Ebook The handbook of C-ARM fluoroscopy guided spinal injections: Part 2

Chapter

Fluoroscopic Images
of the Cervical Spine

7

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Positioning the Patient
Cervical spinal injections can be done in either the supine (Figure 7.1A), prone (Figure 7.1B), or
lateral positions (Figure 7.1C).

A

B

C

FIGURE 7.1
Cervical spine injection positions. (A) Supine position. (B) Prone position. (c) Lateral position.

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Positioning the C-Arm
The C-arm can be positioned in many ways for cervical spinal injections (Figure 7.2). For example,
the C-arm can be positioned from the patient’s side, as when performing lumbar procedures (Figure
7.2A). The C-arm can also be positioned from behind the patient’s head (Figure 7.2B). The C-arm
can be positioned to get a lateral view of the cervical spine as seen in Figure 7.2C and Figure 7.2D.

A

B

C

D
FIGURE 7.2
C-arm positions. (A) At side. (B) At patient’s head. (C) and (D) Positioned for lateral view of cervical spine.


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155

A/P (P/A) View and Lateral View of the Cervical Spine
Images of both the anterior–posterior (A/P) view in the prone position, the posterior–anterior (P/A)
view in the supine position and the lateral view of the cervical spine, look quite different from
images of the A/P and lateral view of the lumbar spine (Figure 7.3). This is due to the unique
shapes of the cervical vertebrae.

B

A

C

D

Mandible

FIGURE 7.3
The cervical and the lumbar spine. (A) P/A view of the cervical spine. (B) A/P view of the lumbar spine. (C) Lateral view
of the cervical spine. (D) Lateral view of the lumbar spine.


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Comparison of Cervical Vertebrae and Lumbar Vertebrae
Like a lumbar vertebra (Figure 7.4B), a cervical vertebra (Figure 7.4A) consists of the vertebral
body, two transverse processes, two pedicles, lamina, two superior articular processes, two inferior
articular processes, and a spinous process. However, the cervical vertebra differs from the lumbar
vertebra. Their differences are summarized in Table 7.1. Figure 7.5 is a P/A view image of the
cervical spine.

A

B

C
D

FIGURE 7.4
(A) Cervical vertebra (superior view). (B) Lumbar vertebra (superior view). (C) Lateral view of the cervical spine from C4
to C7. (D) Lateral view of the lumbar vertebra.

TABLE 7.1
Comparison of Cervical Vertebrae and Lumbar Vertebrae
Cervical Vertebra

Lumbar Vertebra

Vertebral body

Small

Large

Transverse process

Quite small
Connects to lateral surface of vertebral body
Anterior to the pedicle
Has transverse foramen
Anterior to the superior articular process

Large
Connects to posterior surface of vertebral body
Posterior to the pedicle

Lateral to the superior articular process

Pedicle

Short
Connects to posterior surface of transverse
process

Long
Connects to posterior surface of lumbar
vertebral body

Spinous process

Varies in length
Ends in two tips (called bifid tips)

Long
Ends in only one tip

Superior articular
process

Connects to pedicle only

Connects to pedicle and transverse process

Inferior articular
process

Articular pillar connects the superior and
inferior articular processes

Pars interarticularis (part of lamina) connects to
superior and inferior articular processes


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157

4

3
2

1
FIGURE 7.5
Fluoroscopic image of the P/A view of the cervical spine. (1) Spinous process, (2) transverse process with transverse
foramen, (3) articular pillar, (4) vertebral body.


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Lateral and Oblique Views of the Cervical Spine
Figure 7.6 is a lateral fluoroscopic image of the cervical spine. We usually rotate the fluoroscopic
image horizontally if the patient is in a supine position (Figure 7.7).

Mandible

3

6

2
1
4

7
5

FIGURE 7.6
Fluoroscopic image of the lateral view of the cervical spine. (1) Spinous process, (2) articular pillar, (3) superior articular
process, (4) inferior articular process, (5) vertebral body, (6) pedicle, (7) transverse process with transverse foramen.


