Pain, 56 (1958) 79-85 = (©1506 tnemationa Associaton forthe Stay of Pain. 0364-3989 96/1500, PAIN 3173 Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami Sei Fukuis*, Kiyoshige Ohseto', Masahiro Shiotani*, Kenji Ohno, Hidetake Karasawa", Yoshikazu Naganumat and Yasumasa Yuda? "Pain Cini. Kanto Techn Hospi, Tokyo Lapa Deparment of Anesthesiology, Hiei Univerty Schoo of Medicine Sikes Japan) and Departmen of Aethrils, Hannan Cental Hospi, 3-28 Miramishinmach. Moibara. Osaka S80 (Japan) (Received 19 February 199, revised weion ceived 25 Apel 1996, eceped 1 May 1996) Summary The purpose ofthis study was to determine the distribution of refered pain from the cevieal2ygapophyseal joints (CAN to CATH and the cervical dorsal rami (C3 40 C7). The subjects were 61 patients who had occipital neck, and shoulder pain of suspected =ygapophyseal origin in whom pain was reproduced by injection of contrat medium into the joints or by electrical simulation of the dor Sal rami. Under Muoroscopic contol, the zyzapophyseal oins from COMI to C7/TAl were stimulated bythe injection of corrast medio and while electrical stimulation of the cervical 2ygapophysea dorsal rami at segments C3 1 C7 was performed during facet denervation. IF injection or electrical stimulation reproduced the patient's usual pain, te distribution of ceferred pain was determined andthe sites of re fevred puin were divided into 10 areas, otal of 181 joints and 62 segments were stidied, Each joint and dorsal ramus produced refered prin witha characteristic distribution The main distribution of refered pain was as follows. Pain in the occipital region was refered from (C2/3 and C3, while pain in the upper posterolateral cerviel region wae refered from COV1, C1/2, and C2F3. Pain inthe upper posterior cervical region was refered from €2/3, C4, and C3, tht in the middle posterior cervical region from C4, C45, and C4, and that nthe Tower posterior cervieal region from C45, C516, C&, and C5. In adiion, pin inthe suprascapular region was refered from CAS, CSI6 and Chat nthe superior angle ofthe scapula from C57, C6, and C7 and that inthe mi-scapuar region rom CT/ThI and C7 Key words: Zygapoptyseal pain; Cervical zygapoptyscal joint; Referred pai; Dorsal rami; Radiofrequency facet denervation; Neck pain Introduction Various structures in the cervical spine, such as the Zy- ‘gapophyseal joints, intervertebral discs, root ganglia, mus- les, and ligaments, are capable of causing headache, neck ‘pain, and shoulder pain (Bogduk and April 1993), Recently, many stadies have focused on the zygapophy- seal joints asa significant cause of back pain. Bogduk and “Marsland (1988) reported that cervical medial branch block and zygapophyseal joint block relieved pain completely in 17 out of 24 patients with chronic neck pain. ‘The cervical ~zygapophyseal joints have also been reported 10 be a sig- nificant source of cervicogenie headache (Edmeads 1988; Busch and Wilson 1989; Bovim etal. 1992). Thus, the 2y- ‘gapophhyseal joints are increasingly being recognized as a Significant source of cervicogenic headache, neck pain, and © Gormiponding author: Sei Fukui, Deparment of Anesthesiology annan Copal Mospal, 33-28. Minamishinmachi, Matar, ‘Ou 50, Japan Tel (1) 723392100, Fan (8) 73-3205, PH $0308.3959(86)03173-9 shoulder pain (Edmeads 1988; Aprill and Bogduk 1992; Bovim et al. 1992) Zygupophyseal joint block and arthrography have been used as both diagnostic and therapeutic procedures. Repro: duction of pain by distension of the joint after the intrsar- ticular administration of contrast medium and relief of pain ‘by zygapophyseal joint block have been used as the diag- nostic criteria up until now (LASP Task Foree on Taxon- ‘omy 1994). When zygapophyseal joint block does not yield long-term improvement, radioffequency denervation is commonly performed as a safe method of achieving fong- lasting pain relief (Shujter and Koestsveld-Baart 1980; Uerrest and Stolker 1991). Zygapophyseal joint arthrogr phy