Cervical Zygapophysial Joint Nerve (Medial Branch) Injection—Lateral Approach: Fluoroscopic Guidance

Abstract

This chapter describes the lateral approach to fluoroscopically guided cervical medial branch injection. The cervical Z-joints are a well-documented source of acute and chronic neck pain. Symptomatic cervical Z-joints typically produce axial pain. In addition, the upper Z-joints may demonstrate sclerotomal referral patterns that radiate superiorly and anteriorly to involve the head, whereas the lower joints demonstrate patterns that radiate inferiorly and laterally to involve the shoulder and the upper thoracic region. The patient’s history, physical examination, and imaging studies will be suggestive of but not specific for Z-joint pain. The standard for the diagnosis of zygapophysial joint (Z-joint) pain is diagnostic medial branch anesthetic injections. Cervical medial branch blocks may also have a therapeutic benefit. Each Z-joint is innervated by two medial branch nerves. Typically, a lateral projection is best suited for cervical medial branch blockade, especially for the upper segments. The foraminal oblique view ( Chapter 3 ) will assist in visualizing the lower segments, particularly at C7, which may be obscured on a lateral view.

keywords

Cervical Z-Joint, facet joint, fluoroscopy, medial branch, Neck Pain, Third occiiptal nerve, Whiplash

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

This chapter describes the lateral approach to fluoroscopically guided cervical medial branch injection. The cervical Z-joints are a well-documented source of acute and chronic neck pain. Symptomatic cervical Z-joints typically produce axial pain. In addition, the upper Z-joints may demonstrate sclerotomal referral patterns that radiate superiorly and anteriorly to involve the head, whereas the lower joints demonstrate patterns that radiate inferiorly and laterally to involve the shoulder and the upper thoracic region. The patient’s history, physical examination, and imaging studies will be suggestive of but not specific for Z-joint pain. The standard for the diagnosis of zygapophysial joint (Z-joint) pain is diagnostic medial branch anesthetic injections. Cervical medial branch blocks may also have a therapeutic benefit. Each Z-joint is innervated by two medial branch nerves. Typically, a lateral projection is best suited for cervical medial branch blockade, especially for the upper segments. The foraminal oblique view ( Chapter 3 ) will assist in visualizing the lower segments, particularly at C7, which may be obscured on a lateral view.

Note that this is one of the few procedures in which the trajectory view is the lateral view (i.e., one of the multiplanar views).

Special attention should be paid to Fig. 30H.1 , which illustrates the variability of the cervical medial branch nerves’ anatomic courses.

Trajectory View ( Fig. 30D.1 )

Tilt the fluoroscope cephalad or caudad.
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  Line up the vertebral superior end plate and the inferior end plate to the appropriate orientation.
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  Superimpose the articular pillars.
Oblique the fluoroscope minimally (i.e., keep it near neutral).
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  Note that a slight degree of obliquity may be required to superimpose the articular pillars to obtain a trapezoid view.
Confirm the level by counting inferiorly from C2.
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  The target needle destination depends on the targeted medial branch.
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  The needle is advanced by remaining parallel to the fluoroscopic beam until the periosteum is encountered. See Chapter 30H for the exact location of medial branches.
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  To differentiate superficial ipsilateral vs. deeper contralateral cervical medial branches, use one of the techniques described in Chapter 3 .

The Trajectory View (Lateral) Is Also a Multiplanar View

Notes on Positioning in the Trajectory View

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The needle is placed parallel to the fluoroscopic beam.
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Please note that setup is performed separately for each level by changing the tilt and obliquity as necessary.
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See Chapter 30H for a diagram of the exact locations of medial branches.

Trajectory View Safety Considerations

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Avoid the spinal nerve and vertebral artery anteriorly.
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Avoid inadvertent needle placement too superiorly or inferiorly into the intraarticular joint and potential penetration into the dural sac or spinal cord.