Table 5

Studies examining history (including referral patterns) and physical examination signs for patients with cervical facetogenic pain

Author, yearPatientsDesignResultsComments
Dwyer et al 1990774 asymptomatic volunteers and 1 patient with neck pain whose cervical facet joint capsules were ‘stimulated’ using 1 mL IA contrastProspective cohort studyPain referral maps produced for C2–3 (lower head, upper neck), C3–4 (upper neck), C4–5 (well localized to mid-neck below C3–4), C5–6 (top of scapula and shoulder above the scapular spine) and C6–7 (lower neck to inferior angle of scapula) jointsPain produced by injection in 9 out of 11 joints
Aprill et al 19901310 pts with neck pain received MBB with LA and steroidProspective cohort studyConcordance between painful joint level(s) predicted based on clinical evaluation and response to diagnostic blocks4 pts had undergone anterior cervical fusions. 3 pts had negative discography results for cervical discogenic pain
Barnsley and Bogduk, 19937616 pts with chronic neck pain, with or without referred pain in the head or shoulder after MVC, received controlled MBB with LAProspective study11 of 16 pts had complete relief of neck pain with restoration of neck movements after cervical MBB; 4 of the remaining 5 pts had a positive cervical MBB at non-predicted levelsNo control group.
Levels for cervical MBB chosen based on pain maps and sites of maximal tenderness. No patient had radiculopathy. Normal imaging studies. The 25 MBB performed were highly specific
Lord et al 199475100 pts with chronic neck pain after whiplash received double diagnostic MBB with LAProspective studyC2–3 joint was responsible for headaches in 27% of pts confirmed by diagnostic TON block. Tenderness over C2–3 joint on examination predicted positive blockNo control group. C2–3 joint responsible for headaches in 53% of pts when headache was main symptom
Lord et al 19966824 pts with chronic neck pain after MVC with Quebec Task Force WAD grade I–IV selected by double diagnostic MBB with LA and placebo injection who underwent medial branch RFAProspective RCT44% of screened pts had headache and neck pain from cervical facet jointsSham medial branch RFA group included
C2–3 facet joint pain in 33% of pts
Fukui et al 19965161 pts with neck pain from the cervical facet joints confirmed by IA capsular stimulation or electrical stimulation of dorsal rami C3–7Prospective cohort studyPain region and source (joint and/or DR):
Occipital region: C2–3 and C3 DR
Upper posterolateral cervical region: C0–1, C1–2, and C2–3
Upper posterior cervical region: C2–3, C3–4, and C3 DR
Middle posterior cervical region: C3–4, C4–5, and C4 DR
Lower posterior cervical region: C4–5, C5–6, C4, and C5 DR
Suprascapular region: C4–5, C5–6, and C4 DR
Superior angle of scapula: C6–7, C6, and C7 DR
Mid-scapular region: C7/Tl and C7 DR
Jull et al 199841320 pts with neck pain who had complete pain relief with dual MBB. Assessed the diagnostic accuracy of physical examinationObservational study15 of 15 (100%) pts with cervical MBB-proven facet joint pain (and no CMBB-negative pts) were correctly identified based on physical examination. The correct segmental level was identified in all ptsInternal controls were asymptomatic joints. 100% sensitivity and specificity of physical examination to predict block response. Incidence of cervical facet joints as the cause of neck pain was 75%
Cooper et al 200749194 pts with neck pain who underwent dual comparative MBBProspective observational studySegmental patterns of pain arising from cervical facet joints identified:
Suboccipital: C1–2, C2–3
Posterolateral neck: C3–4
Neck to shoulder girdle: C4–5
Lower neck to upper limb girdle: C5–6, C6–7
Pain patterns of adjacent segments overlapped
Cohen et al 20072092 pts who underwent cervical medial branch RFARetrospective study to determine factors associated with successful RFAParaspinal tenderness associated with successful outcomeRadiation of pain to head, opioid use, and pain exacerbated by neck extension and/or rotation associated with failure
King et al 200779173 pts with suspected cervical facet joint pain based on physical examination studied with MBBObservational studyPhysical examination lacked validity, refuting results of a previous study with overlapping authors.413
Examination had a high sensitivity (88%) but low specificity (39%)
Pts with previous cervical spine surgery and those with negative physical examination signs were excluded
Smith et al 20137390 subjects with WAD >6 months duration post-MVC who received IA injections and MBB; 30 healthy controlsCross-sectional design comparing physical and psychological examination in responders and non-responders with WAD to control pts58 of 90 (64%) achieved at least 50% pain relief with IA or MBB. No difference in objective sensory testing, muscle activity or ROM between facet block responders and non-responders, but all were abnormal compared with controls. Facet non-responders had greater medication use and catastrophizing scores compared with respondersLarge proportion of participants were lost to follow-up
Schneider et al 201480125 pts with neck pain in whom a clinical examination protocol was validated against positive dual cervical MBB outcome (≥80% reduction of pain)Prospective cohort studyA protocol consisting of MSE, PST, and ER test had a specificity of 84% (95% CI 77% to 90%) and a positive likelihood ratio of 4.94 (95% CI 2.8 to 8.2) for cervical facet joints being the source of neck painSensitivity of PST and MSE were 94% (95% CI 90% to 98%) and 92% (95% CI 88% to 97%), respectively. Any single test was insufficient for diagnosis
  • DR, dorsal ramus; ER, extension rotation; ITT, intention to treat; LA, local anesthetic; LR, likelihood ratio; MBB, medial branch block; MSE, manual spinal examination; MVC, motor vehicle collision; PP, per protocol; PST, palpation for segmental tenderness; pts, patients; QTF, Quebec Task Force; RFA, radiofrequency ablation; ROM, range of motion; TON, third occipital nerve; WAD, whiplash associated disorders.