A 65yr old female patient presented with severe left sided neck pain just below the skull. The pain had come on some years earlier but had gradually intensified despite analgesia. When she came in for her consultation she used her hands to help support the weight of her head as this alleviated some of her neck pain. She described the pain as worse in rotation, and as a result had very limited movement in rotation.

CT cervical spine revealed the left C1-2 facet joint was severely arthritic (Fig 1).

The joint space had been completely destroyed by osteo arthritis. The right C1-2 facet joint was normal (Fig 2). She was scheduled for surgery.

Symptomatic osteoarthritis of the C1-C2 facet joint is rare. It affects only 4% of patients with osteoarthritis elsewhere in the body. The unique anatomy of the C1-C2 joint i.e. lacking an intervertebral disc, leads to a distinct clinical syndrome resulting from the joint degeneration—severe pain just below the skull on the pathological side exacerbated by lateral rotation. While conservative treatment such as analgesia, steroid injections etc should always be attempted, intractable pain often culminates in surgical intervention to fuse the C1-C2 joint.

This patient underwent a C1-C2 posterior fixation. During the procedure four screws were inserted, left and right side of C1 and left and right side of C2 (Fig 3). Stereotactic navigation was used to help guide the screws in safely without injuring nearby structures such as the vertebral artery, the spinal cord or nerve roots (Fig 3).

The patient woke up pain free for the first time in several years and was extremely happy with the result of her surgery. 2 years later she remains pain free.