Persistent neck pain – what hurts and where?
Persistent neck pain – what hurts and where?
David Evans, Honorary Research Fellow, The British School of Osteopathy, UK
People with neck pain often visit osteopaths for treatment. In approximately half of those with persistent symptoms, it is likely that the source of pain is one or more cervical zygapophysial joint.1–4 Knowing the source of pain helps clinicians select and direct an appropriate treatment. Unfortunately, there is no non-invasive clinical test that is able to accurately diagnose pain arising from zygapophysial joints. The gold standard for diagnosing pain from these structures is the response to fluoroscopic imaging-controlled, local anaesthetic injections that block conduction of the medial branches of the cervical dorsal rami, which innervate the putatively painful joint or joints. Obviously, this is not an approach used diagnostically by many osteopaths.
An alternative approach to improve the likelihood of correctly diagnosing pain emanating from zygapophysial joints is to establish recognisable spatial patterns (or maps) of pain known to be emanating from certain zygapophysial joints. In pursuit of this goal, a small number of studies5–7 have used several methods, primarily evoking pain in the zygapophysial joints of healthy volunteers. However, none have provided a comprehensive map of the distribution and prevalence of zygapophysial joint pain in real neck pain patients at particular cervical segments, as was the case in a recent study by Cooper et al.8
Cooper et al. conducted a study in a hospital clinic specialising in spinal pain, with patients referred from general practitioners and specialists. The study sample consisted of 194 patients with persistent (>6 months) neck pain, seen between January 1999 and October 2003, in whom cervical zygapophysial joint pain was being investigated. To begin with, each patient drew the location of their symptoms on a standardised template picture of the upper trunk, shoulders, and head. A diagnostic anaesthetic ‘block’ was then performed at a segmental level, close to the location of pain, as selected by the physician who performed the block.
Strict criteria were used to define a positive or negative response to the diagnostic block. A negative response was defined as no relief of pain. A positive response was defined as either complete relief of all pain, or complete relief in a definable portion of the patient’s area of pain, such as complete relief in the upper or lower half of the area, although not in the remaining area. Reduction in intensity of pain, but without complete relief in any topographical region, was not accepted as a positive response. For a particular joint to be classed as symptomatic, the patient had to obtain complete relief of pain whenever that joint was anesthetised, and provided that they obtained short-lasting relief (typically 1–2 h) when a short-acting agent was used (lignocaine 2%), and long-lasting relief (typically 2–5 h or longer) when a long-acting agent (0.5% bupivacaine) was used.
Patients with pain at consecutive segmental levels had to obtain complete relief of the upper half of their pain when the upper of two consecutive joints was blocked, complete relief of the lower half of their pain when the lower joint was blocked, and complete relief of all of their pain when both joints were blocked. Patients who had upper neck pain with headache, as well as lower neck pain, had to obtain complete relief of their upper neck pain and headache when an upper joint was blocked, and complete relief of their lower neck pain when a lower joint was blocked. In all instances, the responses at each level had to be corroborated by controlled blocks. In patients with bilateral pain, each side was investigated separately, on a different occasion, following the same protocol as that used for unilateral pain. Responses for each side were recorded and analysed separately, unless the diagnostic block relieved contralateral pain. If the block was negative, testing was terminated, or initiated at another segmental level that might reasonably have been responsible for the pain. In this manner blocks were continued until all possible levels that might reasonably have been the source of pain proved negative or until a positive response was encountered. If a positive response was encountered, that level was again tested on a subsequent occasion, once the patient’s pain had returned, and no earlier than 1 week later. The response was tested and verified using comparative local anaesthetic blocks. Blocks were performed on a double blind basis such that neither the patient nor the assessing nurse knew the agent used.
In total, 347 diagnostic blocks were performed on these patients (163 on the left side and 184 on the right). One hundred and thirty-four patients (69% of total) had at least one symptomatic zygapophysial joint, and 186 blocks (54% of total) were positive. The most striking finding was the relative prevalence of pain arising in certain segmental levels. The level most commonly found to be symptomatic was C2–3 (36%), followed by C5–6 (35%), and then C6–7 (17%). Joints at C3–4, C4–5, and C1–2 were each symptomatic in less than 5% of cases. Of the patients with zygapophysial joint pain, 52% had only 1 symptomatic joint. In the remainder, multiple symptomatic joints occurred in various combinations. These included both zygapophysial joints of the same segment (e.g., C2–3 or C5–6), consecutive joints on the same side (e.g., C5–6 and C6–7), non-consecutive joints on the same side (C5–6 and C2–3), and other combinations of these patterns. Rarely were C3–4 and C4–5 symptomatic alone. Most often they were symptomatic together with an adjacent joint.
As well as these prevalence data, the study also produced maps of the typical location of pain that arises from a particular segment, which will certainly be of use to many osteopaths. In summary: pain from C1–2 and C2–3 tends to arise in the suboccipital region; that of C3–4 encompasses the posterolateral neck, overlying levator scapulae; pain from C4 to C5 is nestled into the angle between the neck and the shoulder girdle; and, pain from C5–6 and C6–7 occurs over the lower neck and spreads into the upper limb girdle. These findings from real patients with persistent neck pain patients were broadly similar to those produced using pain induced in healthy volunteers.5–7 However, there were some subtle differences. The neck pain patients depicted pain that was less neatly distributed.
References
1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995;20:20–6.
2. Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: A placebo-controlled prevalence study. Spine 1996;21:1737–45.
3. Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001;174:174–6.
4. Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002;5:243–9.
5. Dwyer A, Aprill C, Bogduk N. Cervical zygapophysial joint pain patterns I: A study in normal volunteers. Spine 1990;15:453–7.
6. Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain 1996;68:79–83.
7. Windsor RE, Nagula D, Storm SA, Verton A, Jahnke S. Electrical stimulation induced cervical medial branch referral patterns. Pain Physician 2003;6:411–8.
8. Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med 2007;8:344–53.
International Journal of Osteopathic Medicine
Volume 11, Issue 3, September 2008, Pages 114-119
