Both posterior and lateral approaches have been described for joints C3 to C7 (17,18). The plane of the joint is oblique anteroposteriorly, so that the posterior joint is accessible via a puncture two or more segments distal to the target in the prone patient. An angled fluoroscope into the plane of the joint (a pillar view) facilitates this projection. The needle should be directed to hit the end plate bone adjacent to the joint and determine the depth before intra-articular entrance of the needle. Lateral fluoroscopy will also confirm the needle depth. Following the injection of
0.3 mL of contrast, a volume of no more than 1.0 mL of local anesthetic, with or without a corticosteroid, is injected intra-articularly so that capsular rupture does not occur (Fig. 1).
A lateral intra-articular block is performed, with the patient lying on the side with the head supported parallel to the table and the target joint up. To identify the target pillar and joint, the C-arm is rotated slightly anteroposteriorly before and after the needle is inserted into the bone margin of the joint. The needle can then be readjusted so that its tip is felt to enter the joint capsule but not advanced into the joint to prevent entering the epidural or subarachnoid space or the spinal cord. The injection of 0.3 mL of contrast medium will provide confirmation of the intra-articular position (Fig. 2). Intra-articular blocks at C2-C3 can be performed via a lateral approach with a straight tube or with angulation of the tube caudally until the joint is parallel to the beam (Fig. 3) (18).
The lateral atlantoaxial joint can be entered via posterior approach with the needle directed into the lateral aspect of the joint to avoid penetration of the C2 ganglion and ventral ramus. The needle is introduced with 5 mm increments and intermittent fluoroscopy to touch the articular bone before entering the joint, so that the depth of the needle is established. The needle tip should only just enter the joint capsule and the intra-articular position is confirmed with the injection of 0.3 mL of contrast (18). CT scan can also be used to guide a 22- or 25-gauge needle into the posterior C1-C2 joint (Fig. 4) (19).
A lateral fluoroscopic approach to the atlantoaxial joint has also been described by Dreyfuss et al. (20).
The patient is placed on the fluoroscopy table in the lateral position and the "C" arm fluo-roscope is rotated until the C1-C2 articular pillars are aligned. Then the C arm is angled cepha-locaudad to image the joint parallel to the beam. A 25-gauge needle is positioned in the lateral suboccipital neck to reach the junction of the anterior one-third and posterior two-thirds of the joint bone margin before intra-articular placement. This position is confirmed by anteroposte-rior (AP) open mouth fluoroscopy, and the needle is then introduced into the joint followed by the intra-articular injection of 0.3 mL of contrast (Fig. 5).
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