(Radiographics. 1999;19:93-104.)
© RSNA, 1999
Lumbar Facet Joint Arthrography with the Posterior Approach
Laurent Sarazin, MD1,
Alain Chevrot, MD1,
Eric Pessis, MD1,
Atossa Minoui, MD1,
Jean-Luc Drape, MD, PhD1,
Nathalie Chemla, MD1 and
Didier Godefroy, MD1
1 Department of Radiology, Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75679 Paris, France.
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Abstract
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Lumbar facet joint (LFJ) arthrography with intraarticular injections of long-acting steroids and local anesthetics is routinely used for therapeutic purposes in selected patients for relief of low back pain. The procedure may also be used for diagnostic reasons to establish the source of such pain. However, because direct access to the LFJ space is not always possible owing to degenerative changes such as osteophytes, another posterior approach has been proposed for LFJ arthrography. With the patient in the prone position, a spinal needle is inserted vertically into the inferior recess of an LFJ with fluoroscopic guidance and the patient under local anesthesia. To facilitate puncture, cushions are placed under the patient's abdomen to flatten normal lumbar lordosis, which enlarges the inferior recess of the LFJ. Use of cushions also results in a decrease in tissue thickness in the patient, thereby improving image quality and decreasing radiation exposure. LFJ arthrography can demonstrate the causative role of facet disease in abnormalities responsible for low back pain or sciatica and can be performed easily and rapidly with this direct posterior approach.
Index Terms: Arthrography, technology, 33.129 • Spine, anatomy, 33.92 • Spine, arthritis, 33.70 • Spine, facet joints, 33.70 • Spine, radiography, 33.12
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INTRODUCTION
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Lumbar facet joint (LFJ) arthrography is performed mainly for therapeutic purposes for relief of low back pain with intraarticular injection of a steroid and a local anesthetic. The procedure may also be used for diagnostic purposes to establish the cause of lumbar pain.
Two different techniques can be used for arthrography: The joint space can be entered directly (as, for example, in shoulder arthrography) or, when direct access proves impossible or too difficult, an articular recess can be targeted (as, for example, in hip arthrography). In LFJ arthrography, the latter approach is used to insert the needle into the inferior recess of the joint, a procedure that is much easier than inserting the needle into the joint space.
Oblique arthrograms are routinely obtained to demonstrate the LFJ space, which appears as a vertical line on these images. Because of the hemicylindrical shape of the joint, this line represents the middle or anterior aspect of the joint and may confuse the operator, resulting in unsuccessful puncture.
The posterior aspect of the LFJ can be punctured easily with the patient in a prone position. Even the presence of osteophytes should not pose a problem with this posterior approach (Fig 1), in which the needle is inserted directly into the inferior articular recess of the joint. Over the past 10 years, we have obtained more than 15,000 LFJ arthrograms at our institution with this technique and have achieved a 90% success rate. In 6% of cases, opacification of the joint cavity was inadequate due to capsular leakage; in the remaining 4% of cases, it was not possible to insert the needle into the inferior recess.
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Figure 1a. (a) Axial computed tomographic (CT) scan obtained with soft-tissue windowing demonstrates severe facet osteoarthritis with a cyst (arrow). (b) Axial CT scan obtained with bone windowing depicts osteophytes (arrow), which make direct lateral access to the joint impossible.
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Figure 1b. (a) Axial computed tomographic (CT) scan obtained with soft-tissue windowing demonstrates severe facet osteoarthritis with a cyst (arrow). (b) Axial CT scan obtained with bone windowing depicts osteophytes (arrow), which make direct lateral access to the joint impossible.
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In this article, we describe and illustrate a direct posterior approach for LFJ arthrography. We also discuss clinical manifestations of LFJ arthropathy and indications for LFJ arthrography. In addition, we discuss normal and pathologic findings and possible complications associated with the procedure.
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NORMAL LFJ ANATOMY
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The LFJ has two components: the anterosuperior articular facet from the vertebral body below and the posteroinferior articular facet from the vertebral body above.
Facet joints are oriented obliquely to the sagittal plane, and the joint space itself is curved from front to back. The posteriorly located inferior facet is convex, whereas the anteriorly located superior facet is concave. Hyaline cartilage covers joint surfaces as well as parts of the sides of the vertebral bodies.
