Anatomy

The cervical spine consists of three parts based on their unique anatomy and innervation: 1. the upper two vertebrae (the atlanto-occipital [AO], and atlantoaxial [AA] joints) 2. The C2–C3 joints, and 3. The C3–C4 and C6–C7 joints. The C3–C7 vertebrae and joints are similar to each other. The vertebral body is convex on the inferior surface and concave on the superior surface.

The facet joint is a diarthrotic joint with joint surfaces, a synovial membrane, and a joint capsule. It forms an angle of approximately 45^o with the longitudinal axis through the cervical spinal column.

Compared to the lumbar facet joints, the cervical facet joints have a high density of mechanoreceptors.

The ventral rami of the first and second cervical spinal nerves innervate the AO joint and the AA joint.

The C2–C3 facet joint is innervated by two branches of the dorsal ramus of the third cervical nerve, which is a communicating branch and a medial branch; the third occipital nerve.

The facet joints from C3 to C7 are innervated by the medial branch of the dorsal ramus of the segmental nerve. Each facet joint is innervated by nerve branches from the upper and lower segment [1].

Indications

Neck pain is defined as pain in the area between the skull base and the first thoracic vertebra. Cervical facet procedures are used to manage:

• Degenerative cervical facet joint pain
  
• Trauma-related neck pain (whiplash-associated disorders; WAD)
  
• Neck pain radiating into the head (cervicogenic headache) [2].

Technique

The description of the techniques is limited to C3–C7. For details on the procedure on C2–C3, we refer to Govind et al. [4].

There are three different approaches described in the literature for cervical MB block or RF treatment [5] The first described technique by Sluijter et al. is a posterolateral technique with the endpoint of the needle close to the dorsal ramus [6] (Figure 20.1 ). The second technique is the technique as described by Bogduk, Lord et al. [7, 8]. It is a posterior approach with the needle parallel to the cervical MB [9]. The third technique, originally described as a technique to block the cervical MB [10] and later also used to apply RF, is the lateral technique with the endpoint of the needle in the center of the articular pillar [11, 12].

There is no literature comparing the different techniques, and none of the techniques have been validated anatomically. Therefore, the techniques are advocated based on anatomic studies to the course of the cervical MB and the remark that an RF lesion can best be made parallel to the nerve [9, 13]. Based on these anatomic studies, the technique as described by Bogduk et al. and used in the SIS protocol is mostly promoted and used in the literature. Based on anatomic considerations, both the Sluijter technique (posterolateral) and the SIS technique can be used [14]. The lateral technique has its anatomic flaws.

Those techniques can only be compared by comparing the outcome results of studies using different techniques.

Pros and cons of the different techniques are shown below [5]:

For the posterolateral technique, the patient is placed in the supine position with the head slightly extended on a small cushion. The C-arm is placed in an oblique position (+/- 30^o). In this position, the beam runs parallel with the exiting nerve root that runs somewhat caudo-frontal. In this position, the pedicles from the contralateral side are projected on the vertebral body’s anterior half. In the frontal plane (AP direction), the C-arm is positioned at a small angle to the transverse plane. In this position, the intervertebral disc space and the neuroforamen is visible (Figure 20.2

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Complications of Opiate Therapy Complications of Obturator Nerve Block Complications of Cervical Discography Complications of Intradiscal Therapeutic Procedures Complications of Percutaneous Cordotomy Complications of Stellate Ganglion Block (SGB)