Bogduk Evidence Based Spine Continued Cervical Facet Joint Injection

ABSTRACT

BACKGROUND CONTEXT

Cervical facet joints are a common cause of chronic neck pain. Radiofrequency neurotomy is a validated treatment technique for cervical facet joint pain, but the role of intra-articular injections is less clear. Ultrasound guidance can be used to inject the cervical facet joints. Given that the accuracy of any injection technique is likely to affect treatment outcomes, it would be useful to know the accuracy of ultrasound-guided cervical facet joint injections.

PURPOSE

The primary purpose of this study was to determine the accuracy of ultrasound-guided cervical facet joint injections using a lateral technique. The secondary purpose was to describe the technique.

STUDY DESIGN/SETTING

Cohort study of ultrasound-guided cervical facet joint injections performed by an experienced spine and ultrasound interventionist, as assessed by contrast dye arthrography at a community interventional spine practice.

PATIENT SAMPLE

Sixty joints in 36 patients with facet mediated pain.

OUTCOME MEASURES

Accuracy of ultrasound-guided injections as determined by the percent of fluoroscopic contrast dye patterns interpreted to be intra-articular by the operator and an independent imaging specialist. Confidence intervals were determined using binomial "exact" and normal approximation to the binomial calculations.

METHODS

Ultrasound using a long-axis or in-plane approach was used to guide a needle into a facet joint, followed by injection of contrast dye and a lateral fluoroscopic image. The dye pattern was interpreted by the operator. Depending on the pattern, local anesthetic and corticosteroid were injected. The patient was asked whether their neck pain had resolved. If not resolved, another joint was selected and the process was repeated. At the end of the study, all of the contrast patterns were interpreted independently by the imaging specialist. Funding was through a 501(c)(3) foundation without any commercial or sponsorship interests.

RESULTS

The accuracy of ultrasound-guided cervical facet joint injections using the lateral technique ranged from 92% to 98% depending on the criteria used to confirm an intra-articular contrast pattern (95% CI: 0.82–0.97 to 0.91–1.0, and 0.85–0.99 to 0.95–1.00). The distribution of injections was C2–3 (22%), C3–4 (40%), C4–5 (33%) and C5–6 (5%).

CONCLUSIONS

Cervical facet joint injections can be performed with a high degree of accuracy using a lateral ultrasound-guided technique. As with fluoroscopy-guided cervical facet joint injections, the technique requires a careful approach and a high degree of skill.

Keywords

• Accuracy
• Cervical
• Facet joint
• Injection
• Ultrasound
• Fluoroscopy
• Pain

Introduction

The cervical facet joints are a common cause of chronic neck pain [

[1]

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], which is the fourth most common cause for years lived with disability in the world [

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]. Radiofrequency neurotomy is a validated technique for the treatment of cervical facet joint pain of any cause [

,

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]. If performed correctly, and depending on the response to diagnostic blocks, it can result in complete pain relief lasting up to several years [

]. The role of intra-articular injections in the treatment of cervical facet joint pain is less clear. Randomized controlled trials have shown that corticosteroid injections are ineffective for whiplash-related pain [

], but may be effective for cervical facet joint pain not related to whiplash [

[7]

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]. Ultrasound can be used to guide intra-articular cervical facet joint injections [

8

• Galiano K
• Obwegeser AA
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• Maurer H
• et al.

Ultrasound-guided facet joint injections in the middle to lower cervical spine: a CT-controlled sonoanatomic study.

• Crossref
• PubMed
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• Google Scholar

,

9

• Obernauer J
• Galiano K
• Gruber H
• Bale R
• Obwegeser AA
• Schatzer R
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Ultrasound-guided versus Computed Tomography-controlled facet joint injections in the middle and lower cervical spine: a prospective randomized clinical trial.

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,

,

,

]. Given that the accuracy of injections is likely to affect treatment outcomes, the primary purpose of our study was to determine the accuracy of ultrasound-guided cervical facet joint injections using a lateral technique. The secondary purpose was to describe the technique.