LFJs are true synovial membrane–lined articulations and are often involved in synovial inflammatory diseases such as rheumatoid arthritis and ankylosing spondylitis. Folds of synovial membrane may extend between the articular surfaces and may cause pain when inflamed or trapped between the surfaces (1–3). There are two main articular recesses about an LFJ. The superior recess is located anteriorly, is close to the lumbar canal and neural elements, and may extend within the intervertebral foramen. The inferior recess is located posteriorly and has no direct contact with the neural elements (Fig 2). The size of these recesses varies depending on the degree of lumbar lordosis. Increased lordosis tends to enlarge the superior recess, whereas kyphosis widens the inferior recess. Thus, cushions should be placed under the patient's abdomen to facilitate direct puncture of the inferior recess during LFJ arthrography.
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Figure 2a. Photographs show posteroanterior (a) and oblique (b) views of the L4-L5 facet of a skeleton. The articular cavity is materialized by plasticine. In LFJ arthrography, the needle is inserted into the inferior recess of the facet joint (arrow).
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Figure 2b. Photographs show posteroanterior (a) and oblique (b) views of the L4-L5 facet of a skeleton. The articular cavity is materialized by plasticine. In LFJ arthrography, the needle is inserted into the inferior recess of the facet joint (arrow).
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It is now well established that LFJs have a rich sensory innervation (Fig 3) (4–7). This explains why these joints are involved in low back pain. Each LFJ is innervated by a recurrent sensory nerve from the ipsilateral posterior lumbar ramus at its own level as well as by sensory branches from the level above (8,9). This anatomic arrangement may explain why the facet pain in presenting patients is not specific for a particular level. Consequently, LFJ arthrography with steroid injection may be required at multiple levels in the lumbar spine for low back pain.
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CLINICAL MANIFESTATIONS OF LFJ ARTHROPATHY
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Multiple anatomic and biomechanical factors are involved in low back pain. LFJ arthropathy may play an important role in causing these symptoms. "Facet syndrome" is a relatively specific but rarely isolated cause of low back pain. In this syndrome, the pain tends to be worse in the morning, is aggravated by rest and hyperextension, and is relieved by repeated motion. Low back stiffness is common, and local paralumbar tenderness is present at clinical examination (10). Typically, the pain is located in the low back and does not radiate below the knee. Sciatica may be related to other LFJ abnormalities such as a synovial cyst, diverticulum, or osteophytes impinging on a lumbar nerve root in the neural foramen or spinal canal (Fig 4). Because degenerative changes are frequently associated with synovial cysts or diverticula, facet syndrome may also be present in such cases.
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Figure 4a. (a, b) Diagrams illustrate impingement due to cysts and diverticula. When located in the superior recess, these lesions may impinge on the lumbar nerve root (arrow in a) or thecal sac (arrowhead in b). (c) Myelogram demonstrates nerve root impingement due to a cyst of the left L4-L5 articulation (arrow). (d) CT scan obtained after LFJ arthrography shows the nerve root impingement (arrow).
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Figure 4b. (a, b) Diagrams illustrate impingement due to cysts and diverticula. When located in the superior recess, these lesions may impinge on the lumbar nerve root (arrow in a) or thecal sac (arrowhead in b). (c) Myelogram demonstrates nerve root impingement due to a cyst of the left L4-L5 articulation (arrow). (d) CT scan obtained after LFJ arthrography shows the nerve root impingement (arrow).
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Figure 4c. (a, b) Diagrams illustrate impingement due to cysts and diverticula. When located in the superior recess, these lesions may impinge on the lumbar nerve root (arrow in a) or thecal sac (arrowhead in b). (c) Myelogram demonstrates nerve root impingement due to a cyst of the left L4-L5 articulation (arrow). (d) CT scan obtained after LFJ arthrography shows the nerve root impingement (arrow).
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Figure 4d. (a, b) Diagrams illustrate impingement due to cysts and diverticula. When located in the superior recess, these lesions may impinge on the lumbar nerve root (arrow in a) or thecal sac (arrowhead in b). (c) Myelogram demonstrates nerve root impingement due to a cyst of the left L4-L5 articulation (arrow). (d) CT scan obtained after LFJ arthrography shows the nerve root impingement (arrow).
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INDICATIONS FOR LFJ ARTHROGRAPHY
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LFJ arthrography is generally performed for therapeutic purposes with intraarticular administration of long-acting steroids and local anesthetics for relief of symptoms associated with LFJ arthropathy. The procedure should be reserved for patients who have experienced moderate to severe low back pain for at least 3–6 months. If sciatica is present, other abnormalities such as a synovial cyst or a diverticulum should be excluded.
Rarely, LFJ arthrography may be performed for diagnostic purposes when the results of other radiologic studies are equivocal. However, therapeutic injections can also be performed immediately following such a diagnostic procedure.
