Cervical Facet Joints Injection

Acute or chronic capsulitis

Causes and findings:
• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis
• Pain in posterior neck, up to head, into scapula or to point of shoulder
• Increased by sleeping in awkward positions and end-of-range movement
• Painful limitation in the capsular pattern: both rotations, side flexions and extension
• Tender over one or more facet joints

Equipment:
Syringe - 1ml
Needle - 25G 1.5-2 inches (40-50mm) green
Kenalog 40 - 20 mg
Lidocaine - Nil
Total volume - 0.5 ml

Anatomy:
The facet or zygaphophyseal joints in the cervical spine are plane joints lying at angles of approximately 30-45 ° to the vertical. They can be palpated by identifying the spinous process and moving a finger's width laterally, and are felt as a flat pillar. The affected levels are sensitive to pressure.

Technique:
• Patient lies on unaffected side with roll under neck
• Neck is held in flexion and slight side flexion away from the painful side
• Identify and mark the tender joint
• Insert needle just distal to joint parallel to the spinous processes and angle upwards at an angle of 4 5 ° cephalad
• Pass through the thick extensors aiming towards patient's upper ear until point touches bone
• Aspirate to ensure needle point is not intrathecal
• Gently 'walk' along bone until needle touches joint capsule - a hard endfeel
• Inject solution in bolus intracapsular or pepper into capsule

Aftercare:
Patient maintains gentle movement, continues correct posture and is careful to sleep with a suitable number of pillows to maintain the head in a neutral position. Prone lying should be abandoned. Manual traction, mobilizing and sustained stretching techniques together with friction massage to the joint capsule helps maintain comfortable movement.

Comments:
Although this appears to be an alarming injection, it is perfectly safe provided great care is taken that the needle always lies parallel to the spinous process and never angles medially, and that the point touches bone before depositing the solution. The results in the osteoarthritic neck can be good for several months, provided the patient does not strain the neck and maintains mobility and good posture as above.

Alternative approach:
This injection can be done under imaging which ensures correct placement but is less cost effective.