Cervical Zygapophysial Joint Intraarticular Injection, Lateral Approach: Fluoroscopic Guidance

Abstract

In this chapter, the lateral approach to performing a cervical zygapophysial joint (Z-joint) intraarticular injection is described. Some may argue that the lateral approach is technically less demanding than the posterior approach: it can be performed with the use of a smaller-gauge needle (e.g., 25 or 26 G), and less soft tissue is traversed, thereby making it more comfortable for the patient. Regardless of the approach used, the total volume of anesthetic and steroid injected should be less than 1 ml to prevent the rupture of the joint capsule and leakage into adjacent structures.

keywords

Cervical Z-Joint, facet joint, fluoroscopy, Neck Pain, Whiplash, Zygapophysial

Note: Please see pages ii , iii for a list of anatomic terms/abbreviations used throughout this book.

In this chapter, the lateral approach to performing a cervical zygapophysial joint (Z-joint) intraarticular injection is described. Some may argue that the lateral approach is technically less demanding than the posterior approach: it can be performed with the use of a smaller-gauge needle (e.g., 25 or 26 G), and less soft tissue is traversed, thereby making it more comfortable for the patient. Regardless of the approach used, the total volume of anesthetic and steroid injected should be less than 1 ml to prevent the rupture of the joint capsule and leakage into adjacent structures.

The more cephalad cervical joints are featured in this chapter. This approach can be more challenging in the more caudad segments as the shoulders can obscure target visualization in the lateral projection and anteroposterior (AP) views. An ipsilateral/foraminal oblique view (see Chapter 3, Figs. 3.19 ) can be used when there is difficulty visualizing the joint or to confirm needle placement in the correct cervical Z-joint. When performing cervical Z-joint injections, contrast flow into the space of Okada is a common phenomenon. The space of Okada is an extradural space dorsal to the ligamentum flavum. Contrast injection will flow initially into the Z-joint and then out the inferior recess of the joint and track medially into this retroligamentous space (see Fig. 30B.5 ).

Trajectory View ( Fig. 30B.1)

The Trajectory View (Lateral) Is Also a Multiplanar View

Place the patient in a lateral decubitus position with the symptomatic side up.

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Confirm the level using a lateral view (relative to the patient—zero degrees relative to the table if the patient lies perpendicular to it).
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Identify the target by counting down from C2.

If needed, tilt the fluoroscope slightly in a cranial or caudad direction to superimpose the ipsilateral and contralateral facet joints and articular pillars.
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Because the patient is in a lateral decubitus position, the tilt will be used as discussed in Chapter 3 .

If needed, also oblique the fluoroscope slightly to superimpose the ipsilateral and contralateral facet joints and articular pillars.
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Because the patient is in a lateral decubitus position, the oblique will be used as discussed in Chapter 3 .

The lateral image is the trajectory view, and the needle is placed parallel to the fluoroscopic beam.
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To differentiate superimposed ipsilateral from contralateral cervical Z-joints, use one of the techniques described in Chapter 3 .

Trajectory View Safety Considerations

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Avoid the spinal nerve and vertebral artery by not placing the needle too far ventral.
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Depending on patient anatomy (i.e., “short neck”), access to the lower cervical segments may be compromised by the lung apices.

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