Cervical Zygapophysial Joint Intraarticular Injection, Posterior Approach: Fluoroscopic Guidance

Abstract

In this chapter, the posterior approach for injecting the zygapophysial joints (Z-joints) is described. Compared with the lateral approach, the posterior approach allows for access to multiple joint levels on both sides of the spine, thereby negating the need to reposition the patient or C-arm when performing bilateral injections. This approach is often required for injecting the more inferior Z-joints, where a lateral approach may involve the risk of contacting the lung apex or the inferior neurovascular structures. With this approach, the trajectory view is an anteroposterior view with a caudad tilt (i.e., a pillar view), which also serves as the anteroposterior view with multiplanar imaging. Because the lateral view is used to assess depth, one need not step off of the inferior or superior articulation of the joint before penetrating the joint capsule, as is often recommended. A contralateral oblique (CLO) view is an additional multiplanar view and can be used as a relative depth view. Typically a 22- or 25-G needle is used to inject a maximum volume of 1 ml of a steroid and anesthetic mixture into each joint.

Keywords

Cervical Z-Joint, facet joint, Fluoroscopy, Medial Branch, Neck Pain, Third Occipital Nerve, Whiplash

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

In this chapter, the posterior approach for injecting the zygapophysial joints (Z-joints) is described. Compared with the lateral approach, the posterior approach allows for access to multiple joint levels on both sides of the spine, thereby negating the need to reposition the patient or C-arm when performing bilateral injections. This approach is often required for injecting the more inferior Z-joints, where a lateral approach may involve the risk of contacting the lung apex or the inferior neurovascular structures. With this approach, the trajectory view is an anteroposterior view with a caudad tilt (i.e., a pillar view), which also serves as the anteroposterior view with multiplanar imaging. Because the lateral view is used to assess depth, one need not step off of the inferior or superior articulation of the joint before penetrating the joint capsule, as is often recommended. A contralateral oblique (CLO) view is an additional multiplanar view and can be used as a relative depth view. Typically a 22- or 25-G needle is used to inject a maximum volume of 1 ml of a steroid and anesthetic mixture into each cervical Z-joint.

Trajectory View ( Fig. 30A.1 )

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Confirm the level (with the anteroposterior view).

Fig. 30A.1

A, Fluoroscopic image of a trajectory view with the needle in position within the left C5-C6 zygapophysial joint. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.
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Tilt the fluoroscope’s image intensifier caudally to orient the beam parallel to the plane of the Z-joint.
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An optimal tilt is indicated by a hyperlucent, horizontal joint space with crisp bony margins.
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Place the needle parallel to the fluoroscopic beam into the cervical Z-joint.