Materials and methods

Patients and equipment

We studied 60 cervical facet joint injections in 36 consecutive adult (ages ≥18) patients presenting to a community interventional spine practice who met the following inclusion criteria: (1) ipsilateral or bilateral neck pain of at least 1 month duration, exacerbated by neck rotation, with or without referral to the occiput, trapezius, or scapula; (2) focal tenderness to palpation of at least one cervical facet joint while imaging the joint using ultrasound (sonopalpation); and (3) interested and willing to consent to an injection procedure for their neck pain. The exclusion criteria were pain in the shoulder or arm, a history of adverse reaction to contrast dye, steroids or local anesthetics, and pregnancy. Each of the patients completed a written informed consent process for the procedure and the study during which they were informed that ultrasound would be used to identify and guide a needle to the suspected painful joint, followed by fluoroscopic imaging before and after injection of iodinated contrast dye (Isovue-200, Bracco Diagnostics Inc. Monroe Twp., NJ, USA). If contrast dye was confirmed to be intra-articular, a mixture of 0.3 to 0.5 ml ropivacaine 0.5% (Hospira, Lake Forest, IL.) plus 5 to 10 mg of triamcinolone acetonide 40 mg/ml (Bristol-Myers Squibb Co., NY, USA) was injected. While we used sonopalpation, we did not scientifically study or evaluate it.

The study was approved by the Providence St. Joseph's Health Institutional Review Board, and all patients provided written informed consent. Injections were performed by the first author (MB), who assessed the contrast dye patterns at the time of the procedures. The second author (NM) independently (without knowledge of the operator's interpretation) assessed the contrast dye patterns after all 60 procedures had been completed.

Prior to the study, the first author had over 12 years of interventional spine experience and had performed over 700 fluoroscopy-guided and 300 ultrasound-guided cervical facet joint injections. The second author had over 12 years of diagnostic imaging and interventional spine experience and had performed over 1500 fluoroscopy-guided cervical facet joint injections. A Philips iU-22 ultrasound machine with a 12 to 5 MHz transducer (beam width 0.7 mm) was used for the ultrasound-guided injections. The long-axis view or in-plane approach, with the needle placed along its length within the plane of the ultrasound beam so that both its shaft and tip are visible at all times, was used for the injections. A Philips BV-Pulsera C-arm fluoroscopy unit with a 12″ image intensifier and an Arcoma carbon fiber imaging table were used for fluoroscopy. Standard 27-gauge 1.25″ needles were used for most patients, with some being injected with 25-gauge 2.0″ needles and some with 30-gauge 1″ needles (Becton-Dickinson, Franklin Lakes, NJ, USA).

Ultrasound-guided injection technique

The technique was developed and refined by the first author (MB) over a period of several years. The patient is placed in a side-lying position, with the head placed comfortably on a pillow. The operator stands between the patient on his right side and the ultrasound machine on his left side, and the monitor is positioned on a swiveling arm in front. For injections of the right side of the neck, the patient faces away from the operator, and for injections of the left side of the neck, the patient faces towards the operator. For a right-handed operator, the transducer is held with the left hand and the syringe and needle with the right. When injecting the right side of the neck, the needle trajectory is from an anterior-lateral approach, and when injecting the left side, the needle trajectory is from a posterior-lateral approach. The difference in approach between the right and left sides is to ensure consistency in advancing the needle with the dominant hand, but the approach can be reversed if the joint opening is angled in the opposite direction and the operator has a steady nondominant hand. For the study, the fluoroscopy C-arm was pre-positioned to obtain a lateral view of the neck, ensuring that the facets on both sides of the neck were perfectly overlapped.

