Cervical Facet Joint Injections

BASIS:
Cervical facet or zygapophyseal joints are plane synovial joints which allow motion across facets.
cervical facet joints are oriented in a plane 45 degrees from the coronal and sagittal planes and is obliquely oriented in the craniocaudal direction, slanting downward in a pattern often visualized as roofing shingles. The medial branch of the dorsal primary ramus provides sensory nerves to the joint and at the C-3 through C-6 levels courses along the lateral margin of the middle of the articular pillar .The third occipital nerve is an especially large branch and runs a more cephalad course being at the lateral aspect of the C2-3 joint. The C-7 medial branch is in the middle to upper articular pillar region, having been pushed upward by the large transverse process of C-7.The major cause of facet joint disease is osteoarthritis, which may lead to neural exit foramen encroachment with or without vertebral subluxation. The sensory nerves of the facets and surrounding tissues may become inflamed and result in local pain, nondermatomal radiation of pain, and focal tenderness.
HOW TO DIAGNOSE:
local pain over a facet joint
restricted range of motion
local tenderness
nondermatomal radiation of pain to the shoulder, back, or arm above the elbow
headache occassionally
Accurate localization of the symptomatic joint can usually be made by firm palpation to elicit focal tenderness.
Imaging is often not required.
TECHNIQUE:
Under IV sedation
No antibiotic prophylaxis
Under guidance of fluoroscopy, CT or MRI
No. 22 ( stiff and trajectory can be changed) or No.25 ( no local anaesthetic needed)
3 trajectories- posterior, posterolateral or lateral
2 angulations-cranial or caudal
no contrast since it causes delayed inflammatory reaction
Diagnostic--1/2 ml of lignocaine or bupivacaine in cavity and 1/2 ml on medial branch
Therapeutic-- add triamcinolone or betamethasone
avoid large volume since it may extravaste into epidural space and cause false positive test

COMPLICATIONS:
The most common are transient worsening of pain or vasovagal reactions
higher doses of local steroids cause anxiety in the elderly, elevation of glucose in diabetics, and abnormal menses in women
RELIABILITY:
In patients with a facet syndrome, diagnostic and therapeutic blocks can reduce the pain. This helps with diagnosis in difficult cases. The implication for successful surgery after the block, however, is unclear.