Chapter 23 Thoracic Zygapophysial Joint Intraarticular Injection, Posterior Approach

Thoracic zygapophysial (facet) joint injections are indicated for the treatment and diagnosis of axial thoracic (i.e., mid back) pain that typically originates from zygapophysial joint sprains, contusions, or osteoarthritis. These injections are performed with the use of a posterior approach by entering the zygapophysial joint at the inferior aspect of the joint. There is no needle trajectory view for entering the thoracic zygapophysial joint. A substantial caudad tilt of the fluoroscope is required to accomplish a trajectory view of the joint space as a result of the steep coronal orientation of the thoracic zygapophysial joints. Unfortunately, the torso prevents the fluoroscope from reaching the degree of caudad tilt that is necessary for a trajectory view.

The reliable approach described herein can be used to routinely allow for the placement of a spinal needle into the thoracic zygapophysial joint. This technique has been previously described in the literature using a posterior approach using anteroposterior visualization. With anteroposterior visualization, the needle tip can be maintained along the midpedicular line, which corresponds with the midline of the zygapophysial joints and prevents the straying of the needle medially or laterally to avoid neural and pulmonary structures. Contralateral oblique imaging provides for the visualization of the posterior inferior joint space, thereby allowing for needle placement into the joint. A straight or bent needle tip, which is helpful for navigating into the joint and overcoming osseous obstacles in a degenerative joint, can also be used to access the joint.

The needle entry site into the skin is confirmed with anteroposterior visualization at the pedicle one vertebral segment below the designated zygapophysial joint. For example, the entry site in most individuals for a left T8-T9 zygapophysial joint injection is the 6 o’clock position of the left T10 pedicle and the target site for entry into the Z-joint is the 12 o’clock position of the T9 pedicle (Figure 23–1, B). The rationale for the skin entry site and the Z-joint target site is to approximate the “trajectory angle” of the needle tip into the posterior inferior aspect of the joint space due to its near coronal orientation and inability to obtain a trajectory view with fluoroscopy. The needle tip is advanced with fluoroscopy and makes contact with the lamina at the base of the superior articular process of the target Z-joint. The needle tip trajectory is then adjusted and advanced into the Z-joint in the contralateral oblique view.

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

Optimal Needle Position in Multiplanar Imaging

Optimal Needle Positioning in the Anteroposterior View

Figure 23–1 A,

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