Chapter 13 Lumbar Zygapophysial Joint Intraarticular Joint Injection, Posterior Approach

Note: Please see page ii for a list of anatomical terms/abbreviations used in this book.

The lumbar zygapophysial (facet) joints were first recognized as a potential source of spine pain by Goldthwait in 1911.¹ The term facet syndrome was first used by Ghormley in 1933.² Recent literature supports that the lumbar zygapophysial joints have a pain prevalence of 15% to 45% among individuals with chronic low back pain.^3–5 Lumbar zygapophysial-joint–mediated pain cannot be absolutely diagnosed by history, clinical examination, or radiographic imaging.^6–11 The intraarticular injection can potentially provide diagnostic and therapeutic benefits. Depending on the patient’s clinical assessment, these injections can be performed unilaterally or bilaterally.

In this chapter, the approach described involves the use of a trajectory view in an oblique orientation and advancement involving the use of a minimum of two views: anteroposterior and oblique. The use of a lateral view is also recommended for final confirmation, especially when the superior recess needs to be accessed. Inferior recess access will also be described.

Trajectory View

Confirm the level (with the anteroposterior view).

Oblique the fluoroscope’s image intensifier ipsilaterally (Figure 13–1).

If the joint is sagittally oriented, oblique angulation of the fluoroscope may not be necessary.

Correlation with magnetic resonance images or computed tomography axial images may be helpful for estimating the optimal oblique angle at which the joint may be entered.

The target needle destination is at the middle to upper half of the joint and toward the medial border of the joint-space silhouette. The target can be the superior or inferior recess too, which is discussed later in the chapter.

Oblique ipsilaterally until the joint-space silhouette can be identified, and then decrease the angulation until the silhouette begins to fade away. Usually the oblique angle is 5–10 degrees.

This optimizes access to the medial border of the joint by making use of a more medial-to-lateral entry angle.

As the spine ages, bony overgrowth usually occurs off of the superior articular process. If the lateral border of the silhouette is targeted, it corresponds with the superior articular process, thereby resulting in a decreased probability of access.

Figure 13–1 A, Fluoroscopic image of a trajectory view with the needle in position at the L4-L5 Z-joint on the left. B, Radiopaque structures. C, Radiolucent structures.

Tilt the fluoroscope cephalad or caudad, if needed.

Little tilt is needed. Optimize entry into the joint.

At the L5-S1 level, the iliac crest may be superimposed over the zygapophysial joint. Cephalad tilt may be required to optimize the trajectory view.

In the scoliotic spine, cephalad or caudal tilt may be required to better visualize the vertebral level and respective zygapophysial joint of interest.

Trajectory View Safety Considerations

Avoid the spinal nerve by staying over the joint. Do not stray cranially above the joint.

Place the needle parallel to the fluoroscopic beam.

Optimal Needle Position in Multiplanar Imaging

Optimal Needle Positioning in the Oblique View (Figure 13–2)

Figure 13–2 A, Fluoroscopic oblique view with ideal needle position within the joint. Note the medial-to-lateral needle orientation that results from using a less oblique trajectory B, Radiopaque structures. C, Radiolucent structures.

Safety Considerations

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