Fluoroscopic Images of the Cervical Spine

159

Mandible

6
5

2

3

1

4

FIGURE 7.7
Fluoroscopic image of the lateral view of the cervical spine (rotation of fluoroscopic image in Figure 7.6). (1) Spinous
process, (2) articular pillar, (3) superior articular process, (4) inferior articular process, (5) vertebral body, (6) transverse
process with transverse image of the foramen.


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In true lateral images of the cervical spine (Figure 7.8), the vertebral body is squared, the
articular pillar is a trapezoid shape, the facet joint space is open, the transverse process with
transverse foramen cover the posterior–superior portion of the vertebral body, and the spinous
process has sharp superior–posterior and inferior margins.

Mandible

Transverse processes with transverse foramina cover posterior–superior
portion of vertebral body

Vertebral body is squared off
Vertebral body
Transverse process with
transverse foramen
Articular pillar

Spinous
process
A trapezoid
shape of
Articular pillar

Spinous process
has sharp
margins

FIGURE 7.8
Lateral images of cervical spine.

Facet space is open


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161

Figure 7.9 illustrates the comparison between the true lateral view and the false lateral view
of the cervical spine images. The left column illustrates true lateral view images. The right column
illustrates the false lateral images.

A

B
Mandible

C

D

E

FIGURE 7.9
(A) True lateral image. (B–F) False lateral images.

F


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It is very difficult to identify intervertebral foramina on the lateral image of the cervical spine
compared with the lateral image of the lumbar spine (Figure 7.10). This is because the cervical
transverse processes complex opacifies the image of intervertebral foramen. However, if we view
the cervical spine obliquely and inferiorly (Figure 7.11), we can visualize the intervertebral foramina
easily.

Mandible

Transverse processes cover intervertebral
foramens

A

Intervertebral
foramens

B

C
FIGURE 7.10
(A, B) Lateral images of the cervical spine. (C) Lateral image of the lumbar spine.


Fluoroscopic Images of the Cervical Spine

A

B

FIGURE 7.11
(A) Photo of inferior and oblique views of the cervical spine. (B) Photo of the lateral view of cervical spine.

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A unique oblique image of the cervical spine (Figure 7.12) can be obtained by tilting the C-arm
to the injecting side about 45˚ and rotating caudally about 20 to 30˚ (Figure 7.13).

Mandible

FIGURE 7.12

Right-sided obliquely viewed fluoroscopic image of the cervical spine.

FIGURE 7.13
The C-arm positions required to obtain a fluoroscopic image of the cervical spine shown in Figure 7.12.


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165

Cervical Intervetrebral Foramina and the Cervical Spinal
Nerve Roots
There are eight cervical spinal nerve roots and only seven cervical vertebrae. There is no intervertebral foramen between C1 and C2. The first visualized cervical intervertebral foramen is between
C2 and C3. The C3 spinal nerve root travels via this foramen (Figure 7.14). The vertebral artery
goes via the transverse foramina, usually from the C6 foramen to the C1 foramen into the skull (Figure
7.15A and Figure 7.16A). The possible locations of the vertebral artery are demonstrated on the
laterally and obliquely viewed fluoroscopic images of the cervical spine (Figure 7.15B and Figure
7.16B).

Mandible

The foramen between C2 and C3

There is no foramen between C1 and C2
FIGURE 7.14
Method for counting intervertebral foramina and cervical spinal nerve roots.


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Mandible

A
Vertebral artery
B
Vertebral artery
FIGURE 7.15
Location of the vertebral artery on the lateral view of the cervical spine.

Mandible

A
Vertebral artery

B
Vertebral artery
FIGURE 7.16
Location of the vertebral artery on the obliquely viewed cervical spine.