The patient's head and neck are rotated and tilted slightly away from the side being injected so as to flatten the concavity of the neck and facilitate transducer placement. The ultrasound transducer is placed over the lateral aspect of the neck, revealing the undulating pattern of the articular processes (Fig. 1). The joint spaces are seen as small gaps (1 mm) located between the articular processes of young healthy joints (Fig. 2A). The gaps are typically wider in older joints as they represent osteophytes with increased fluid, small surrounding effusions and/or synovial thickening (Fig. 2B). The transducer is translated superiorly until the last undulation, the C2–3 facet joint, is seen. The undulation of C2–3 typically lies slightly posterior to the other levels. Holding the transducer still, pulsations related to the vertebral artery can be seen in the tissue deep and superior to the joint, and with an additional 5 to 10 mm of anterior translation, the vertebral artery itself can be seen, with or without the use of color doppler imaging. The remaining facet joint levels are identified by counting downwards from C2–3.

Fig. 1 First scanning position with the transducer aligned with the long-axis of the neck (A); 12–5 MHz ultrasound image of the lateral aspect of the C3–4, C4–5 and C5–6 facet joints (B); corresponding anterior (C) and posterior (D) anatomical model views.

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Fig. 2 The lateral aspects of the C3–4, C4–5 and C5–6 facet joints in an asymptomatic 16 y old female (A), and an asymptomatic 51 y old male (B). Note the smooth undulating pattern in (A) compared to (B). The joint openings are gaps at the top of the undulations (arrows), much smaller in (A) than in (B), where increased joint fluid (asterisk at C3–4) can be seen.

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At this point a critical rotation maneuver is performed with the transducer to get it into position for facet joint sonopalpation and injection. Typically, the C3–4 or C4–5 or whichever joint has the largest opening, effusion or easily identifiable osteophytes is selected. While maintaining a continuous view of the joint opening or other landmark, the transducer is rotated until it becomes aligned with the angle of the mandible (Fig. 3). In this position, the transducer lies on top of only one joint. The transducer is then used to apply pressure to the joint (sonopalpation) to assess for tenderness. The other joints are similarly assessed by translating the transducer superiorly and inferiorly one joint at a time and using varying degrees of pressure. The most tender joint is selected to be injected first.

For a right-handed injection, the transducer is translated to the left to move the targeted joint to the right side of the screen and closer to the needle entry point. An area of skin approximately 2 × 2 cm to the right side of the transducer is prepared with a 70% isopropyl alcohol pad. Then the needle is inserted just under the skin, 5 to 10 mm from the right-side edge of the transducer, being careful not to touch the transducer. At this location, 0.1 ml of lidocaine 4% (Hospira, Lake Forest, IL, USA) is injected to provide local anesthesia. After waiting 10 seconds, the needle is advanced under the long axis of the transducer in the plane of the ultrasound beam towards the targeted joint. As the needle is advanced, 0.1 to 0.5 ml lidocaine 4% is injected to reduce pain, including outside the joint capsule (see Appendix, Videos 1A–B).

After a final check of the needle and joint position, the needle is advanced 1 to 2 mm through the capsule and into its final position between the articular processes (Fig. 4). Throughout the procedure, the needle and its tip have to be kept in the long-axis view, especially during the final advancement into the joint. As the needle passes through the capsule, there is typically a slight loss of resistance. The needle can then be advanced another 1 to 2 mm into the joint before it encounters the bone of the articular processes. In the rare event that the needle does not encounter bone at this point, it should not be advanced more than an additional 1 to 2 mm. Once the needle is in position, 0.1 ml of lidocaine 4% is injected and the syringe is removed. For the study, a lateral fluoroscopic image was then obtained, followed by injection of 0.1 to 0.2 ml of Isovue-200 and another fluoroscopic image.

Contrast patterns and pain assessment

The resulting contrast patterns were categorized as "linear", "bilobed", "indeterminate", "outside the joint", or a combination thereof based on appearance (Fig. 5, Fig. 6, Fig. 7). If a "linear", "bilobed" or a "linear-bilobed" pattern was obtained, the flow pattern was determined to be intra-articular, and an injection of 0.3 to 0.5 ml ropivacaine 0.5% plus 5 to 10 mg of triamcinolone acetonide (40 mg/ml) was provided using real time ultrasound imaging (see Appendix, Videos 1C–D, 2). The injection was performed slowly until resistance to outflow was obtained or 0.8 ml of the injectate had been injected. As long as an intra-articular contrast pattern had been obtained, if some contrast was seen outside of the joint it did not preclude doing an injection.

