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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

Cervical Disc Disease with Referred Pain to TMJ

A case report of cervical injury from a motor vehicle accident resulting in a cascade of physical changes over six months and referring pain to the TMJ and face.

For many patients and doctors, issues that may relate to cervical pain are often complex and frustrating. It is not easy to determine why a patient suffers cervical, occipital or temporal pain, determine an accurate diagnosis, or create a successful treatment plan. It is now generally accepted in medicine that back pain accounts for the majority of visits to the physicians’ office on a given day and, second to back pain visits, are visits for painful symptoms associated with the cervical or neck region.

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In this article, I hope to highlight some of the common causes of cervical-related pain and referred pain and present a case report that illustrates the premise of referred TMJ pain from cervical injury.


Bogduk1 and others have stated that approximately half of patients suffering cervical-related pain are as a result of changes with the facet joint. Either hypo- or hypermobility of the facet joint or joints can lead to structural changes that reduce intervertebral joint stability and consequently can cause pain and suffering in some patients. One of the problems associated with the spinal column is that there is not a correlation between imaging findings of anatomical change and clinical pain. Diminished joint space, hypertrophic changes, or osteoarthritic changes do not, in themselves, necessarily indicate the cause of pain in a given patient.

Degenerative change in the spinal column is now recognized as a progressive consequence of normal aging and are common imaging findings in those over sixty five years of age, often without symptoms of pain or limitation. The diagnostic dilemma for the physician then is that he/she cannot rely solely on imaging or other findings alone to confirm or deny a pain generator. Cervical-related painful symptoms may be due to either instability, bony spurs, rupture of the facet capsular ligaments, disc bulging/herniation, or multifidus muscle changes.

Some investigators believe that there may often be the presence of inflammatory mediators responsible for pain at a chemical level when the integrity of the intervertebral disc has been compromised. The leakage of disc contents into the surrounding tissues can cause a chemical inflammatory reaction that is painful.1

If a bulging disc extends to the point that the spinal cord or others tissues are compressed by the disc, then a decision may be made to operate and remove the damaged disc. Such a procedure is an anterior discectomy with a bone graft and fixation with metal plate and screws. While this procedure is commonly performed, about half of the patients operated fail to experience any degree of pain relief. The neurosurgeon is operating to effect spinal stability not to stop the pain of the patient. If pain relief occurs, it is only a side benefit of the stabilization procedure rather than the purpose of the operation. In my community, more than half of all neurosurgical procedures performed by a particular surgical group are anterior cervical discectomy with bone grafting and fixation. The referring doctor and the attending neurosurgeon would certainly like to be able to offer the patient some degree of certainty that a given procedure would offer pain relief but that cannot be stated unequivocally.

Part of the problem encountered in cervical pain diagnosis and treatment is that the cervical spine does not function as separate, individual elements. The facet joints, capsular ligaments, intervetebral discs, vertebrae, and the multifidus muscles2 all work together as an integrated system. So, when one part of the system is negatively affected, the stability of the system is often compromised. For example, a hypo- or hypertrophic facet joint can alter vertebral stability and lead to movement of the cervical disc and result in bulging or herniation of the cervical disc. The loss of joint stability can also lead to bony spurs as a result of uneven pressure, or to osteophytic bars that can form on the anterior or ventral surface of the intervetebral canal wall. The latter is often nature’s way of trying to regain structural stability. An injured interveterbral disc can lead to facet joint changes with more instability. Another scenario could include tearing of the facet capsular ligaments with resulting strain or degenerative change of the multifidus muscle tendons3 that insert on the facet joint capsular ligaments. The result of a cascade of changes in the cervical structures can cause pain that is multifactoral in nature and refer pain to the TMJ and facial structures.

Figure 1. Cross-sectional view of the multifidi muscle. Used with permission of Doug Alexander (www.massagetherapypractice.com).

Multifidus Muscle

An often unrecognized consequence of intervetebral instability is hypomobility and fatty deposition in the multifidus muscle that does not automatically restore itself after cervical disc surgery.4 Specific exercises designed to restore tone and integrity of the Multifidus muscle can be the key in some cases to help eliminate the symptoms of cervical related pain. It is common to observe pain relief when the exercises have been started, and to see the pain return when the exercise regimen has not been followed to completion. This muscle is very important in the neck and back because it not only acts to bend the spine, but it is primary in maintaining vertebra-to-vertebra orientation and stability. Some researchers believe that the multifidus muscle (see Figures 1 and 2) is the most important muscle of the neck and back due to its core function of maintaining vertebra to vertebra relationship.