has previously been utilized by some authors to de- termine the distribution of referred pain (Dwyer etal. 1990, Dreyfuss et al. 1994). Bogduk and Marsland (1988) re- ported that neck pain with headache arose from the C23 joint and neck pain with shoulder pain was derived from the C5/6 joint after performing diagnostic cervical medial branch biock and zygapophyseal joint block in 24 con- secutive neck pain patients, Dwyer etal have described the0 Gistribution of refered pain for the C2/3 to C6VT joins, hile Dreyfans ea reported the patterns of refered pain From CO/1 and 1/2 in five normal volunteers Inthe Pres- cat study. we determined the distribution of pain arsing ftom the cervical 2yBapophyseal joints ftom COM to C77 ‘Tht ina large number of patients with suspected 2yg0po- thyscal joint psn. In aditon, to confirm the validity and tehabiliy of the refered pain maps foreach 7 gopophyseal joint. the pain patterns evoked by clectcal stimulation of the cervical 2ygapophysel dorsal rami fom C3 to C7 were Studied during cervical facet denervation ‘C2/ is innervated by the third eciptal nerve with 4 small inconstantcontibstion from communicating branch of the great occipital nerves, while each 2yzap0phy~ seal join below C27 is innervated bythe medial branches Of the cervical dorsal rami above and below it location (Gogduk 1982: Bogdok and Marland 1988) “The acurac, validity, and reliability of the joit pain distribution maps was confirmed by comparing the pattern of referred pun on C23 joint injection to that generated by Stimulation ofthe C3 dorsal rami, while the maps forthe ceric! zyzapophysea joints below C2/8 were compared to the results of stimulation of the dorsal rami above and below each joint Materials and methods ‘The subjzcte were 61 patients who underwent cervical 2gapphysel joint injection ad aofequency feet denervation athe pai cline of fier the Katou Tesin Hospi he Dike Unversity Hospital othe Hanonan Cental Hosp between March 1994 and Janay 1986. The ‘stents complained of oscptl, eck, and shoal pai, hd wel a: feed puraverbel tenderness over the 2} Z0pophyseal Jos and were suspected io have 2 gapophyseal join pan “The site ofeton war chosen eamespond any fea psn senders, ‘Under imge intensifier contol th sympomatie joins at CO! and (CUCE were entered vas tera pyoach. wil the joins from C27 to CITI were eofred vn a ponener oblique appaach (Dery 198: Ds feu and Nicolet 1985) Wedel and Wilson T94S). For the poser hia appeoach the pate was placed on the Suorscopy ae in he prone oblique postion with he taran resting om two plows. The neck tra xed and the Hea wae red 60-5" aay fom the sd af je "ion soa © obtaia prone oblique view. The C-arm was angled ip 2 eb tocando mater unde join caity was manly isu tae Under lorescopi guidance 322 gaape nel was aan ito the trget ont an sll qunity of corr medi akorol: Or riage) wos injected. The accuracy Of placentas confmed Oy Scthograpy of te pint and ijestion war continued under eonstat ‘raging etl pin stared or te inva pes ners ad unr contrast medium cold ot be sel rected withou potently ‘uptrng the caprle Then, amiatre of 05-1 of Joc aesthetic (1 mepivacaine) and img of dentamthazone was injected no he yeaophyel join spce sa tetaeute procedure sce whose pai wae reproduced BY Be ijction of contest me- tian ant scived temporary By "Espen jaa Nack were Se Ice for face denen Under fvoroscapie contol, facet denervation of the dasa ri hove and low ihe syrplomatic joint wae performed when stimulation feprodced he patent's pun. A ralofequency generator (Ralioncs Mosel REG:34N was ose supply cure thoogh 4 22 gauge needle etd (Sluyte-Met Kit [00 ong wih 24m exposed Up) ee Eeagulton ofthe dorsal eam. The procedure was performed withthe pent ying on te rscopy we te oq poston nd th he Mee ie eased by 20° “The target rea for Ft denervation was the Waist of the enteral ticular pla where the medal branch of the cervical dos ams ‘ows 3 conan rinship tots tone Presse needle placement wi verified wit