Thoracic Technique

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Thoracic spine z-joint injections are a relatively recent phenomena and uncommon. Although fluoroscopic techniques have been described, the thoracic spine is one area where CT may be advantageous for demonstrating the joint. The difficulty with using CT guidance is identifying the precise level, and typically more than one joint is injected during a single session. Therefore, CT fluoroscopy would be advantageous in this setting, but there is increased radiation exposure to the patient and the operator.

The fluoroscopic technique is as follows (21). The patient is placed prone on a radiolucent table with a C-arm fluoroscope. Posteroanterior imaging is employed intially. The skin entry zone overlying the inferior vertebral end plate of the same numbered vertebral body for T1-T5

FIGURE 7 Cervical zygapophyseal joint injection arthrography: Contrast injection is typically 0.1 to 0.3 mL so as not to rupture the joint capsule prior to anesthetic and corticosteriod administration. (A) A ring-like configuration is seen on the anteroposterior projection (arrowhead ); (B) the superior recess (small arrow ) and inferior recess (large arrow ) are identified on the lateral projection.

FIGURE 7 Cervical zygapophyseal joint injection arthrography: Contrast injection is typically 0.1 to 0.3 mL so as not to rupture the joint capsule prior to anesthetic and corticosteriod administration. (A) A ring-like configuration is seen on the anteroposterior projection (arrowhead ); (B) the superior recess (small arrow ) and inferior recess (large arrow ) are identified on the lateral projection.

FIGURE 6 Cervical zygapophyseal joint injection lateral approach: For the C3-C6 level a lateral projection is obtained profiling the joint margins. Under fluoroscopy the mid-point of the joint is targeted (arrow).

z-joints or just superior to the pedicle of the vertebral body below the level of interest for T6-T10 z-joints is marked (Fig. 8A). The inferior aspect of a z-joint will be located at or slightly above the superior aspect of the pedicle of the lower vertebral body forming that articulation on PA imaging. The skin just above the superior portion of the pedicle below the level of interest is marked. The spinal needle is inserted through the skin mark angling about 60° toward the target joint. Proximal segments (T1-T5) may require a more obtuse angle. Using intermittent PA imaging, the needle is advanced cephalad toward the superior articular process of the articulation of interest. The needle should not stray medial to the medial aspect of the pedicle on PA imaging in order to prevent epidural or subarachnoid puncture. After a few centimeters of

FIGURE 8 Thoracic zygapophyseal joint (z-joint) injection (A-F). Posteroanterior imaging is utilized first, in this example, the T11-T12 z-joint is to be blocked, so the inferior aspect of that z-joint will be located at or slightly above the superior aspect of the T12 pedicle on posteroanterior imaging. The skin just above the superior portion of the pedicle below (L1) is marked (arrow in A). The spinal needle is inserted through the skin mark angling about 60° toward the target joint. Proximal segments (T1-T5) may require a more obtuse angle. Using intermittent posteroanterior imaging, the needle is advanced cephalad toward the superior articular process of T12. The needle should not stray medial to the medial aspect of the pedicle on PA imaging to prevent epidural or subarachnoid puncture. After a few centimeters of needle insertion, the tip should be projected over the mid-aspect of the T12 pedicle (arrow in B). The C-arm intensifier is then rotated away from the side being injected until the outline of the joint is first clearly visible. This requires almost full lateral imaging (typically 20-30° from true lateral and also with minor rotational changes until the X-ray beam is aligned with the plane of the joint). The tip of the needle should be seen at or near the inferior aspect of the target joint. If the angle is not suitable (arrow in C shows that the tip is too high; arrowhead in C shows region of the inferior recess) then the trajectory may be readjusted, being careful not to deviate too much medially or laterally. The needle should be advanced such that the tip projects in the inferior recess on the lateral projection (arrow in D). This will correspond to the cephalad aspect of the T12 pedicle (arrow in E). Injection of contrast should show an arthrogram with ovoid or ringlike collection on the posteroanterior projection (arrowheads in F) and/or opacification of the superior and inferior recesses on the lateral projection.

needle insertion, the tip should be projected over the mid-aspect of the pedicle of the lower vertebral body (Fig. 8B). The C-arm intensifier is then rotated away from the side being injected until the outline of the joint is first clearly visible. This requires slightly off-lateral imaging; typically 20° to 30° from true lateral and also with minor rotational changes until the X-ray beam is aligned with the plane of the joint. The tip of the needle should be seen at or near the inferior aspect of the target joint. If the angle is not suitable (Fig. 8C), then the trajectory may be readjusted, being careful not to deviate too much medially or laterally. The needle should be advanced such that the tip projects in the inferior recess on the lateral projection (Fig. 8D). This will correspond to the cephalad aspect of the pedicle of the lower vertebral body (Fig. 8E). Injection of contrast should show an arthrogram with ovoid or ring-like collection on the PA projection (Fig. 8F) and/or opacification of the superior and inferior recesses on the lateral projection. For the thoracic spine, a 23- or 25-gauge needle may be used. A small amount of contrast (0.3-0.5 mL) is injected to confirm intra-articular location by the demonstration of a z-joint arthrogram. Obliqueing the tube and/or using the lateral projection may be needed to verify intra-articular opacification. Subsequently, local anesthetic and or corticosteroid combination may be injected. Typically, a higher concentration of local anesthetic is used given the small intra-articular volumes of the z-joints (2% or 4% lidocaine). The total injectate should be approximately 1.5 to 2 cc.

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