Info

FIGURE 10 Lumbar zygapophyseal joint injection oblique approach: In the oblique approach the C-arm is started in the PA projection and centered over the joint of interest. While using continuous fluoroscopy, the tube is rotated toward the lateral direction until the first profile of the articular margins is encountered. This should be the posterior joint space and may or may not be similar to a "Scotty dog" projection. Note that in this example that the projection is similar to the traditional 45° oblique position. (A) shows the needle tip projected over the inferior aspect of the joint {arrow). The tip is slightly bent, which often indicates that it is intra-articular. (B) shows an early arthrogram as a linear region of intra-articular opacification (arrowheads). (C) shows a later arthrogram as ovoid contrast accumulating in the superior recess (arrow).

FIGURE 10 Lumbar zygapophyseal joint injection oblique approach: In the oblique approach the C-arm is started in the PA projection and centered over the joint of interest. While using continuous fluoroscopy, the tube is rotated toward the lateral direction until the first profile of the articular margins is encountered. This should be the posterior joint space and may or may not be similar to a "Scotty dog" projection. Note that in this example that the projection is similar to the traditional 45° oblique position. (A) shows the needle tip projected over the inferior aspect of the joint {arrow). The tip is slightly bent, which often indicates that it is intra-articular. (B) shows an early arthrogram as a linear region of intra-articular opacification (arrowheads). (C) shows a later arthrogram as ovoid contrast accumulating in the superior recess (arrow).

is not necessarily the correct target in many patients. If one simply just positions at this designated angle without observing for the most posterior portion of the joint, then the needle will not be able to access this area because of bone. This approach is also problematic for lumbar z-joints with prominent osteophytosis.

The posterior approach is also known as the European approach (26). In this approach, the X-ray tube is left in a vertical position centered over the level of interest. The goal is to access the inferior recess. The target zone is just below the superior articular process along its infero-medial aspect. Often the landmarks of the superior articular process are not well visualized and an alternative target zone is just above the pedicle at its superomedial aspect (Fig. 11). The skin is marked and the needle is placed straight down until the bone is encountered. For the L5-Sl (lumbosacral junction) the target zone is just below (inferior to) the superior aspect of the

FIGURE 11 Lumbar zygapophyseal joint injection posterior approach. (A) The target zone is just below the superior articular process along its inferomedial aspect. However, often the landmarks of the superior articular process are not well visualized and an alternative target zone is just above the pedicle at its superomedial aspect (arrow). (B) shows an arthrogram as ovoid area of contrast accumulating in the expected region of the zygapophyseal joint (arrowheads).

FIGURE 11 Lumbar zygapophyseal joint injection posterior approach. (A) The target zone is just below the superior articular process along its inferomedial aspect. However, often the landmarks of the superior articular process are not well visualized and an alternative target zone is just above the pedicle at its superomedial aspect (arrow). (B) shows an arthrogram as ovoid area of contrast accumulating in the expected region of the zygapophyseal joint (arrowheads).

FIGURE 12 Lumbar zygapophyseal joint injection posterior approach for the lumbosacral junction. (A) For the L5-S1 level (lumbosacral junction), the target zone is just below (inferior to) the superior aspect of the sacrum (arrow). (B) shows an arthrogram as a curvilinear ringlike configuration (arrowheads) with contrast accumulating in the superior (small arrow) and inferior joint recesses (large arrow).

FIGURE 12 Lumbar zygapophyseal joint injection posterior approach for the lumbosacral junction. (A) For the L5-S1 level (lumbosacral junction), the target zone is just below (inferior to) the superior aspect of the sacrum (arrow). (B) shows an arthrogram as a curvilinear ringlike configuration (arrowheads) with contrast accumulating in the superior (small arrow) and inferior joint recesses (large arrow).

sacrum (Fig. 12). Once the needle encounters the bone, passage into the joint is often perceived as a "pop" or loss of resistance as the tip passes through the capsule.

With either the oblique or posterior technique, a z-joint arthrogram should be obtained with the installation of a small amount (0.5 cc) of contrast material. The arthrogram may be circular (ring-like) and there is often flow into the superior recess (Figs. 10B and C, 11B, and 12B). Often the PA projection is sufficient and no other deviation of the fluoroscope is needed to visualize the arthrogram. However, if flow is not perceived but rather a "blob" sign is identified, then rotating the C-arm may be useful. In the lumbar spine, the z-joint arthrogram may be quite variable with contrast passing to the contralateral side and either around or communicating with the contralateral z-joint. Alternatively, contrast may proceed cephalad to the z-joint above. If a pars defect (spondylolysis) is present, it is often opacified by injecting the z-joint.

Was this article helpful?

0 0
Dealing With Back Pain

Dealing With Back Pain

Deal With Your Pain, Lead A Wonderful Life An Live Like A 'Normal' Person. Before I really start telling you anything about me or finding out anything about you, I want you to know that I sympathize with you. Not only is it one of the most painful experiences to have backpain. Not only is it the number one excuse for employees not coming into work. But perhaps just as significantly, it is something that I suffered from for years.

Get My Free Ebook


Post a comment