lec simlaon a2, 5,20. snd SO He dey the exact poston ofthe dora ams WA stmulaon at? and $ Ha, tempts were made to cist agling ssa tin or paraspinal minclecontaton inthe neck tan intensity of less than 1. Wit sensory sinuation 20a $0 fates were mae to cause parcthes and to bt exact or simile reprndicion of te patents wel pain a a intnaty of less thin VI he patient fk Simulation at tresbold under 0 Vhs wax aceped as confrmion that the ned pa clo to tenure. Otherwise the ecode was ‘pniioned. After checking the positon hy ingestion of sal amoont ‘fconrat medium the mesial ranch wat snettized with 03 of 2% mepivacsne ad adilresuenc eon wae Made 90°C over 90- Woe ‘uring ineton snd (ast denervation, each patent vat asked shtber thei il psin wa reproduced. When the pion pin wat Teorodced by copslr istenson during artozraphy and clot ‘molaiee, the patent was aked wo describe the dbo of he toced pi. oer to splfy Ine comparsn of pin ditto, the ses of velered pais were cased int the following 10 region (0) ‘cipal repon (2) upper posterolateral eon (ose ale towards the masod process, (3) wpper posterior cervical region, (3) ‘nile poser cervical rain, (8) lower poner cecal region, () ‘pascal region, 7) saperie angle of he sap 8) mid apr ‘epi (9) shoulder oi, and (1) appr am (Fp). The sabes were ‘estricted to patients whose wsual pain was reproduced by nastier {rjectan ory elec stimlaion of he dna ra 2 tal of 6 patients were stoted (18 joints ad 62 dorsal rm). There wer 10 Ct joins 10C1/2 joins, 14 C2! joins, 21 C4 os. tell 6 8 C3 a1 Cram 21 CS eam, 18 C6 eam, and 7.7 rat ‘The patents were aged from 25 tH ycar, with 2 meth age a Si yea Thee were no signtcat complicatons arising 07 the rove. Fig. Rafe pin dsb (1) (sip ion: (2) spp es feo ericsson: 3) pe poster eevclregion; 4 mile fseror cereal pon, (9) lower poner ori region () st frasepalar rein: (7) sperior ane ofthe seanul: (®)midseapulr ‘in (shoulder ot (10) ep tm,a [REFERRED PAIN DISTRIBUTIONS FOR THE ZYGAPOPHYSEAL JOINTS FROM Cd! TO C7/THE AND THE DORSAL RAMI FROM C370 C7 H 2 2 @ 5 6 7 a 3 0 300 10c0) : 2 7 7 z 2a 1900 2 16) 15) . e oe sap 16178) 1153) é oS . 7 : 12 286) 380 204) 1) i= . = 2) 70s) 14) BGG 2H) sD) 2) : . = 1 93) 30) 4) a 40 1, 7 7 : : 2 lus) 228) 6a) 22H 114) 4 225 Bute) 2G) = 7 . ' 1) SUS) G65) 1) 1m) : 2 . 3) 1G) 6) TAM =a . = . e 30m $674) ga 2449) : : 2a) ds) 20) 1 octal ron; 2 = mide posterior cervcl ron: 3 = upper postior caval ion ‘el egion: 6 = supascaplr region; 7» superior angle ofthe saps; 8 = midsapular rein: 9 = shale jit se perentages| Results ‘The distribution of referred pain for each 2ygapophyseal joint and dorsal ramus is shown in Table I. The main spe- cific referred pain distribution from each joint and dorsal ramus were as follows (COMI joint (n= 10): occipital region (30%) and upper pos- terolateral cervical region (100%) C12 joint (n= 10): occipital region (20%) and upper pos terolateral cervical region (100%) (C23 joint (n= 14): upper posterior cervical region (64%), ‘occipital region (50%), and upper posterolateral cervi- cal region (50%). (C3V4 joint (n= 21): upper posterior cervical region (76%), middle posterior cervieal region (52%), and occipital region (38%). CANS joint (n= 46): lower posterior cervical region (76%), middle posterior cervical region (54%), and supra: scapular region (43%) 16): suprascapular region (50%), lower Fig. 2. Main eer pain dstbtions forthe 2yEapophysl ois roe {Cv C7 and he oral ras C3 497 = mile posterior censiclrepon = lower posterior ce per tm Data paras posterior cervical region (46%), superior angle of the scapula (35%), middle posterior cervical region (15%), and shoulder joint (11%). C67 joint (n= 27): superior angle of the scapula (48%), ‘mid-scapular region (41%), lower posterior cervical region (33%), shoulder joint (15%), and suprascapular region (11%). CATAL joint (n= 7): mid-scapular region (86%) and supe- ror angle of the scapula (28%). C3 ramus (n= 8) upper posterior cervical region (100%), ‘ccipital