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Bibliography
Bontrager, K.L. and Anthony, B.T., Eds., Textbook of Radiographic Positioning and Related Anatomy, 2nd ed.,
C.V. Mosby Company, St. Louis, MO, 1990.
Brown, D.L., Ed., Atlas of Regional Anesthesia, 2nd ed., W.B Saunders, Philadelphia, 1999.

Clemente, G.D., Ed., Gray’s Anatomy, 13th ed., Lea & Febiger, Philadelphia, 1984.
Fenton, D.S. and Czervionke, L.F., Eds., Image-Guided Spine Intervention, W.B. Saunders, Philadelphia, 2003.
Netter, F.H., Ed., Atlas of Human Anatomy, Ciba Geigy Corporation, 1989.
Waldman, S.D., Ed., Atlas of Interventional Pain Management, 2nd ed., W.B. Saunders, Philadelphia, 2004.


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Chapter

Cervical Injections

8

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Cervical Injections

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In this chapter, we will discuss injections around the cervical spine for the relief of pain due to
headaches, neck pain, shoulder pain, and arm and hand pain. We will first begin with cervical facet
injections, both intra-articular and medial branch injections and radiofrequency denervation, and
we will then proceed to cervical epidural and nerve root injections. Both interlaminar and transforaminal epidural steroid injections will be discussed.
The pain physician should be very familiar with lumbar injections prior to attempting any

injections in the neck. Familiarity with airway management is also recommended for physicians
who perform cervical spinal injections.

Preparation for the Performance of Cervical Injections
Patient preparation: We advise the patients to have no solid foods for a minimum of 6 h,
particularly prior to cervical injections. We recommend that the patients have another individual
available to transport them home following the procedure. Sterile preparation and drape are required;
preparation above and below the hairline may be required, particularly for the upper cervical
injections. Monitor the patient’s heart rate, blood pressure, and oxygen saturation. The American
Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines report no evidence of
additional risk for patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) who received
spinal or epidural analgesia.1 However, when performing cervical transforaminal injections, it is
the author’s practice, as a precaution, to ask the patients not to take aspirin for 7 to 10 d prior to
the procedure and not to take NSAIDs (with the exception of COX-2 inhibitors) the day of the
procedure.
Equipment/Materials:
•

•
•
•
•

•
•

•
•

A 22- or 25-gauge 3½ in. spinal needle, with or without a distal curved tip in the direction of the

bevel, is used for most cervical procedures performed in the prone position. A 25-gauge, 2 in. spinal
needle is adequate for the vast majority of cervical foraminal and facet injections that are performed
with the patient in the supine position. It is very rare, even in obese patients, to require a 3½ in.
spinal needle for cervical transforaminal injections.
Intravenous (IV) access for all cervical transforaminal injections as a safety precaution in the event
of intravascular injection.
Oxygen delivered at low flows via nasal cannula is suggested.
Water-soluble nonionic dye.
Local anesthetic (e.g., 0.25 to 0.5% bupivacaine or 2% lidocaine) and steroid for a total of 1 ml or
less of injectate. Note that the local anesthetic and steroid may be injected together as a combined
solution or separately.
We recommend using the least particulate steroid available for transforaminal epidural steroid or
selective nerve root injections. Steroids are not necessary for medial branch injections.
A syringe (or syringes) for injecting the local anesthestic and steroid. A 3 ml or smaller is recommended; a 10 ml syringe is too large and will generate too much pressure with aspiration and risk
inadvertent vascular injection.
Connection tubing to allow for contrast injection without fluoroscopy exposure to the hands. This
also facilitates an immobile needle.
Lidocaine (0.5 to 2%) and a 25- to 27-gauge needle for local infiltration. We do not recommend the
use of needles greater than 1 in. for skin infiltration for cervical procedures, particularly in thin
patients. We recommend very superficial, subcutaneous injections of local anesthetic to avoid intravascular or brachial plexus injections.

Sedation: Light sedation is recommended, e.g., with midazolam 1 to 2 mg intravenously.


