Cervical facet joint, one of the potential sources of spinal and extremity pain, is susceptible to arthritic changes, degenerative process, inflammation, and injury and all of which will lead to painful event upon movement and restriction in range of neck motion. A definite diagnosis will help us to make sure the exact reason for the discomfort. We herein report a case with neck discomfort after surgery due to prior degeneration of cervical facet joint, rather than the operative procedure or internal fixator fixed in neck. Combination of high sensitivity of SPECT and high specificity of CT, as hybrid SPECT/CT, has been shown to obtain diagnostic accuracy in clinical practice. With the help of hybrid SPECT/CT imaging in vertebral disorders, the clinical pictures of our patient to identify facet joint arthropathy, rather than surgical procedure or implantation. The fact of unilateral facet joint erosion at C3/4 confirmed the role of prior facet pathology and a setback in the recovery upon a subsequent injury, returning to the holy tasks performed by neurosurgeon.
Chronic neck pain commonly comes across in modern health attention . Unlike the thoracic and lumbar spines, the cervical spines have distinct size and shape of vertebral components, particularly transverse and posterior processes, and facet (zygapophyseal) joints; the latter has been created as one of the potential sources of spinal and extremity pain [2,3]. Cervical facet joint is susceptible to arthritic changes, degenerative process, inflammation, and injury, and all of which will lead to painful event upon movement and restriction in range of neck motion [4-6].
In respect to consequence of neck injury due to vehicle accident or other incidents, if any discomfort remained after operation, the discomfort patients concerned was usually attributed to surgical procedure or implantation, no matter how the endeavor has been paid from the surgeons. A definite diagnosis will help us to make sure the exact reason for the discomfort. We herein report a case with neck discomfort after surgery due to prior degeneration of cervical facet joint, rather than the operative procedure or internal fixator fixed in neck.
Patient, a 50 year-old man, suffered from a vehicle accident on 21/10/2018. The accident happened when he was riding a motorcycle and hitting by a rushing car, and he lost his consciousness for 1-2 hours at that time. He was sent to our ER, where multiple injuries were noted, including fractures of orbital floor, metatarsal bones, right 4th metatarsal bone, left ulna and left distal radius, and most important, closed fracture of atlas (C1) spine, shown as Computed Tomography (CT) scan in (Figure 1a-1e). He experienced multiple operations since them. Of them was C1 posterior spinal fusion surgery. The post-OP plain films of C-spine showed the good alignment of internal fixator (Figure 2a-2d). Unexpectedly, he reported severe neck pain, tenderness and numbness over scalp and neck stiffness two weeks after operation. Besides, he mentioned right upper limb pain with numbness from shoulder, upper arm, elbow, to the back of the hand of 1-3 fingers. The pain exaggerated while he was yawning (pain score = 8).
Figure 1: CT scan of cervical spine.
Coronal section (a) Sagittal section, (b) Axial section of C1, (c) Axial section of C3, (d) 3D Reconstruction, and (e) showing obvious fracture in the C1 vertebra.
R = Right side; L = Left side.
Figure 2: Plain films of cervical spine after surgical internal fixation.
AP view (a) Lateral view, (b) Hyper-flexion view, (c) Hyper-extension view and (d) showing apparent restrict range of motion while doing hyperextension of cervical spine.
The condition has persisted for 6-7 months even after C spine surgery, and became worsen leading to poor sleep. He came to our OPD for help, and showed the exact painful location (Figure 3). Physical examination showed limited neck ROM at every direction, decreased muscle power over right upper limb, and decreased right-sided DTR. C-Spine MRI performed on 06/04/2019 only revealed herniation of intervertebral discs, C3-4, C4-5, C5-6, and C6-7. Bone scan with hybrid images was suggested and performed on 25/02/2019 disclosing increased bone turnover located at right C3/4 facet joint (Figure 4). Instead, there was no any increased uptake found in C1 and operated area. Patient received the fact that the painful discomfort came from his prior old C3/4 arthropathy, rather than the surgical procedure or metallic implantation.
Figure 3: The significant tender point in the right-sided neck pointed out by left middle finger tip of our case.
Figure 4: Images of bone scan of the case.
Image of whole body bone scan seen from behind (a) SPECT/CT images (b) Coronal section (upper panels X 3), Sagittal section (middle panels X 3), and axial section (lower panels X 3).
An increased uptake in the C3/C4 facet joint can be seen on the right side compared to the corresponding location on the left side.
R = right side; L = left side.
Under the diagnosis of unilateral facet joint arthropathy in C3/4, patient agreed to allow us to treat him by using blocking the medial branches of the dorsal ramus of the spinal nerves under local anesthetic. He was lying in a lateral position on the injection table with a pillow was placed under his head. The exact position of the injection was marked, and a 22 gauge needle was forwarded under sonographic guide until it contact to the facet joint capsule. When the needle was in the proper position, the steroid was injected. No allergic reactions or cardiovascular abnormalities took place, and neurological examination was normal. The relevant injections provided significant pain relief, and the painful restriction improved much after the twice pain-killing procedures. Patient refused to have the identical hybrid images for follow-up.