After the first facet joint had been injected, the patient was asked to sit up, wait two minutes, then turn their head and answer whether their pain was resolved, better or the same. If the pain was resolved, the procedure was considered complete. If the pain was better or the same, the next most tender joint was targeted and injected, followed by reassessment and additional injections as necessary until their pain was resolved and the procedure was considered complete. No patients reported worse pain after their procedures.

After 60 facet joint injections had been completed, the fluoroscopic images were sent to the second author (NM) for an independent assessment of contrast patterns. The primary criterion for accuracy was that both authors independently determined that a contrast pattern was intra-articular. The secondary criterion for accuracy was that after independent review, the authors discussed any indeterminate or extra-articular injections to learn what could have contributed to the discrepancy.

Additional data and statistical analysis

In addition to type of contrast pattern, data collected included patient age, sex, facet joint level, body mass index (BMI) and ponderal index (PI). PI was used because it is a more accurate indicator of relative body dimensions than BMI. Accuracy was calculated as a straight percentage, and 95% confidence intervals were calculated using binomial "exact" and normal approximation to the binomial calculations [

].

Results

Our patients included 28 women and eight men, ranging in age from 30 to 89 (median 59.5, SD 13.4). BMI ranged from 18 to 44 (mean 26.6, SD 5.6), and PI from 12 to 28 (mean 16, SD 3.5). 10 out of 36 (28%) of our patients had a history of whiplash injury preceding the onset of their neck pain.

The following cervical facet joint levels were injected: C2–3, six right and seven left (22%); C3–4, 12 right and 12 left (40%); C4–5, 11 right and 9 left (33%); C5–6, one right and two left (5%). There were 30 injections on the right side of the neck and 30 on the left side of the neck. A single facet joint was injected in 19 patients, two in 9 patients, and three in two patients, all unilateral. Among the subset of 10 patients with a history of whiplash, 13 joints were injected (three of which were repeated), and the distribution was C2–3 (31%), C3–4 (31%), C4–5 (31%) and C5–6 (7%).

Bilateral C3–4 and right C4–5 injections were provided in one patient. One patient had repeat injections to the right C3–4 and C4–5 facet joints 8 months later, while another had the left C2–3 facet joint injected again 1 month after the left C2–3 and C3–4 joints had been injected. One patient had the left C4–5 facet joint injected 1 month after the left C3–4 and C5–6 facets had been injected. Another patient had a repeat right C2–3 facet injection 3 months later.

In 58/60 (97%) of the facet joint injections, the first and second authors independently agreed that the contrast dye patterns were either linear, bilobed, or the linear-bilobed types, confirming intra-articular placement. One facet joint had an unexpected ovoid pattern related to an oblique view, which was determined to be intra-articular (Fig. 8), raising the latter to 59/60 (98%). In one of the injections, both raters, and in three of them, one rater or the other, added "indeterminate" to the interpretation, as in "linear-indeterminate." In three of these injections the volume of contrast was very low, and in one, a patient with a large neck, the needle was placed in a perfect intra-articular position on ultrasound, but after contrast was injected an extra-articular contrast pattern was seen on fluoroscopy. In this case, the operator placed the ultrasound transducer back on the neck and noted that the needle had pulled out of its original position. The needle was repositioned using ultrasound, followed by contrast injection confirming intra-articular placement. In this case, the needle was too short, resulting in it being pulled out because of expansion of the soft tissues of the neck after the operator had removed his hand from the needle and the neck to obtain the fluoroscopic images. The latter instance was the only time that a needle was positioned or repositioned based on a fluoroscopic image. If three of these injections are categorized as extra-articular, the accuracy rate is 56/60 (93%), and if four of them, then 55/60 (92%). Confidence intervals (95%) were 0.82 to 0.97 and 0.91 to 1.0 for the 55/60 (92%) and 59/60 (98%) accuracy rates based on a binomial "exact" calculation, and 0.85 to 0.99 and 0.95 to 1.0 based on the normal approximation to the binomial calculation [

].

