What is the recommended treatment for a patient with multilevel facet (facetal joint) arthropathy and moderate to severe right C3/4 foraminal (canal) stenosis due to spurring?

Treatment for Multilevel Cervical Facet Arthropathy with C3/4 Foraminal Stenosis

Begin with at least 6 weeks of conservative therapy including NSAIDs, physical therapy, and activity modification before considering any interventional or surgical options. 1

Initial Conservative Management

• Conservative treatment should be attempted first as most cases of cervical neck pain with radicular symptoms resolve spontaneously or with conservative measures. 1
• Conservative therapy includes NSAIDs, physical therapy, cervical traction, and activity modification for a minimum of 6 weeks. 1
• During this period, imaging findings of facet arthropathy and foraminal stenosis must be correlated with clinical symptoms, as degenerative changes are commonly seen in asymptomatic patients over 30 years of age and correlate poorly with neck pain. 1

When Conservative Treatment Fails

Diagnostic Workup

• MRI of the cervical spine is the preferred imaging modality to evaluate nerve root impingement and confirm that imaging findings correlate with clinical symptoms. 1
• CT cervical spine provides excellent definition of bony foraminal stenosis from facet or uncovertebral joint hypertrophy, though it is less sensitive than MRI for nerve root compression. 1
• CT myelography can be useful when MRI is contraindicated or findings are equivocal, as it effectively diagnoses foraminal stenosis and nerve root compression. 1

Interventional Options (Limited Evidence)

• Cervical facet joint injections have diagnostic value for identifying facet-mediated pain in properly selected patients with cervicalgia without radiculopathy, pain aggravated by extension, and facet tenderness on examination. 2
• However, facet joint injections are NOT effective as a therapeutic intervention for chronic neck pain, with studies showing only 7.7% of patients achieve complete symptom relief. 1, 3
• The American Society of Anesthesiologists notes that facet joint injections serve primarily as a diagnostic tool rather than definitive treatment. 2

Surgical Treatment - The Definitive Option

For moderate to severe C3/4 foraminal stenosis with persistent radiculopathy after failed conservative therapy, surgical decompression is the recommended treatment. 4, 5

Surgical Approach Selection:

Posterior approach (medial facetectomy/foraminotomy):

• Medial cervical facetectomy is highly effective for radiculopathy due to foraminal stenosis, preserving the lateral third to half of the facet joint to avoid instability. 4
• This approach is particularly appropriate when foraminal stenosis is caused by facet or uncovertebral joint hypertrophy. 4, 5
• Posterior foraminotomy can be performed with or without fusion depending on the degree of facet resection required. 5

Anterior approach (ACDF):

• Anterior cervical discectomy and fusion is appropriate when there is associated disc herniation or central stenosis in addition to foraminal stenosis. 5
• This approach addresses both anterior and foraminal pathology simultaneously. 5

Combined anterior/posterior approach:

• Reserved for severe multilevel disease with both central and foraminal stenosis requiring extensive decompression. 5

Surgical Outcomes

• Surgical treatment of C3/4 radiculopathy shows excellent to good results in 87% of patients (20 of 23 patients in the largest case series). 5
• The most common presenting symptom is suboccipital neck pain/headache with or without radiation to retroauricular or retro-orbital regions. 5
• Medial facetectomy provides significant benefits with preservation of stability when the lateral facet joint is maintained. 4

Critical Pitfalls to Avoid

• Do not rely on imaging alone - degenerative findings on MRI are commonly seen in asymptomatic patients and must correlate with clinical symptoms. 1
• Do not use facet injections as primary treatment - evidence shows they are ineffective therapeutically, with facet joints being the primary pain source in only 10% of patients. 1, 3
• Do not proceed to surgery without adequate conservative trial - at least 6 weeks of conservative management is required unless red flag symptoms are present (myelopathy, progressive neurological deficit). 1
• Ensure proper patient selection - high cervical radiculopathy (C3/4) can be missed clinically and requires careful correlation of symptoms with imaging findings. 5

Special Consideration for Radiofrequency Ablation

• Radiofrequency neurolysis of medial branches may provide long-term benefit for facet-mediated pain, with 85% of cervical cases showing at least 50% improvement for extended periods (average 10.8 months for excellent responders). 6
• This option should be considered after diagnostic facet blocks confirm facet-mediated pain, but only after conservative therapy has failed. 6
• However, this addresses facet arthropathy pain, not the foraminal stenosis causing radiculopathy, which requires surgical decompression. 6, 4