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Role of Facet Joints in Spine Pain and Image-Guided Treatment: A Review

J.L. Bykowski and W.H.W. Wong
American Journal of Neuroradiology September 2012, 33 (8) 1419-1426; DOI: https://doi.org/10.3174/ajnr.A2696
J.L. Bykowski
aFrom the Department of Radiology (J.L.B.), UCSD Medical Center, San Diego, California
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W.H.W. Wong
bDepartments of Radiology and Anesthesia (W.H.W.W.), Center for Pain Medicine, UCSD Medical Center, San Diego, California.
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  • Fig 1.
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    Fig 1.

    The left C2–3, C3–4, C4–5, and C5–6 facet joints are fluoroscopically identified in orthogonal planes, with the patient prone, for diagnostic medial branch nerve blocks. The patient had prior cervical disk replacements. Frontal projection (A) confirms proper needle placement at the lateral aspect of the facet joints, and the lateral projection (B) confirms the appropriate depth.

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    Fig 2.

    Fluoroscopic guidance is used for cervical facet intra-articular injection in a patient with chronic nonradicular neck pain and C2–5 facet joint tenderness. The pain was refractory to medial branch nerve ablation 9 months prior. The right C2–3 and C-4 facet joints are identified, and 3.6-inch 22-ga spinal needles are advanced with fluoroscopic guidance in lateral (A), dorsal (B), and oblique projections. C, A test injection of contrast confirms the appropriate placement and excludes vascular access, before injection of steroid and anesthetic.

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    Fig 3.

    A, A 3.5-inch 22-ga spinal needle is advanced into the right L4–5 facet under intermittent CT guidance, with the patient prone. B, Injection of 0.2 mL of contrast confirms placement in the joint, and epidural extension is seen after continuing contrast injection. Note that the images are displayed with the patient's right side on the right side of the image, rather than by radiologic convention. We find this orientation easier when performing procedures, especially in the situation of planned bilateral access.

  • Fig 4.
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    Fig 4.

    Frontal (A) and lateral (B) fluoroscopic projections of the lumbar spine with the patient prone confirm appropriate cannula placement for left L2–3, L3–4, and L4–5 medial branch nerve RFA, with the tips of the cannulae at the base of the superior articular process for each level. Frontal (C) and lateral (D) fluoroscopic projections of the cervical spine confirm appropriate cannula placement for bilateral C2–3 and C4–5 medial branch nerve RFA. E, Motor and/or sensory stimulation through each probe is performed in a series, to confirm proximity to the medial branch nerve at each level, before heating.

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    Fig 5.

    A, Sagittal T2-weighted MR image reveals a large left L4–5 synovial cyst causing moderate central canal stenosis and compression of the exiting left L4 nerve root, corresponding to the patient's radicular symptoms and neuroclaudication episodes. B, CT is used to localize the facet and reveals large overhanging osteophytes limiting joint access. C, CT guidance is then used for a left sublaminar approach. D, Rapid forceful injection of contrast into the cyst is performed; epidural spread of contrast confirms cyst rupture. The patient's pain scale was 8/10 preprocedure and 2/10 postprocedure.

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    Fig 6.

    Axial (A and B) and sagittal (C) T2-weighted MR images reveal synovial cysts at L4–5 bilaterally, causing severe central canal stenosis in a patient with neuroclaudication symptoms. A small tail is seen extending from the posterolateral aspect of the left synovial cyst to the left L4–5 facet joint (B), with associated degenerative changes of the facet joint. D, Two 22-ga 3.5-inch spinal needles are advanced with CT guidance into the posterior aspect of the L4–5 facet joints bilaterally, and a test injection of contrast confirms appropriate access to each joint, respectively. E, After forceful injection of contrast mixed with steroid, epidural extension of contrast material is seen, confirming cyst rupture. Contrast extravasation is also noted along the needle trajectory, (F).

  • Fig 7.
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    Fig 7.

    Frontal (A) and lateral (B) projections confirm the appropriate trajectory for the guide pin extending to the facet joint. A small incision is then made in the skin, and the spatula and drill devices are sequentially advanced into the facet joint to form the appropriate cavity. The tamping device is then advanced (C) to seat the dowel of bone allograft material (D). Note that the allograft is difficult to see under fluoroscopic guidance (C). Image D provided courtesy of Trufuse (Clearwater, Florida).

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American Journal of Neuroradiology: 33 (8)
American Journal of Neuroradiology
Vol. 33, Issue 8
1 Sep 2012
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Cite this article
J.L. Bykowski, W.H.W. Wong
Role of Facet Joints in Spine Pain and Image-Guided Treatment: A Review
American Journal of Neuroradiology Sep 2012, 33 (8) 1419-1426; DOI: 10.3174/ajnr.A2696

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Role of Facet Joints in Spine Pain and Image-Guided Treatment: A Review
J.L. Bykowski, W.H.W. Wong
American Journal of Neuroradiology Sep 2012, 33 (8) 1419-1426; DOI: 10.3174/ajnr.A2696
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  • Article
    • Abstract
    • ABBREVIATIONS:
    • Patient Evaluation
    • Image-Guided Therapy
    • Intra-Articular Facet Joint Injection
    • Medial Branch Nerve Ablation
    • CT-Guided Decompression of Synovial Cysts
    • Emerging Percutaneous Image-Guided Interventions
    • Conclusions
    • References
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  • Fluoroscopically Guided Facet Injections: Comparison of Intra-Articular and Periarticular Steroid and Anesthetic Injection on Immediate and Short-Term Pain Relief
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