Discussion

Galiano et al. were the first to describe a lateral ultrasound-guided cervical facet joint technique in cadavers [

[8]

• Galiano K
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]. Obernauer et al. evaluated the accuracy of this technique using computed tomography (CT), noting a 100% (26/26) accuracy of placing the needle tip within the joint space [

[9]

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Ultrasound-guided versus Computed Tomography-controlled facet joint injections in the middle and lower cervical spine: a prospective randomized clinical trial.

• Crossref
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]. Narouze et al. described a posterior approach [

,

], while Freire et al. performed a cadaver study of this approach, noting a 78% (31/40) accuracy rate in injecting latex into the joints [

[12]

• Freire V
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].

Our study is the first to assess the accuracy of ultrasound-guided cervical facet joint injections as assessed by contrast dye arthrography in patients. Our accuracy of 92% to 98% is comparable to that of Obernauer et al [

[9]

• Obernauer J
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Ultrasound-guided versus Computed Tomography-controlled facet joint injections in the middle and lower cervical spine: a prospective randomized clinical trial.

• Crossref
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]. The lower accuracy rate of Freire et al. is likely due to the joints being deeper from the back of the neck compared to the side, making them more difficult to see and inject.

We are not aware of any studies specifically assessing the accuracy of fluoroscopy-guided cervical facet joint injections. In the study by Dwyer et al., an experienced operator successfully placed a needle into 10 out of 11 (91%) of cervical facet joints in a group of four asymptomatic volunteers [

]. A study of 50 to 100 facet injections with independent assessment of fluoroscopy contrast patterns would be warranted.

In a series of 125 patients, experienced physical therapists using tests of neck extension-rotation, posterior palpation and thrust were able to identify painful facet joints with 94% sensitivity and 84% specificity [

]. Among our patients, the most commonly involved painful joints were C3–4 (24/60, 40%), C4–5 (20/60, 33%) and C2–3 (13/60, 22%). By contrast, among whiplash injured patients Lord et al. noted the most commonly involved joints to be C2–3 (17/38, 45%) and C5–6 (9/38, 24%), with the remaining being C3–4 (6/38, 16%), C4–5 (2/38, 5%) and C6–7 (4/38, 10%) [

]. Among our subset of whiplash patients, we had relatively fewer C5–6 (1/13, 7%) and no C6–7 joints.

The difference in the distribution of facet joint pain between our patients and those of Lord et al. is most likely due to differences in patient populations, mechanisms of injury, and random variability. The median age of our patients was 59.5 years, while Lord et al.'s was 41. The chief complaint and key selection criterion for our patients was pain in the neck exacerbated by rotation. Hypothetically, neck rotation starts at the top, with rotation of the head, followed by the upper and middle cervical facet joint components of the kinetic chain, which might be affected earlier and to a greater degree than the lower. The loading patterns and progression of cervical facet joint osteoarthritis over the course of a lifetime would be expected to be much different than that of whiplash injury, caused by a sudden event involving high flexion, extension and rotation forces applied to the entire head and neck. Random variability is evident in the study by MacVicar et al. (median age 48) [

], in which two similar practices had marked differences in the distribution of C6–7 facet joint pain, with 1/43 (2%) in Practice A versus 14/87 (16%) in Practice B.

It is interesting to note that while age-related disc degeneration is most prevalent at the C5–6 and C6–7 levels, facet arthropathy was more common at the C2–3, C3–4 and C4–5 levels among our patients. This is in contrast to the lumbar spine where facet and disc degeneration are more often at the same level. This is most likely because of differences in biomechanics between the cervical and lumbar spine.

