hartMemberOctober 13, 2011 at 6:52 amPost count: 34
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.
BTW: I finally saw a local spine surgeon.Donald Corenman, MD, DCModeratorOctober 17, 2011 at 1:26 amPost count: 8506
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. CorenmanhartMemberOctober 17, 2011 at 2:32 amPost count: 34
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.
CheershartMemberOctober 19, 2011 at 1:36 amPost count: 34
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.
CheersDonald Corenman, MD, DCModeratorOctober 19, 2011 at 9:28 pmPost count: 8506
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. CorenmanhartMemberOctober 20, 2011 at 4:51 amPost count: 34
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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