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  • kristina76
    Participant
    Post count: 8

    Hi Dr. Corenman,

    I have a very complicated cervical pain problem and would love some advice. I’m a Physical Therapist and have had chronic neck/thoracic pain for about 15 years but have always managed it with exercise/massage,etc..

    About 9 months ago, it spiraled out of control. I have severe muscle spasms, pinched nerve pain at left C2 and C3 with stabbing headaches, cracking, and any minimal use of my arms causes neck pain and spasms, especially on the left side of my neck. I’ve tried every treatment under the sun with no relief. All kinds of diagnostics as well. MRI shows moderate left foraminal narrowing at C3 and small disc herniation with no cord compression at C4. I am currently pursuing injections. Here are my questions:

    1. I can palpate lateral left C3 vertebra which gives a nerve-like pain and there are spasms in this region. I get stabbing head pain that originates from this area. Turning my head to the left is difficult, sleeping makes the pain worse due to pressure on my neck. Its a debilitating pain. Does this sound more like C3 nerve compression from the foramenal narrowing or facet pain? Pain meds hardly even help.

    2. I have pain/spasms on the left side of my neck with even the lightest lifting or use of my left arm. I used to think there was some instability (which may still be true) but could the C3 foramenal narrowing or facet involvement cause this kind of severe limitation with use of my arms going right to the left side of my neck? Have you ever heard of this complaint? This symptom is very hard to function with and has pretty much disabled me.

    3. If the pain generator is more from the C3 nerve compression at the foramen, would they ever perform a foraminotomy due to the severe pain and radiating into the head? I know the indicator for surgery is usually more arm pain, but the C3 nerve doesn’t go down the arm. Wouldn’t relieving pressure on the nerve still help the localized nerve pain to palpation at left C3 vertebra?

    Thank you so much for your time!

    Kristina

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    Your symptoms sound more like facet syndrome of C2-3 and C3-4. The reason it is called a syndrome is that you can prove facet dysfunction causing the symptoms by elimination of the symptoms through facet blocks (injections) but you cannot identify the disorder by imaging (X-rays and MRI). Now, you can identify (sometimes) degenerative facet disease by X-rays and MRIs but many individuals with facet degeneration do not have your symptoms and some with symptoms have no identifiable facet disease.

    Diagnosis is by history, physical examination and injection studies. Your symptoms seem to fit and you can palpate and reproduce symptoms with deep facet pressure, the physical examination test.

    Lifting of the left arm is facilitated through the levator scapulae muscle which inserts in this neck region and can aggravate the symptoms but shoulder disorders can also do this. You must rule out tendinitis or tear of the rotator cuff before the diagnosis can be fully made.

    The diagnosis is made by facet block (see website for pain diary) and treatment is by rhizotomy (neurolysis of the medial branch of the posterior fascicle- see website). Generally, surgery is rarely needed.

    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.
    kristina76
    Participant
    Post count: 8

    Hi Dr. Corenman,

    Thank you so much for your thorough reply. As time goes on, I feel my symptoms point more and more to facet syndrome at C2-3, C3-4. I am scheduled for facet injections next week.

    My only concern is when I palpate near the C3 facet joint, the pain is nerve-like, kind of like pushing on a toothache. And the pain I have from this area going into my head is stabbing in nature. The area is so hyper sensitive that I have pain with any small movement of my arms or even if I push down on a stationary bike with my legs, I will feel that area in my neck.

    My theory is that the nerves surrounding the facet joint are irritated due to the swollen facet, or the medial branch itself is getting pinched at the joint. Because the nerves are inflamed, any contraction of my neck muscles to stabilize my arms or legs is pulling on the inflamed facets/nerves in the region.

    Have you seen people with cervical facet syndrome with these type of nerve complaints? The nerve symptoms are what concern me the most as they are hard to pinpoint, treat, don’t respond to pain meds, and cause a lot of pain.

    My MRI does not show much degeneration or disc problems, so I am hoping the facet is inflamed, not permanently damaged, and that facet injections may calm the area enough for me to be able to restore normal joint mobility in my cervical spine with treatment and stop the irritation. (I think faulty joint motion that I am currently treating may have cause excessive stress to C2-3 facets) I don’t believe there is nerve entrapment due to scar tissue because I have already treated and addressed that and still have the pain.

    What are your thoughts about the nerve irritation and prognosis of pain relief with injections? I’m concerned about the whole chronic pain cycle that can be started and is hard to reverse. I think the problem has been building over time, but only this bad for about 10 months.

    Thank you so much for all your help! I wish more Doctors were like you.

    Kristina

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    Your observations are spot on. The medial branches of the facets are painful and palpation will reveal the types of pain you experience.

    Don’t worry too much regarding the chronic pain cycle starting up. Most patients when treated for the pain generator will not have continuing pain.

    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.
    kristina76
    Participant
    Post count: 8

    Hi Dr. Corenman,

    I had contacted you a while back regarding C2-3, C3-4 facet pain. I had received some pain relief with my second cortisone injection, though not complete relief, so this tells me that at least some of my pain is facet related.

    I am currently considering the ablation procedure and had a few questions for you.

    1. I have heard that the C2-3 facet is a more risky area for ablation, and that it doesn’t have as high a success rate due to involvement of the occipital nerve. Do you find this to be true in your experience?

    2. I am a PT and given my anatomy training, I am concerned about nerve damage/worsening pain from the ablation. I know this is rare, but can you give me a ballpark idea of how frequently this occurs? I have heard some people get great relief, and others where it seems like a horror story of worsening nerve pain after the ablation.

    3. I also have researched pulsed radiofrequency ablation, where the nerves are stunned instead of burned. This seems like a safer option, but not many doctors in Mass. do this and I have also heard people may not get as good pain relief. What are your thoughts?

    4. And finally, I have also read that Cat Scans are best for getting a better view of the facets. I have had multiple x-rays and MRI’s which show some degeneration in the facets, but not bad. I was wondering if it would be beneficial to get a Cat Scan to rule out any bone spurs around the facet joints? I just don’t want to expose myself to extra radiation if it’s not necessary since I’ve had so many tests.

    If you don’t mind taking a few minutes to answer these questions, I would greatly appreciate it. I just can’t deal with this nerve pain anymore!!

    Thank you,

    Kristina Jaeckel

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    Facet rhizotomies are relatively safe but this really depends upon the experience and care of the treating physician. C2-3 and C3-4 facets are the most common of all the facet treatments I order.

    Ablation depends upon normal anatomy. The “burn zone” from the treatment probe in my understanding is about 3-4 mm. If the nerve is not in a normal anatomic position, the burn zone may “miss” the nerve. If the nerve is in the outside edge of the zone where a partial burn occurs, this could theoretically damage the nerve without fully destroying it.

    In my experience, this procedure works about 75% of the time. There are a small subset of patients that become worse but normally, the flair-up of symptoms resolve in about three months. About 30% of patients need a repeat rhizotomy after about one year due to the nerves attempt to grow back.

    Pulsed ablation in my understanding is more common in the thoracic spine where the medial branch nerves are much closer to the origins of the roots and there is some increased concern of injury. In my experience, pulsed frequency is less effective.

    Cat scans may not be necessary in the case of facet originated pain. Sometimes, the facets may not look too degenerated but still will cause pain. Using the X-rays, MRI and a good physical examination should reveal facet mediated pain in the majority of cases. There are circumstances that CT scan is valuable but less than you might think.

    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.
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