During ultrasound-guided cervical facet joint injections, we have observed young healthy joint capsules to expand until increased resistance is experienced (typically after 0.6 to 0.8 ml). At this point if the operator releases the plunger of the syringe, the plunger may rise back up as fluid returns to the syringe because of elastic contraction of the capsule. We have observed some capsules to expand, become distended, then suddenly decompress, possibly indicating the opening of a small or partially healed capsule tear. Yet others expand minimally or not at all, even after 1.0 ml or more has been injected, indicating a capsular rupture, incompetence or a connection with the space of Okada [

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A significant limitation of ultrasound-guidance for cervical facet joint injections is in imaging joints in patients with large necks or those with increased adipose tissue. At depths of 3 cm or greater, the joint space openings become more difficult to see. Another limitation of ultrasound is the inability to perform contrast angiography to detect intravascular flow if a needle has been placed into a blood vessel. Using ultrasound, however, it is possible to see blood vessels as small as 1 mm and avoid them [

].

Since 2013, we have performed over 2000 ultrasound-guided cervical facet joint injections using the described technique. One patient with increased adipose tissue, small joints and prominent osteophytes experienced a transient (15 minute) alteration of mental status. During her procedure, the short-axis view or out-of-plane approach was used to make final adjustments to the needle before injecting 0.2 ml of local anesthetic. Also, because of osteophytes, an approach parallel to the lateral joint line had been taken. The limitation of the short-axis view is that the tip of the needle can migrate outside of the ultrasound beam where it cannot be seen, which in her case was anteriorly in the vicinity of the vertebral artery. This cannot occur in the long-axis view. It is thus imperative these injections be performed in the long-axis view perpendicular to the diagonal orientation of the facet joints (Figs. 4 and 9).

We are aware of at least one case in which an experienced operator passed a needle through a facet joint and into the spinal cord during a fluoroscopically-guided injection. An advantage of ultrasound guidance using the long-axis view or in-plane approach is the ability to aim for a target while simultaneously knowing the depth of the needle. By contrast, fluoroscopy requires two orthogonal views and intermittent rotation of the C-arm to assess the depth of the needle. This advantage is not realized using the short-axis view in which the operator advances the needle blindly aiming for a target visualized under the ultrasound transducer. Eventually the needle arrives within the ultrasound beam and into view, ideally at the location of the target. However, with this technique it is very easy for the needle to miss the target and go too deep. We are aware of a case report of a practitioner attempting to do a C7 medial branch block via a short-axis approach and passing the needle into the spinal cord [

,

[21]

Ju Seok Ryu, 2017 Case report "Spinal cord injury during ultrasound-guided C7 cervical medial branch block." Email correspondence, from Nov. 2021.

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].

A potential limitation of our study is that anteroposterior (AP) fluoroscopic views were not obtained, raising the possibility that a needle could have passed through a facet joint and into the central spinal canal. However, this is not possible with a needle approach perpendicular to the diagonal orientation of the lateral joint line and at an angle to the lateral aspect of the articular pillar (Fig. 5, Fig. 6, Fig. 7 and 9). Unlike with fluoroscopy, a direct lateral approach to the joint cannot be performed because the ultrasound transducer overlies the targeted facet joint.

Fig. 8 Oblique fluoroscopic image of a C2–3 facet joint after ultrasound imaging demonstrated clear intra-articular placement of the needle and contrast: (A) ovoid pattern indicating intra-articular placement, similar to dotted line in anatomical model in (B). Compare to true lateral views of C2–3 injections (Figs. 5 and 6).

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Fig. 9 Anatomical model depicting the orientation of the needle after it had been placed using ultrasound guidance for a right (A) and left (B) C3–4 facet joint injection. Each needle is perpendicular to the diagonal opening of the joint and at 45 degrees relative to the lateral aspect of the articular pillar. Note the similar needle positions in the fluoroscopy images (Fig. 5, Fig. 6, Fig. 7).

