Ultrasound-guided cervical facet joint injection, in-plane approach, technique, and weak points

There are two difficulties when I do facet joint injections by an in-plane technique.
The first one is finding the exact levels.
If you are a beginner, you may put the same level at two intended shots.
so spend enough time to scan until you assure where you are going.
Today, I will share a clinical practice of ultrasound-guided cervical facet joint injection
and think about the weak points of the in-plane technique.  
My target is the right cervical 3-4th, 4-5 facet joints.
let the patient have a lateral decubitus position with the target site upside.
I do not recommend the prone position.  
In a prone position, the needle trajectory in the body is usually farther than the lateral decubitus position.
The longer the needle pathway, the more challenging control the needle.
Also,  It is more awkward to manipulate the needle and make it more painful.
Put the probe on the arm, not on the head or neck.
The minor careless conduct makes the patient unpleasant feeling.
I draw fluid to make a 2ml total volume to apply 1ml in each facet joint.
The composition consists of  1ml of 40 % of dextrose and 0.5 % of lidocaine.
If you want more information about drug protocol and ultrasound anatomy,
please find and review this video.
I will add 1ml of dexamethasone palmitate. It looks turbid, mimicking particulate steroids.
but, it is not triamcinolone and then connects with 1.5- inches 25 gauze needle.  
let me shake it and remove the air bubble.
The Air bubbles are the worst obstructors in the ultrasound procedure.
Before pre-scanning, put on the prepared aseptic gel consisting of chlorhexidine and 80% alcohol.
If you want more information on making a sterile gel, please find this video and study it.
I prefer the transverse in-plane technique.
It is easier and quicker than a longitudinal scan with an out-of-plane approach.
let's watch the transverse scan along the lateral neck,
focusing on the facet joint and articular pillar line

The levator scapular muscle is the major muscle on the surface of the facet joint at this transverse section.
The curved echogenic line is the articular pillar,
and the intervening low echoic structure is the free window of the facet joint.
The intermittently seen cortical break is the oblique scan of the facet joint with adjacent subarticular bone.

let me show you a longitudinal scan of the facet joints.
Again, there are waveforms of the cortical surface and intermittent low echo gaps.  
The periodic low echo gap is the facet joint windows.

there are two difficulties when I do facet joint injections by an in-plane technique.
The first one is finding the exact levels.
If you are a beginner, you may put the same level at two intended shots.
The second one is the correct navigation of the needle to the facet window.

so spend enough time to scan until you assure where you are going.

you may guess how serious I am before putting the needle.
Once your needle is in the right place, and you have to watch your feeling of piston resistance and fluid distension.
The low resistance and scant local fluid distension is the critical element of confirming the correct needle placement.

Next,  I will move on to the C4-5 facet joint.
I may go to the same target repeatedly.
So, point to the previous needle puncture site on the skin and maintain the ultrasound probe's alignment.

Thank you for watching. See you in the following videos.



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