Cervical small joint pain syndrome is the most common painful disease in outpatient clinics, most of them cannot find the exact cause, and the effect of traditional conservative treatment is poor or unsustainable. 58 cases of cervical small joint pain syndrome were treated with radiofrequency denervation, and good results were obtained, which are reported as follows.
1, clinical data.
(1) General data: Among the 58 cases, 33 were male and 25 were female, the shortest duration of the disease was 3 months, the longest was 26 years, the youngest was 17 years old, the oldest was 65 years old, there were 7 cases of unilateral neck pain, 51 cases of bilateral neck pain, the clinical diagnosis was acute and chronic sprain in 6 cases, cervical strain in 12 cases, occipital neuralgia in 8 cases, interspinous ligament strain in 9 cases, cervical rib syndrome in 3 cases, small joint disorder in 9 cases, and cervical myofasciitis in 11 cases.
(2) Clinical manifestations: history of long-term low head work strain injury, or history of neck hyperflexion and hyperextension trauma, cervical tonicity, pain, and limitation of movement, some patients may have headache, dizziness, blurred vision, nystagmus, facial numbness and other head and neck syndromes.
(3) Physical signs: There are often no pressure points in the area of pain complained of, but obvious pressure points can be found on the deep bone plate about 2 cm next to the midline of the cervical spinous process associated with it, and in some patients, the myofascia there is elevated or striated, stiff with pressure pain, and pain can be induced by activities such as extension of the spinal joint and flexion of the affected side. On palpation, there may be cervical scoliosis, limited cervical stiffness and movement, and cervical joint popping on auscultation. Neurological examination is normal, such as brachial plexus pull test and squeeze test are negative.
(4) X-ray: X-ray film shows straightening of physiological flexion, reduction or disappearance of anterior cervical convexity or retroflexion, or widening of the posterior edge of the intervertebral space, and the vertebral body may be laterally displaced, and lateral film shows bilateral shadow.
(5) Diagnosis: Diagnosis can be made based on clinical manifestations, signs, x-ray and excluding inflammation, tumor, tuberculosis, disc herniation, spinal slippage and other diseases.
(6) Efficacy evaluation: excellent: pain disappears and normal work and life is resumed; good: pain is significantly reduced and basic work and life is resumed; poor: pain is not significantly reduced and daily work and life is affected.
2.Treatment methods.
(1) Fixation: Most of the pain areas on the small joints of the neck are really small joint pains. The posterior branch of the spinal nerve from c3 to c6 needs to be destroyed for neck and shoulder pain, and the posterior branch from c2 to c3 needs to be destroyed for headache.
(2) Position: The patient is placed in the healthy side, with the affected side upward, with a pad under the head to keep the neck parallel to the fluoroscopy table, and the patient’s head in a mildly hyperextended position. Align the x-ray bulb with the segment to be punctured.
(3) Puncture and radiofrequency destruction: take the posterior lateral approach to the affected side, under lateral intermittent fluoroscopy, along the posterior border of the sternocleidomastoid muscle at the level of the spinous process of the treated segment, with 1% lidocaine sufficient skin anesthesia, use a 0.8x12cm radiofrequency needle, enter the needle anteromedially until it reaches the joint column in a tangential position, rotate the c-arm 10~15°, take a left anterior oblique or right anterior oblique position for fluoroscopic observation to determine the tip of the needle reach the articular column.
The medial branch of c3~c6 should be treated by keeping the puncture needle tip anterior to the maximum anterior-posterior diameter line of the joint column and still posterior to the intervertebral foramen. c2 and c3 medial branch destruction should be performed so that the puncture needle tip is located at the posterior edge of the intervertebral foramen of c2~c3, and 3 points of destruction are taken at 1 mm intervals on the bony surface of the articular eminence of c2~c3. The puncture was successfully connected to the radiofrequency pain treatment instrument, and the stimulation parameters were set to 0.5v-50Hz,2v-2Hz, and sensory and motor nerve stimulation were performed, and the patient’s response was observed until a pain or pressure sensation consistent with the usual one was induced, and there was no motor or radicular pain in the upper limbs or face, then the puncture was confirmed to be in place.
Radiofrequency denervation was started by injecting 0.5 ml each of 2% lidocaine via the cannula respectively, and the temperature was set at 70°-30″, 75°-30″ and 80°-90″. After the radiofrequency was completed, 1mg of dexamethasone was injected into each of the cannula needles respectively.
3, Results.
A total of 58 cases were treated, including 7 cases unilaterally and 51 cases bilaterally, and the pain disappeared in 46 cases after one treatment, and 12 cases were treated twice after one week, with an excellent rate of 100% and no complications such as nerve and blood vessel injury and infection. 49 cases were followed up after 6 months, with an excellent rate of 96%.
4. Discussion.
There are many causes of cervical pain, and only 15-20% of them can find the exact cause, such as tumor, infection, rheumatism, osteoporosis, disc protrusion, spinal stenosis, fracture, etc. The majority of cervical pain cannot find a clear cause yet. Pain in the neck is often diagnosed as acute and chronic sprains, cervical strain, interspinous ligament strain, cervical rib syndrome, small joint disorder syndrome, cervical myofasciitis, etc.;
Pain in the cervical region caused by degeneration of the spine, small joint osteophytes, osteoporosis, narrowing of the cervical spine gap, or contracture of the cervical myofascia, resulting in deformation of the small joints of the cervical spine pulling, compressing, or stimulating the posterior limb of the spinal nerve, is commonly referred to as cervical small joint pain syndrome.
The traditional treatment for cervical small joint pain syndrome includes Chinese medicine massage, acupuncture, physiotherapy, local closure, nerve block, application of painkillers, etc. The treatment is simple but ineffective or not long lasting, and the more advanced treatment is the minimally invasive intervention of radiofrequency denervation of small joints. The efficacy of radiofrequency denervation in the treatment of small joint pain has been proven. Since shealy completed the first case of radiofrequency denervation, radiofrequency technology has been improved several times, making radiofrequency small joint denervation increasingly mature.
Long-term chronic injury to the posterior branch of the cervical nerve can lead to persistent spasm and fibrosis of the innervated cervical musculature. The spastic cervical musculature can cause partial or complete entrapment of the cervical nerve as well as the brachial plexus nerve, forcing the patient to adopt a forced position for a long time in order to relieve pain, and degeneration of the cervical spine and its surrounding supporting tissues often occurs later.
Because most of the painful areas on the small joints of the neck are true small joint pain, the pressure areas on the small joints of the neck deep in the paracervical region corresponding to the patient’s painful symptoms are often the posterior spinal nerve segments that require treatment. However, the localization of the small cervical joints on extracutaneous compression is not precise, and small joint pain is associated with multiple posterior spinal nerve branches, so radiofrequency treatment of the four segments from c3 to c6 is required. If accompanied by head and facial pain symptoms then the posterior branches of c2~c3 need to be destroyed.
Radiofrequency denervation has the characteristics of minimally invasive and rapid pain relief. With the electrical stimulation test function of radiofrequency instrument, the electrode needle is kept away from the motor nerve, and by adjusting the size of radiofrequency output power and setting the action temperature, the scope of destruction can be precisely controlled so that only the nociceptive fibers are destroyed and not the motor fibers, thus achieving a long-term therapeutic effect. Dexamethasone injection can reduce local edema and eliminate local sterile inflammation.
The authors adopted c-arm guided puncture, which has the advantages of easy operation, short time, little pain, high cure rate, and minimal surgical risk due to the controllable destruction area and destruction temperature, and can even be performed on outpatients.