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LFJ ARTHROGRAPHIC TECHNIQUE
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Our technique consists of directly approaching the inferior articular recess of an LFJ. The patient is placed in a prone position with cushions under the abdomen to flatten lumbar lordosis. As explained earlier, this flexion of the lumbar spine enlarges the inferior recess and facilitates puncture (Fig 5). Use of cushions also results in a decrease in tissue thickness in the patient, thereby improving image quality and decreasing radiation exposure to the patient and operator. The x-ray beam is vertically oriented, and the inferior recess is seen beneath the lower pole of the inferior apophyseal process, which represents the target point for needle insertion. Sometimes the inferior apophyseal process is not well seen, especially when osteoporosis is present. In such cases, the target point is located at the medial projection of the vertebral pedicle. At the L5-S1 level, the site of puncture is located just below the superior aspect of the sacrum (Fig 6). After the skin is cleansed with iodine and alcohol, a local anesthetic (0.5% lidocaine [Xylocaine; Astra USA, Westborough, Mass]) is administered. Under aseptic conditions, a 22-gauge spinal needle is then vertically inserted parallel to the x-ray beam and toward the inferior articular recess under fluoroscopic guidance. Needle passage through the joint capsule is frequently perceived by the operator. Adequate needle placement is confirmed with contrast material–enhanced imaging following injection of a nonneurotoxic contrast agent (iohexol [300mg/mL of iodine] [Omnipaque; Sterling Winthrop, New York, NY]). Use of a nonneurotoxic contrast agent is mandatory due to the proximity of neural structures and the possibility of capsular leakage. If optimal needle placement is achieved, contrast medium is seen to flow immediately up into the superior recess of the joint. If the needle is extraarticular in location, the contrast agent pools around the needle tip. In such a case, it is better to avoid introducing excessive amounts of contrast agent into the periarticular soft tissues because this may compromise the study.
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Figure 5. Diagrams of an LFJ (oblique view) illustrate how the size of the inferior articular recess varies depending on the degree of lordosis. Flexion resulting in kyphosis enlarges the inferior recess (arrow) and facilitates needle puncture. Extension or increased lordosis enlarges the superior recess (arrowhead).
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Figure 6a. Diagram (a) and LFJ arthrogram (b) illustrate the location of the puncture site under the tip of the superior facet (arrow in a, arrowhead in b). Note that the site is located at the medial projection of the pedicle. At the L5-S1 level, the puncture site is just beneath the superior aspect of the sacrum (arrow in b).
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Figure 6b. Diagram (a) and LFJ arthrogram (b) illustrate the location of the puncture site under the tip of the superior facet (arrow in a, arrowhead in b). Note that the site is located at the medial projection of the pedicle. At the L5-S1 level, the puncture site is just beneath the superior aspect of the sacrum (arrow in b).
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When the needle is in an optimal position, an average of 2 mL of contrast agent is injected. Generally, only posteroanterior images of the LFJ are obtained. If the examination is being performed for diagnostic purposes or if an abnormal finding is present, additional (eg, oblique or lateral) images are obtained. Before the needle is removed, 1 mL of a long-acting steroid (cortivazol [Altim; Diamant, Paris, France] or 2.5% prednisolone acetate [Hydrocortancyl; Diamant]) and 1 mL of 0.5% lidocaine (Xylocaine [Astra USA]) solution are injected into the joint for therapeutic purposes. It is essential to watch the patient's reaction following injections of an intraarticular steroid and a local anesthesic to determine whether the pain normally experienced by the patient is decreased. This observation may verify whether the patient's symptoms are related to the LFJ disease at this vertebral level. If necessary, several LFJs may be injected on either the same or different occasions because the pain may originate from different levels.
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NORMAL FINDINGS
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A normal LFJ has a ring appearance on posteroanterior images and an S-shaped appearance with smooth and regular margins on lateral images (Fig 7). Normal joint volume is roughly 1–3 mL but varies considerably. The superior and inferior recesses are well demonstrated and communicate freely with each other.
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Figure 7a. Posteroanterior (a) and lateral (b) LFJ arthrograms demonstrate normal anatomy. Note the ring appearance of the joint in a (arrowheads) and the S-shaped appearance in b (arrow).
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Figure 7b. Posteroanterior (a) and lateral (b) LFJ arthrograms demonstrate normal anatomy. Note the ring appearance of the joint in a (arrowheads) and the S-shaped appearance in b (arrow).
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Occasionally, small synovial diverticula can be seen arising from the superior or (more frequently) the inferior recess but have no clinical significance.
