Not all pain is in the head

Our first case concerns an 86 y old woman in good general health who suffers from severe high neck pain and head ache, all on the right side. The symptoms are present since one year and she cannot turn her head right or left without marked exacerbation of her pain. An MRI shows arthritic changes of the interverterbal cervical joints from C1/2 to C6/7 on both sides and a small synnovial cyst in the external part of the right C1/2 joint.

Head ache is a common manifestation of pathology in the three uppermost cervical joints (C0/1, C1/2 and C2/3) caused by trauma or degeneration touching these joints. The head ache is often situated around the eye and is explained by convergence between the trigeminal nucleus and the nerve supply to these joint levels in the upper spinal cord.

 

The relationship between pain and joint pathology is usually established by injections of small volumes of a potent local anesthetic on the nerves that supply these joints or, for the two uppermost joints, by injection of the local anesthetic directly into the joint.

 

Before being referred to our pain centre, the patient had been tested in another institution excluding the C2/3 joint on the right side as the source of pain.

Our working hypothesis was that the patient's pain was caused by the arthritis in the C1/2 joint and/or by the cyst at the same level.

A thin needle was placed under fluoroscopic guidance into the right C1/2 joint from behind and x-ray contrast injected. This injection produced increase in the patient's usual pain at the same time as the cyst filled up with contrast. This lead us to puncture the cyst via a second needle. A communication of fluid between the joint and the cyst was established by injecting into the joint needle and aspirating the same fluid via the cyst needle. Each time the cyst was emptied, the pain completely disappeared. Finally the cyst was drained and a small dose of cortisone injected via the joint needle in order to reduce the inflammation that was the probable cause of the cyst formation.

The patient left the pain clinic one hour after the intervention without any pain and on follow-up one month later she was completely free of pain in the neck and head.