried the youtube method. The quality does not look very good.

I am reading about Cervical Facet Syndrome. There is some good information here!

Whatever this is, it REALLY hurts.

Cheers

BTW: I finally saw a local spine surgeon.

Donald Corenman, MD, DC
Moderator

October 17, 2011 at 1:26 am

Post count: 8660

#4999

Sub-occipital headaches can originate from the C2-3 and C3-4 facets. Physical therapy and chiropractic manipulation can be helpful to control these headaches. With such a short period of time you have had these, especially without trauma, most likely they will go away. Treatment can hasten their disappearance.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

hart
Member

October 17, 2011 at 2:32 am

Post count: 34

#5006

Dr. Corenman:

I am pretty sure this is at C2-C3 (vs. C3-C4). I now have some pins and needles in the C2-C3 distribution after my PT sessions and at other times.

This problem started about 6 weeks ago. After about 2 weeks, I couldn’t turn my head enough to drive safely. After trying the other usual stuff, I had a few days of prednisone (from an emergency stash) — 20mg/day (BW~50kg). The result was marked — even after just a day. I continued 20mg for 5 days and then 10mg for another 5 days. After a couple days, my range of motion and my pain had dramatically improved. I completed this trial of steroids about 2.5 weeks ago.

This seems to be a bit of synovitis if you ask me. But no signs of inflammation on MRI — not even a little bit of edema? Is the C2-C3 facet joint adequately imaged in the typical C-spine MRI views? Would one expect MRI findings if there was synovitis of 6 week duration? (I do vaguely remember seeing a physio back in Australia maybe 5 years ago for an annoying problem — probably soreness/stiffness on rotation — which she told me was at C2-C3. I went to physio a couple times a week for a few weeks and it got better. I didn’t need any tablets for pain. This time around is a different story!)

While no one really LIKES to use prednisone (including the person taking it), what type of doses do you prescribe for these sorts of things? I read of high doses (60-80 mg) with taper being used. I get the feeling, the practice I have been going to passes out dose packs in the physiologic dose range. That is quite a variation in prescribing habits!

Do you have anything to say about injections for this problem? Risk vs. benefit.

BTW, I go to physio 4 times a week. I think the “manipulation” might be stirring things up a bit. I have been laying off that and doing pilates sessions with a different physio in the office instead this last week. My physio (the same guy who helped me with T spine for months) is brilliant but I just feel like the current treatments are fueling the inflammation.

Cheers

hart
Member

October 19, 2011 at 1:36 am

Post count: 34

#5013

Dear Dr. Corenman:

I had my second appointment for this problem. An MRI was ordered during the first appointment and the purpose of the second appointment was “to review the MRI”. There were no findings on MRI consistent with the complaint. (There is an incidental disc protrusion at C5-C6.) From what I can find, it does NOT sound like the cervical facet joints are generally well imaged on an MRI, the oblique X-ray or CT possibly being better exams. I have a feeling that the lack of findings on MRI does not reasonably rule out facet joint pathology. Office X-rays were done but no oblique view.

A referral to “Pain Management” was made. This must be a dumping ground for patients who ask too many questions!

I appreciate your reassurance! This is VERY helpful! I think this may be resolving! It was a difficult episode of almost 6 weeks duration. I would like to understand what this is and why it happened in hopes of avoiding recurrence.

Cheers

Donald Corenman, MD, DC
Moderator

October 19, 2011 at 9:28 pm

Post count: 8660

#5020

MRIs famously do not typically reveal facet syndrome. The imaging quality of the MRI does not have enough resolution to reveal the microscopic inflammation that causes the pain.

Pain management physicians come from different backgrounds. Some are excellent in diagnosis and interventional treatment and some try to control pain with whatever means at their disposal.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

hart
Member

October 20, 2011 at 4:51 am

Post count: 34

#5026

Hi Dr. Corenman:

I hit the prednisone again. 20mg yesterday morning. This morning, true pain is all but gone. My neck is sore but that I can deal with. Rotation and more so lateral flexion are still limited. I had another 20mg of prednisone today. Maybe a couple more days of 10mg. Obviously, prednisone is not good for the back in the long run!

So pain can be quite easily controlled in this instance. I want to understand why I have this problem and how to avoid future occurrences. IOW, I would like to figure out if there is something in my movements, my habits that I can change. Is this problem usually just insidious as in comes and goes with no rhyme or reason? I never really thought twice about facet joints until now. Seems they are pesky little things.

The pain management doctor recommended in this instance is an anesthesiologist by training. I have a suspicion that there may be (a small number perhaps) surgeons out there who do not want to prescribe medications or otherwise treat pain when there is no operation at stake. They would rather just get you off their hands pronto. I have great respect for the pain management field. However, I don’t think this is an especially difficult case in regard to pain per se. I am aware of a diagnostic study, sometimes done by pain management physicians (including this one), that involves injection of a local anesthetic agent and steroid into joint space. The pathology or source of pain at least is presumed to be in the facet joint if the patient reports improvement after the injection? Is this procedure simply diagnostic or does it typically help with the pain/soreness/ROM for any meaningful period of time? From the information I am able to obtain, this exercise sounds a bit sketchy. It seems structures are pretty tight in there — what are the chances of hitting the target while avoiding other structures? I feel certain the pain is at the C2-C3 facet joints bilaterally. It is “joint pain” for sure.

A non-contrast standard C-spine MRI series has been done. Do you see any benefit in further imaging the facet joints by oblique plain film or CT scan. Of course, one must consider the radiation of the head CT in weighing the benefits. What is one likely to find if anything? What can be REASONABLY be done about it anyway? It sounds like some are resorting to seemingly drastic measures. I am NOT interested in fusing C2-C3

There is one more little tidbit on MRI that should probably mentioned at the outset: flattening of the normal cervical lordosis. Clinically, I have also been told that I lack the normal thoracic kyphosis.I don’t believe this has been reported on any radiologic studies though. If one is to believe the spine is curved for a good reason, this can’t exactly be a good thing. Would straightening of the cervical lordosis possibly be a factor in cervical facet problems. Could this affect facet joint alignment (there is probably a better word!)?

Is there anything I can do in terms of exercises or therapy to get curves or at least to maintain the existing curvature. Are McKenzie retraction and extension exercises likely to be useful (or at least harmless) in the setting of presumed (by me) cervical facet pain at C2-C3? The retraction feels good to me but the extension not so good! There are no symptoms of spinal nerve root compression and no findings on MRI suggestive of nerve root compression…or anything else at this level ;)

Thank you so much for you assurances and meaningful responses,

PS. How do I find a chiropractor? This is new territory for me!
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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.

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