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A number of limitations of our study are worth noting. First, the patients were carefully selected and examined prior to the procedures. Our results cannot be generalized to patients selected and examined using other methods. Second, our results cannot be generalized to operators without extensive interventional spine and ultrasound experience, or using ultrasound machines with lower imaging resolution. The procedure requires concentration and precise hand-eye coordination to guide a 0.4 mm diameter needle within the plane of a 0.7 mm wide ultrasound beam to a 1 mm joint space opening. A study assessing accuracy as a function of operator experience would be worthwhile in the future. Third, there were more women than men in our study. Men have larger necks, which means that the distance from the skin to the facet joints is greater, but they also have larger joints, which means that the injection targets are bigger. It is unclear whether having a more equal proportion of men and women in the study would have affected our results.

Fourth, we injected very small quantities of contrast dye (0.1–0.2 ml) in the joints in order to leave room for the local anesthetic and corticosteroid injectate that followed. This reduced the radiographic contrast effect and may have contributed to three facets having linear-indeterminate patterns and one, noted on ultrasound to have a large synovial sac extending out onto the articular pillar, having flow only into the sac and categorized as "outside of the joint". Fifth, we only used lateral fluoroscopic views to confirm intra-articular contrast patterns. If AP and oblique views had been taken, contrast might have been more easily seen in some of the joints. Sixth, our sample size of 60 facet joints is relatively small, but our 95% confidence intervals for 55/60 (92%) and 59/60 (98%) accurate injections are narrow at 0.82 to 0.97 and 0.91 to 1.0 based on a binomial "exact" calculation, and 0.85 to 0.99 and 0.95 to 1.0 based on the normal approximation to the binomial calculation [

]. Seventh, the C6–7 facet joint, which is smaller and deeper than the more cephalad joints, was not injected in our study. A study of accuracy at the C6–7 level would be indicated in the future.

The strength of our study includes the number of joints injected, the narrow confidence intervals, the broad range of age, body mass and ponderal indices, and the primary criterion of agreement between two independent raters. There were no complications observed during the study. Since completion of the study, we have performed over 2000 cervical facet joint injections, gaining further experience with the described technique with no complications noted other than a transient alteration in mental status in one patient as noted above.

Conclusion

Ultrasound-guided cervical facet joint injections can be performed with a high degree of accuracy using a lateral technique, without the use of ionizing radiation or contrast dye. The advantages of ultrasound guidance using a long-axis view or in-plane approach include the ability to aim a needle at a target, advance it in real time and simultaneously know its depth. Additional advantages of ultrasonography include the ability to visualize effusions, capsules and the surface topography of bones, thus facilitating entry into complex joints, as well as adjacent nerves, muscles, tendons, ligaments and blood vessels. As with fluoroscopy-guided cervical spine injections, ultrasound-guided cervical facet joint injections require a high degree of skill and concentration. Ultrasonography in the spine will likely become even more important in the future with further advancements in techniques, value-based health care and increasing use of biologic injectates in research and clinical practice.

Acknowledgments

The authors would like to thank Tiffany Flossman MD, Renata Jarosz DO, Kelly Williams DO and Andrew Toy MD for their contribution to the background research, cadaver injections, patient recruitment and procedures, Kristin Sainani PhD for her guidance on statistical analysis and the non-profit 501(c)3 Napa Medical Research Foundation for their support.

Declarations of competing interests

Authors have no conflicts of interest to disclose.

Appendix. Supplementary materials

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Article Info

Publication History

Published online: January 27, 2022

Accepted: January 18, 2022

Received in revised form: November 10, 2021

Received: October 1, 2021

Footnotes

FDA device/drug status: Not applicable.

Author disclosures: MB: Nothing to disclose. NM: Nothing to disclose. YU: Nothing to disclose.

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DOI: https://doi.org/10.1016/j.spinee.2022.01.011

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