Pain
Collin M. Young, DO
Resident
Indiana University
INDIANAPOLIS, Indiana, United States
Henry J. Kotlinski, II, DO
Resident Physician
Ascension St. Vincent
Zionsville, Indiana, United States
Collin M. Young, DO
Resident
Indiana University
INDIANAPOLIS, Indiana, United States
Acute axial neck pain secondary to intraspinal facet synovial cysts and hypermobility
Case Description:
A 65-year-old woman with Behcet’s disease, fibromyalgia, migraines, and osteoarthritis presented for management of chronic axial neck pain due to myofascial pain and cervical dystonia. Botulinum toxin injections had previously been effective after failed treatments including interlaminar epidural steroid injection, medial branch blocks, radiofrequency ablation, and trigger point injections. Six days following repeat botulinum toxin injections, she sought emergent evaluation for severe axial neck pain. A computed tomography (CT) angiogram did not demonstrate acute pathology. The patient returned to clinic reporting dizziness, lightheadedness, and pain worsened by cervical extension. Neurologic function and sensation were intact, though bilateral C8 weakness was noted. Cervical MRI demonstrated right facet arthropathy with intraspinal synovial cysts compressing the right C8 nerve root, causing severe neural foraminal narrowing—a new imaging finding. Flexion/extension radiographs revealed cervical hypermobility and instability with new right sided Hoffman’s at neurosurgical evaluation. The patient elected to undergo posterior spinal fusion (PSF).
Discussions:
Routine therapeutic doses of botulinum toxin rarely cause major side effects in patients with myofascial pain and cervical dystonia. Potential adverse effects include worsened neck pain, dizziness, muscle atrophy, dysphagia, dyspnea, or systemic spread. In this case, new neurologic symptoms prompted further evaluation to identify the cause of worsening axial neck pain. Synovial cysts may develop over time from facet joint degeneration. In patients with hypermobility, these cysts can impinge adjacent structures, causing dynamic stenosis and axial neck pain with intermittent radicular symptoms. Compared to anterior cervical discectomy and fusion (ACDF), PSF offers more definitive stabilization and may reduce the risk of persistent dysphagia.
Conclusions:
This patient developed new severe axial neck pain following routine botulinum toxin injections. Imaging revealed intraspinal facet synovial cysts and cervical hypermobility. The patient elected for PSF for symptom relief.