region (50%), middle posterir cervical re- gion (33%), and upper posterolateral cervical region 25%. C4 ramus (n= 11): lower posterior cervical region (55%), suprascapular region (55%), and middle posterior vical region (45%) C5 ramus (n= 21): lower posterior cervical region (52%), superior angle of the scapula (33%), suprascapular re- on (29%), and shoulder joint (19%. C6 ramus (n= 15): superior angle of the scapula (47%), suprascapular region (33%), mid-scapular region 23%), shoulder joint (27%), and lower posterior eer vical region (203), C7 ramus (n=7): mid-scapular region (71%), superior angle of the scapula (71%), shoulder joint (29%), lower posterior cervical region (29%), and suprascapu- lar region (14%). “The main joints and dorsal rami responsible for referred pain at each site were as follows: occipital region, C2/3 and ‘C2, upper posterolateral cervical region, CO/1, C1/2 and 213; upper posterior cervical region, C2/3, C3/4 and C3; riddle posterior cervical region, C3/4, C4/5 and Ca; lower posterior cervical region, C4/S, C5/6, C4 and C5; supra: scapular region, C4/5, C5/6 and Ci; superior angle of the scapula, C6/7, C6 and CT; mid-scapular region, C6/T, C7! ‘Tal and C7 ig. 2)2 Discussion April and Bog (1992) reported that 2ygapophysal joint block lieved pain and ardropraphy reproduced pain im 82 (66%) out of 128 patients with chron neck pain, In Addition, double-blind controled studies have shown that up to 60% of neck pain after whiplash injury stems from the zyeapophyseal joints (Barnsley etal. 1994, 1995), “The zygapophycal joins are richly supplied with nerve fibers that may mediate pain (Ashmed et al. 1993), and these joints are increasingly being recognized as a common source of significant occipital, neck, and shoulder pain in Addition to the intervertebral diss (Cloward 1959 “The clinical features are pain associated with well localized parspinal tenderness over the 2ysapophyscal joims,inceased pain on extension, increased pain on rt tion of the spine, and the absence of neurologic signs or toot tension signs Jackson and Spurling tests). However, these findings ate not specific enough to be of diagnostic Yalue. A zygapophyseal joint can be deemed symptomatic 3 provocation by injetion of contrast medium exactly r= produces the patient's pan and if anesthetizing the joint promptly relieves the pain (Barnsley etal, 193; IASP Task Force on Taxonomy 1994) If the patient receives excellent but short-term it by joint blocks Barnsley eal. 19946, radiofequency denervation can be used a long-term treatment for 2ygapophyseal joint pain. The technique is Anite simple and canbe easily done safely onan outpa- tent basis (rest and Stoker 1991), Dreyfuss ctl. (199) showed that the atlano-ociptal (CO.CI) and slano-axial (CI-C2) zygapophyscal joins ould be potential sources of occipital and upper cervical Pain by injecting contrast medium in ive normal volin- tecrs. In aditon, Duy eta. (1990) showed that he 2y spophyseal joints from C2-C3 to C6.CT could be potential Soures of neck pain and refered pain to the head and Shoulder girdle by injecting contrast medium in five normal volunteers. Apil tal. (1990) confirmed the accuracy of the pain chart of Dwyer et al. (1990) by performing ans- thesa ofthe medial branches ofthe dora rami sbove and below the symptomatic joint inpatients with zygapophy- seal pin. Although the results of Duyer and Dreyfuss have een widely accepted, their provocative joint injection studies involved only five subjects and thus were of imted value for creating reliable pain dstbution maps. Ia the resent study, the refered pin distribution of each 2ys2- Pophyseal jin fom COV to C7/ThI was established in large number of patients with suspected 2yzapophyscl jolt pain. “Te main distribution of refered pin from each joint was a follows: COV, upper posterolateral cervical ego: C12. upper posterolateral cervical region; C2, upper posterior cervisl regio, occipital region. and upper pos: teolateral cervical region: C3Y4, upper posterior cervical region and middle posterior cervical region; C45, middle posterior cervical region, lower posterior cervical region, and supracapola region; CS(6, lower posterior cervical region and suprascapulae region; C67, superioe angle of the scapua and midscapular region; CT/Tb, superior angle of scapula and midscapoler region. The main distribution of referred pun determined on electrical stimulation of the dorsal rami was a5 follows: C3, occipital egion and upper posterior cervial region; Cé, midale posterior cervical Tegion, lower posterior cervical region, and suprascapoar region: C5, lower posterior cervical region: C6, superior angle of the sapelas C7. midscapular region and superior angle ofthe scapula The refered pain distribution for C2/3 was almost iden tical to that for the C3 ramus andthe distribution forthe joins below C23 was similar othe composite distribution Of the dorsal rami ahove and below each joint. This, the accuracy of the refered pain distribution for each joint bined by injection of contrast medium was confirmed by the pain charts foreach dorsal rams and the validity ofthe ‘maps was coafimmed. The refered pain distibution from the COM, C12, and C20 joints was comparatively 1e- Stricted, but we found several variations of referred pain from the joins below C23. The zygapophysal joints be- low C26 are innervated by the medial branches of the cervical dorsal rami from above and below the joint and this may be cause of the variations in the refered pain atten, Anatomic studies have shown that the C2/ joint innervated by the third occipital nerve wth a smal incon- stant contribution fom a communicating, branch of the treat occipital nerve, while the COM and CI/2 joins ace ‘ccasonally innervated by the ventral ami of C1 and C2 (Gogduk 1982: Bogduk and Marland 1986), This might explin the restricted refered pain distribution fom these Joins. Referral of pain othe shoulder joint region from the CAS to C7TTM rygapophyscal joints was found asa new variation. Stimulation of the dorsal rami from C4 to C7 dso produced pain over the shoulder joint, so the pain dis- ition ofthe dorsal ram confirmed the acuracy of the chats for these 2ygapophysal joints Tn previous investigations, referred pain from the 2yg0- pophyseal joint has been sted by injection of contrast tnediam (Dwyer etal. 1990), However, the referred pain distribution obsaned by electrical timation of the dorsal rami innervating the 2ysepophyseal joints has not been repo previously. The refered pain distribution forthe Zygapophyseal joins and dorsal rami constructed the present stedy may provide @tsefl guide for determining ‘which joint o investigate ist and which nerve to reat ist in patents with suspected cervial 2yeapophyseal joint Dain who are undergoing. eygapophysea join block or facet denervation Patients with neck pain due to die dscase, bone dis case, and nerve rot compression ae lags recognized by Conventional diagnos methods and wndergo established treatment. However, cervical zyzapophyseal joint disorders te poorly understood or even not considered in conven: tional practice (Bogduk and Marsland 1988). Our referedpain distribution maps of the zygapophyseal joints from COM to C7/Tht and the dorsal rami from C3 to C7 should provide helpful information about the localization of head, ‘neck, and shoulder pain stemming from the zygapophyseal joins. References ‘Ahied, M, Blu A Kekbergs, A and Shluaberg, Ms Senson ‘Se autonome intrvtion ofthe foe joa in theft utara, Spine 181993) 2121-2126. April Cand Rog, N. The prvalence of cervisslzagspophysel Sela pn Spine 17 (1992) 18-747 Apel, Dwyer, Aad Bogak, N. Cevial agapghysel jit pain Pavers a cinial evalanon, Spe, 6 (1990) 458-461 Bares, L, Lod. Sand Bogith. N. Comparative local anestitic ‘block i the diagnosis of ceric 2yeaphyscl int pai, Pl 38 1993) 99-106. ‘Barney 1. Lor, Sand Bod N., Whiplash jr, Pan $8 (19948) 2 aaley. L, Lod, S. 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