An injury in the region of the cervical area presents the examining doctor with a difficult situation. The patient is usually seeking pain relief, but the doctor cannot insure that a procedure will give pain relief if the patient is suffering a bulging cervical disc. The patient, once informed, will often have the procedure with the hope that pain relief might happen even though the surgeon cannot offer hope of pain relief with disc surgery. Fortunately, about half of patients who undergo anterior cervical discectomy with graft and fixation do obtain some degree of pain relief as is evidenced in the case that follows in this article. If the patient’s primary symptoms of cervical and occipital and temporal headache or pain is discogenic in nature, then the discectomy may eliminate or reduce the pain. However, if the pain is facet joint capsule related, then discectomy may not reduce or stop the pain.

A patient may have a C-4 to C-5 and C-5 to C-6 disc bulging with accompanying headache, neck ache and shoulder and hand pain. One may also find that the pain over time (six months or more) may also refer into the TMJ and face area of the affected side. This is not commonly recognized in these cases injured in the C-4 to C-5 and C5 to C-6 areas as the patient’s doctor is often unfamiliar with referral into the spinal nucleus of

Figure 2. Longitudinal view of the multifidi muscle. Used with permission of Doug Alexander (www.massagetherapypractice.com).

Case Report

A mid thirties white female experienced a motor vehicle accident (MVA) while stopped at a traffic light. Hit from behind by a mid-sized truck traveling 30-35 miles an hour without braking, the impact itself stopped the truck. The truck driver had blood alcohol just below legal limit. The patient was a front seat passenger with no prior trauma or MVAs in her history. Patient was well-nourished, alert, with no motor or sensory deficits, and no cervical, cranial, or facial pain prior to the MVA. Her past medical history was non-contributory to the symptoms of the accident.

Following the accident, the patient immediately went to her family physician who did cervical radiographs and noted loss of normal lordotic curvature of the cervical spine. The family doctor referred the patient to a physical therapist who treated the patient for six months with equivocal results. Some days she felt better and some days the physical therapy felt worse. For six months, the headache and neck pain, bilateral in nature, worsened. Additional pain began to be referred to the temporomandibular joints and cheek and temple.

Other symptoms included stiff neck, stiff and painful shoulders and jaw pain. TMJ exam showed sore and painful lateral capsular ligaments at the TMJs. Patient remarkably did not have temporal tendonitis or other TMJ-related pathology. A TMJ oral orthotic appliance was made but its use did not affect the referred pain at the TMJs. At the end of six months, the patient was also referred to a neurosurgeon who did an MRI of the brain and cervical spine. Bulging cervical discs were noted at C-4 and C-5 and C-5 and C-6 segment levels. An osteophytic spur was noted at the C-6 neural foramina as well. The neurosurgeon suggested that the patient wait to see if the pain would improve from management with meds and limited activity. By the first quarter of 2007, the pain had increased from a 6 or 7 on the VAS scale to a 9 and 10 with little relief from muscle relaxants and hydrocodone, motrin, and other analgesics.

The patient was suffering to the point where she could not sleep and the combination of sleep-loss and pain began to affect her vision. In May of 2007, the neurosurgeon took another MRI. The patient also experienced less than effective insurance support as neither carrier seemed to take timely action in moving the case forward so that neurosurgery care could be initiated. Finally, in December of 2007 and January of 2008, insurance difficulties were resolved with legal action and the patient was scheduled for anterior cervical discectomy with fixation at C-4/C-5 and C-5/C-6 in February 2008. The patient tolerated the procedure well and in her words eleven months later: “I have felt 99% better than prior to the surgery. I still have times that I have neck, head or facial pain but I feel it is probably due to the fact that the muscles are now weakened from lack of activity (it took 4 years to get the surgery). I am now currently exercising and feeling better. I am not having the headaches that I had even four months ago. Oh, I am having that tingling sensation go down my back when I sit a certain way. I didn’t have that prior to surgery so I am assuming that it’s probably a result of the surgery.”

This patient was a very good communicator with regard to her symptoms and, having been very athletic, was aware of her physical body. She is fortunate that she fell into the category of patients who received pain relief from the discectomy.


This case is interesting in that a cervical injury from a MVA—through a cascade of changes over a six month period—caused referred pain to the TMJ and face on a bilateral basis. My exam did not reveal any TMJ-related injuries in her case but the symptoms referred to the TMJ and face, once started, persisted until the neurosurgery procedure was performed. At eleven months after surgery, the patient can now pick up her child which she could not do before the surgery without suffering intense pain. Some doctors do not equate C-4 to C-6 disc injury to TMJ and facial pain, but this is not an uncommon finding. I believe that this patient is receiving benefit from her exercising by improving muscle tone and elevating the endorphin levels—both of which improve her ability to regain most of the mobility she had before the accident. From the start of this patient’s ordeal beginning on December 27, 2004, I have been able to follow this case more closely than most because the patient is a family member. The attorney for this patient encouraged her to not give up in the process of trying to get resolution through surgery. Some patients without an advocate do not persist against the obstacles that may obstruct or impede their access to care. Persistence and determination are critical in getting the requisite care and a claim not filed is a claim not paid.

Last updated on: January 24, 2012
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