The articular cartilage is demonstrated on oblique images as a linear radiolucent defect within the opacified joint cavity.
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PATHOLOGIC FINDINGS
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Abnormal Articular Volume
Increased joint volume is frequently seen when degenerative changes are present. The joint cavity may also appear heterogeneous due to small fibrous and cartilaginous loose bodies (Fig 8). The synovial membrane frequently demonstrates multiple small diverticula.
Decreased joint volume is a rare entity similar to adhesive capsulitis. With decreased joint volume, a high injection pressure is usually noted, and leakage of contrast material or rupture of the capsule may be encountered (2).
Synovial Cysts and Diverticula
Synovial cysts and diverticula are often associated with degenerative disease of the facet joint and spondylosis. These lesions are usually well demonstrated at CT and magnetic resonance (MR) imaging. Cysts have thick walls, whereas diverticula develop from folds in the normal synovial membrane and tend to have thinner walls. Large synovial cysts and diverticula can cause sciatica if located in the superior articular recess and low back pain or facet syndrome if located in the inferior recess of an LFJ (Fig 9) (11–14).
LFJ arthrography may demonstrate these synovial protrusions in the spinal canal (Fig 10). Contrast agent leakage from these protrusions may occur during LFJ arthrography. This finding has no adverse effect on the patient and may even result in definitive cure of the diverticular disease. If the pain usually experienced by the patient is reproduced during injection, cysts or diverticula are the probable cause.
Abnormal Communications
During LFJ arthrography, opacification may occur in other joints, including an upper or lower ipsilateral facet joint (vertical communication) or a contralateral facet joint (horizontal communication) (Fig 11). Ipsilateral facet joint opacification is common in patients with lumbar spondylolysis (Fig 12). The pars interarticularis represents the only boundary between the inferior recess of one facet joint and the superior recess of the adjacent ipsilateral joint. The defect through the pars interarticularis creates a communication between these two otherwise separate recesses. Occasionally, spondylolysis may also cause a horizontal communication via the retrodural space with contrast material flowing into the contralateral facet joint at the same level (15).
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Figure 11. Diagrams illustrate abnormal communications between two ipsilateral facet joints (vertical communication) (left) and two contralateral facet joints (horizontal communication) (right).
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Figure 12a. (a) Lateral LFJ arthrogram demonstrates a defect in the pars interarticularis (arrow). (b, c) Right (b) and left (c) LFJ arthrograms demonstrate a communication between the L5-S1 and L4-L5 joints (arrow in b, arrowhead in c). (d) Lateral LFJ arthrogram demonstrates contrast material within the pars interarticularis defect (arrow).
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Figure 12b. (a) Lateral LFJ arthrogram demonstrates a defect in the pars interarticularis (arrow). (b, c) Right (b) and left (c) LFJ arthrograms demonstrate a communication between the L5-S1 and L4-L5 joints (arrow in b, arrowhead in c). (d) Lateral LFJ arthrogram demonstrates contrast material within the pars interarticularis defect (arrow).
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Figure 12c. (a) Lateral LFJ arthrogram demonstrates a defect in the pars interarticularis (arrow). (b, c) Right (b) and left (c) LFJ arthrograms demonstrate a communication between the L5-S1 and L4-L5 joints (arrow in b, arrowhead in c). (d) Lateral LFJ arthrogram demonstrates contrast material within the pars interarticularis defect (arrow).
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Figure 12d. (a) Lateral LFJ arthrogram demonstrates a defect in the pars interarticularis (arrow). (b, c) Right (b) and left (c) LFJ arthrograms demonstrate a communication between the L5-S1 and L4-L5 joints (arrow in b, arrowhead in c). (d) Lateral LFJ arthrogram demonstrates contrast material within the pars interarticularis defect (arrow).
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Contralateral facet joints may also communicate via the interspinous process space in Baastrup disease, a condition characterized by degenerative changes between two adjacent spinous processes that result in bursitis. Such a communication is well demonstrated on lateral images (Fig 13) and usually occurs between a large diverticulum and an interspinous bursa. This type of communication has a "butterfly" appearance on a posteroanterior LFJ arthrogram (Fig 14).
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Figure 13a. Figures 13, 14. (13a) Sequential LFJ arthrograms obtained in a patient with advanced Baastrup disease demonstrate a horizontal communication. Note the progressive opacification of the interspinous process (arrow) followed by that of the contralateral facet joint (arrowhead). (13b) Lateral LFJ arthrogram clearly demonstrates opacification of the interspinous process (arrow). (14) LFJ arthrogram shows a horizontal communication with the classic butterfly appearance.
