Cervical Zygapophysial Joint Precision Treatment

This article is a stub.

This article deals with the treatment of cervical facet (zygapophyseal) joint pain when diagnosed by a precision diagnosis technique, in contrast to so-called “non-specific neck pain.” In New Zealand the precision diagnosis is usually made by two positive single-blind concordant medial branch blocks with a pain reduction of >80%. In this setting, radiofrequency neurotomy of the cervical medial branches has good evidence.[Level 2]

A variety of radiofrequency procedures have been described for the treatment of proven facet joint pain, including conventional thermal radiofrequency neurotomy, pulsed radiofrequency, and cooled radiofrequency. In New Zealand, conventional thermal radiofrequency neurotomy (with a parallel technique) is typically used for cervical facet pain. Cooled radiofrequency neurotomy is an alternative with comparable outcomes, and emerging variations include joint-capsule–targeted approaches. Health insurers in New Zealand generally fund cervical medial branch blocks and radiofrequency neurotomy. ACC may support coverage if there is clear evidence of causation.

Fusion Surgery

There are no robust RCTs supporting cervical fusion specifically for proven facet joint pain; therefore, it remains a non-evidence–based option in this scenario. Fusion has negative RCT evidence in broader “non-specific” spinal pain, but not specifically in precisely diagnosed cervical facet pain.

Facet Joint Innervation

Each cervical facet joint from C3/4 and below is innervated by the medial branches of the dorsal rami at that level by the level below. For example the C5/6 facet joint is innervated by the C5 and C6 medial branches. The third occipital nerve (the superficial medial branch of C3) supplies the C2-3 joint. Consequently:

• The C3 dorsal ramus provides innervation to the C2-3 facet (via the “third occipital nerve”).
• Each facet joint typically receives dual innervation from two separate medial branches.
• To achieve complete denervation of a single facet joint, two adjacent medial branches may require treatment.

Intraarticular Injections

There is scant and inconclusive evidence for intraarticular steroid injections in the cervical facet joints. Studies that do exist are either methodologically weak or show no long-term benefit. The 2020 Engel review did not find high-quality controlled trials supporting intraarticular injections for cervical facet pain relief.

Therapeutic Medial Branch Blocks

In the US medial branch blocks are occasionally repeated for short-term relief in patients unsuitable or unwilling to proceed to radiofrequency neurotomy. However this is not standard practice in New Zealand and is unlikely to be supported by funding providers. As with lumbar procedures, the mechanism of extended benefit remains speculative and may involve temporary inhibition of nociceptive input, blockade of local inflammatory mediators, or interruption of sympathetic reflex arcs. However, repeated blocks alone are not considered curative.

Radiofrequency Neurotomy Procedures

Radiofrequency neurotomy (RFN) for cervical facet (zygapophyseal) joint pain has multiple RCTs and observational studies with varied outcomes depending on the selection criteria and the exact technique used.

Despite some controversies—e.g. operator dependence, needle orientation (parallel vs perpendicular), lesion size, and how many lesions per level—data consistently show that the most crucial factor for success is proper patient selection by diagnostic blocks that confirm the facet joint is the actual source of pain.

Systematic reviews differ in their conclusions because they often lump together data from studies using different selection criteria (e.g. one positive block vs. two blocks; 50% relief vs. complete relief). However, multiple analyses confirm that if patients are selected via two comparative cervical medial branch blocks each producing nearly 100% temporary pain relief, radiofrequency neurotomy has substantially higher success rates (often 50–70% with complete relief at six months) compared to weaker or single-block criteria.

Selection by Comparative Medial Branch Blocks

Studies indicate that two positive comparative blocks (e.g. lidocaine vs. bupivacaine) with 100% pain relief confer the highest chance of success. Pooled data in systematic reviews show around a 60% chance (or higher) of achieving complete pain relief at six months, with repeated neurotomy often prolonging relief for one to two years.

Selection by Single Medial Branch Block

Using just one block, or accepting <100% relief as “positive,” introduces a higher risk of false positives. Consequently, the success rates for radiofrequency neurotomy tend to be lower. Some authors still report moderate benefit (e.g. 30–40% with ≥50% relief), but complete relief outcomes typically drop significantly.

Clinical Features Alone

No clinical sign, symptom, or exam finding has been validated to reliably identify cervical facet joint pain without confirmatory blocks. Trials that selected patients purely by “neck pain” or “cervicogenic headache” features without blocks have generally shown outcomes equivalent to placebo or sham procedures.

Cervicogenic Headache

Radiofrequency neurotomy can also treat headaches arising from the upper cervical facets, especially the C2-3 facet mediated via the third occipital nerve. As with lower cervical levels, confirmatory diagnostic blocks are essential. When carefully selected (e.g. two positive comparative blocks producing complete headache resolution), approximately 60–70% of patients may achieve near-complete or total relief for 6–12 months. Repeated treatments can restore these effects if headaches recur with nerve regrowth.

Bottom Line

• Radiofrequency neurotomy of the cervical medial branches has Level 2 evidence[Level 2] if patients are selected by precise diagnostic blocks showing >80–100% relief.
• Single-block or purely clinical “diagnoses” have higher false-positive rates, leading to lower RFN success.
• Proper technique (parallel needle placement, adequate lesion size) and thorough follow-up are critical for good outcomes.
• If/when pain returns, repeat neurotomy can reinstate relief in most cases.

Resources

Cervical medial branch radiofrequency neurotomy systematic review - Engel 2020.pdf - 353 KB (f)

Literature Review

Literature Review

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