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Cervical Facet Injections
Headaches and pain felt in the neck, shoulders, and upper back may originate in the upper, middle,

and lower cervical facets, respectively.2,3 Cervicogenic headaches differ from vascular headaches
both in their symptoms and in the origination of cervicogenic headache from the posterior superior
neck. These headaches may also be reproduced by palpation of the painful facet joint, with lateral
neck movement, and particularly with neck extension. Cervicogenic facet and radicular pain are
similar in character when originally from the upper cervical levels (C1–C4). The C2/C3 joint was
reported to be a source of headaches following whiplash injury. Excellent response has been reported
for relief of these headaches from lesions of the third occipital nerve, which innervates the C2/C3
facet joint.4 Below C4, cervical facet pain radiates to the shoulder and upper back; while cervical
radiculopathy involving the C5 root and below involves the shoulder then radiates distally to the
arm (Figure 8.1).


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C1
(atlas)

C2
(axis)

C7

T1

FIGURE 8.1
The cervical spine, viewed from the lateral approach. The needles indicate the target areas for both medial branch and
intraarticular facet injections on the left side.

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Intra-Articular Facet Injections
C1/C2 Joint Injection
The C1/C2 or atlantoaxial (AA) joint (Figure 8.2A) receives innervation from the C2 nerve root.
Pain, generally posterior headaches, that comes from the C1/C2 joint is generally localized to the
suboccipital region and may be exacerbated with neck rotation. Pain coming from the upper cervical
facets is more often manifested as headache rather than neck pain.5 The C-arm should be adjusted
in order to obtain the clearest view into the joint. The angulation of the C1/C2 joint is not as caudal
as it is in the lower cervical facets. The vertebral artery is just lateral to the C1/C2 joint; thus. the
needle should stay medial to the lateral border of the C1/C2 joint at all times. If the needle enters
medial to the junction of the lateral one third of the joint, the likelihood of an intrathecal injection
increases (Figure 8.2B).

(A)

Atlantoaxial (AA) joint

(B)
FIGURE 8.2
(A) Photograph of a spine model of the C1/C2 joint. (B) The spine with the C1/C2 joint marked.

Indications:
1.
2.

Neck pain with associated posterior headache

Upper neck pain exacerbated by neck movement


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Contraindications:
1. Patient refusal
2. Systemic anticoagulation or coagulopathy
3. Systemic or localized infection at the site
4. Unstable cervical spine

Patient position: The patient is placed in the prone position; a pillow may be placed under
the chest to allow for slight neck flexion (Figure 8.3).

A pillow under the chest
FIGURE 8.3
The patient position for C1/C2 intraarticular injection.

C-arm position:
1.
2.

3.

The C-arm is placed at the head of the bed in front of the patient (or, alternatively, it may be at the
patient’s side).
If the image intensifier is at the head, then it is rotated approximately 20˚ toward the head to get an
anterior–posterior (A/P) view of the joint. This is best accomplished with the patient’s mouth open.

Adjust the image intensifier angle until a sharp image of the AA joint is visualized.
We recommend saving copies of the A/P and lateral views showing the location of the needle tip
before and after the injection of contrast into the joint.

Procedure:
1.
2.
3.
4.
5.
6.

The patient’s posterior occipital region is prepped in a sterile fashion above and below the hairline
and then draped.
The C-arm is positioned as described above.
A 22- or 25-gauge, 3½ in. spinal needle is used. A slight curved tip often makes the needle easier
to steer and allows for “bevel control.”
It is easier to visualize the AA (C1/C2) joint if the patient’s mouth is open (Figure 8.4A and Figure 8.4B).
The needle is advanced from the caudal aspect of the AA joint and enters the joint at the junction
of the lateral one third and medial two thirds of the joint in the A/P view.
The needle depth is ascertained in the lateral view, and the needle tip position within the AA joint
is determined in the A/P view.