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Figure 13b. Figures 13, 14. (13a) Sequential LFJ arthrograms obtained in a patient with advanced Baastrup disease demonstrate a horizontal communication. Note the progressive opacification of the interspinous process (arrow) followed by that of the contralateral facet joint (arrowhead). (13b) Lateral LFJ arthrogram clearly demonstrates opacification of the interspinous process (arrow). (14) LFJ arthrogram shows a horizontal communication with the classic butterfly appearance.
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Figure 14. Figures 13, 14. (13a) Sequential LFJ arthrograms obtained in a patient with advanced Baastrup disease demonstrate a horizontal communication. Note the progressive opacification of the interspinous process (arrow) followed by that of the contralateral facet joint (arrowhead). (13b) Lateral LFJ arthrogram clearly demonstrates opacification of the interspinous process (arrow). (14) LFJ arthrogram shows a horizontal communication with the classic butterfly appearance.
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Vertical or horizontal communications may also result from communicating cysts and diverticula in patients with advanced facet osteoarthritis (Fig 15).
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Figure 15. LFJ arthrogram obtained in a patient with advanced facet osteoarthritis reveals a communication between the left L4-L5 and L3-L4 joints (straight arrow) and the interspinous process bursa (curved arrow).
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COMPLICATIONS OF LFJ ARTHROGRAPHY
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Capsular leakage of contrast agent frequently occurs during or after injection but has no adverse effects (Fig 16). Capsular leakage occurred at the beginning of LFJ arthrography in 6% of our patients and resulted in inadequate opacification of the joint cavity. Such leakage is not a contraindication for local administration of a periarticular steroid; instead, it allows the medication to diffuse around the branches of the spinal nerve and into the neural foramen where the lumbar nerve root exits. In the 4% of our patients in whom intraarticular placement of the needle was not achieved, steroid injection was performed in the periarticular areas.
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Figure 16a. (a) LFJ arthrogram obtained at the beginning of opacification demonstrates a cyst located superiorly (arrow). (b) LFJ arthrogram obtained at the end of contrast material injection shows leakage with opacification of the soft tissues surrounding the facet joint (arrowhead). Such leakage has no adverse effects and may even result in complete resolution of the lesion if it occurs at the level of a cyst or diverticulum.
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Figure 16b. (a) LFJ arthrogram obtained at the beginning of opacification demonstrates a cyst located superiorly (arrow). (b) LFJ arthrogram obtained at the end of contrast material injection shows leakage with opacification of the soft tissues surrounding the facet joint (arrowhead). Such leakage has no adverse effects and may even result in complete resolution of the lesion if it occurs at the level of a cyst or diverticulum.
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Increased lumbar pain or sciatica may be experienced when cysts or diverticula are opacified. Patients must be warned of this possibility and told that the pain is usually transient and improves after intraarticular steroid administration.
Transient paresthesia may occur after epidural leakage of the local anesthetic (12). For this reason, the use of a low (0.5%) concentration of lidocaine (Xylocaine; Astra USA) solution is recommended.
Septic arthritis is a rare but extremely severe complication of LFJ arthrography. The symptoms may be subtle because of local steroid administration. To avoid septic arthritis, aseptic conditions must be rigorously maintained during the procedure. The needle must be positioned rapidly and not manipulated unnecessarily. If adequate positioning of the needle is not possible, it is safer to inject a steroid periarticularly than to prolong the procedure and increase the risk of infection.
Calcification of the articular synovial membrane may develop after steroid administration, particularly in a cyst or diverticulum wall. To avoid this complication, a low-molecular-weight steroid solution should be used for injection.
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CONCLUSIONS
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LFJ arthrography can be performed easily and rapidly even in cases of osteophytic degenerative changes with a direct posterior approach in which the needle is inserted into the inferior recess of the joint. Placing the patient in the prone position facilitates puncture and reduces radiation exposure. LFJ arthrography can demonstrate the causative role of facet disease in abnormalities responsible for low back pain or sciatica. In addition, this procedure should be routinely performed with local intraarticular injections of long-acting steroids and local anesthetics for relief of symptoms.
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Acknowledgments
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We express our deep appreciation to H. Duong, MD, for reviewing the manuscript.
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Footnotes
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Address reprint requests to L.S.
Presented as a scientific exhibit at the 1996 RSNA scientific assembly.
Abbreviation: LFJ = lumbar facet joint
Received for publication July 14, 1997.
Revision received August 4, 1997. March 13, 1997.
Accepted for publication March 16, 1997.
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Abstract
INTRODUCTION
