What is the recommended treatment approach for patients with facet hypertrophy of the cervical spine?

From the Guidelines

The recommended treatment approach for patients with facet hypertrophy of the cervical spine typically begins with conservative management, focusing on reducing inflammation and pain, as well as improving biomechanics through physical therapy and activity modification. Initial treatment includes non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-4 weeks to reduce inflammation and pain 1. Physical therapy focusing on cervical spine stabilization exercises, posture correction, and gentle stretching should be implemented for 6-8 weeks, with 2-3 sessions per week. Activity modification to avoid positions that exacerbate symptoms is essential. For patients with persistent pain, muscle relaxants like cyclobenzaprine (5-10mg at bedtime) may be added for short-term use (1-2 weeks).

Key Considerations

• The use of provocative injections in the cervical spine to identify a pain source is controversial, and there is no evidence to support using cervical provocative discography or anesthetic facet or nerve blocks 1.
• Imaging may not be required at the time of initial presentation in the absence of red flag symptoms, as spondylotic changes are commonly identified on radiographs and MRI in patients >30 years of age and correlate poorly with the presence of neck pain 1.
• If conservative measures fail after 6-12 weeks, interventional procedures such as facet joint injections with a combination of local anesthetic (like lidocaine 1%) and corticosteroid (such as methylprednisolone 40mg) can be considered. These injections may provide diagnostic information and therapeutic benefit. Radiofrequency ablation of the medial branch nerves might be appropriate for patients with temporary relief from diagnostic blocks. Surgery, including posterior decompression or fusion, is reserved for patients with severe symptoms, neurological deficits, or those who fail all conservative and interventional treatments.

Treatment Approach

• Conservative management is the first line of treatment, with a focus on reducing inflammation and pain, as well as improving biomechanics through physical therapy and activity modification.
• Interventional procedures and surgery are considered only if conservative measures fail, and the patient has severe symptoms, neurological deficits, or has not responded to other treatments.
• The primary goal of treatment is to improve the patient's quality of life by reducing pain and improving function, while also minimizing the risk of morbidity and mortality.

From the Research

Symptoms of Facet Hypertrophy of the Cervical Spine

• Neck pain is a common symptom, observed significantly more frequently in patients with facet hypertrophy 2
• Hypertrophic change of the facet joint usually occurs unilaterally, at the mid-level of the cervical spine, and is more frequent in males 2
• Referred pain pattern and tenderness on physical examination may indicate facet pain syndrome from osteoarthritis 3

Diagnosis of Facet Hypertrophy of the Cervical Spine

• Diagnosis is typically based on history and physical examination of the patients, combined with a diagnostic block of the medial branches innervating the joints 4
• Imaging techniques, such as CT or MRI, may be used for procedure planning, but have no additive value for diagnosing cervical facet pain 4
• Medial branch blocks are more predictive than intra-articular injections for selecting patients for cervical medial branch radiofrequency ablation 5

Treatment Approach for Facet Hypertrophy of the Cervical Spine

• Conservative management, including exercise therapy, is the first line of treatment for cervical facet pain 4
• Radiofrequency treatment of the medial branches may be considered when conservative management does not result in adequate improvement of pain, and can provide long-term analgesia 4, 6, 5
• Facet joint injection may be used to treat facet joint osteoarthritis or whiplash injury provoking referred pain, while decompression may be necessary in cases of mass effect from a facet joint cyst or hypertrophied superior articular process 3