the Shoulder Joint
may be performed with or without fluoroscopy. Studies of major joint
injections (knee, hip, and shoulder) have shown significant rates
of failure to localize the joint when fluoroscopy was not used.29
When performed without fluoroscopy, the patient is placed sitting
or supine with the shoulder externally rotated. The point of entry
is marked just medial to the head of the humerus and just below
(inferolateral) the coracoid process (Figs. 67-2 and 67-3). After
sterile skin preparation, the skin and subcutaneous tissues are
anesthetized with lidocaine using a 27- or 30-gauge needle. Then
a 22-gauge 1½- to 2½-in.
needle is advanced posteriorly with a slight superolateral angle.
The resistance of the joint capsule will be obvious. The needle
is advanced until it “pops” through the capsule
and is advanced 0.5 cm. After careful aspiration, 2 to 3 mL of anesthetic-corticosteroid
suspension is injected. If pressure is encountered during injection,
the needle should be repositioned slightly medially.
Shoulder and chest injections. Needle A–Demonstrates
needle trajectory and placement for injections of the acromioclavicular
joint. Needle B–Needle placement for the lateral approach
to the subacromial bursa injection. Needle C–Needle placement
for the anterior approach to the shoulder joint. Needle D–Demonstrates
the approach to the sternoclavicular joint. Needle E–Demonstrates
the approach to the costosternal joint.
Anterior approach to intra-articular shoulder injection.
Entry site is just inferior and lateral to the coracoid process
Never inject any joint if resistance is encountered, as the needle
ending may be in ligament, tendon, or cartilage and these structures
can be damaged by mechanical disruption from a direct injection.
Aspiration is important prior to injecting the agent, as it is possible
for the needle to enter the axillary or subclavian vessels.
A posterior approach may also be used. The patient is in the
sitting position with the arm internally rotated and adducted. This
is best accomplished by having the patient place the hand of the arm
to be injected on the opposite shoulder. The needle entry point
is marked just under the posteroinferior border of the acromion.
After sterile preparation and local anesthesia, a 22-gauge 2½-in.
needle is advanced anteriorly with a slight cephalomedial angle
(Fig. 67-4 and 67-5). Again, the needle is advanced 0.5 cm through
the capsule and anesthetic–corticosteroid suspension is injected.
Posterior approach to shoulder injections. Needle A–Posterolateral
approach to the subacromia bursa injection. Needle B–Posterior
approach to injection of the shoulder joint.
Posterior approach to the shoulder joint.
Intra-articular shoulder joint injections are used chiefly for
diagnostic purposes to help determine if the shoulder joint is contributing
to a patient’s pain problem. There is insufficient data
to determine whether or not shoulder injections have long-term therapeutic
the Subacromial Bursa
This injection can be performed using a lateral or posterior
approach. Using the lateral approach, the needle entry site is marked
on the lateral shoulder just inferior to the acromium. A 22-gauge
1½-in. needle is advanced toward the
inferior border of the lateral acromium (see Fig. 67-2). After the
needle contacts the acromium, it is “walked” inferiorly
until it slips off the inferior edge of the acromium. Then it is
advanced 0.5 to 1.0 cm and 2 to 3 mL of anesthetic-corticosteroid
suspension is injected.
The posterior approach is the preferred approach because there
is a larger space between the acromium and humeral head. The point
of entry is marked 1 cm below the posterior acromium, at or just
medial to the angle of the acromium (Figs. 67-4 and 67-6). A 22-gauge
1½-in. needle is advanced anteriorly
with a slight cephalomedial angle to contact the acromium. The needle
is walked inferiorly until it slips off the inferior edge and then
it is advanced 0.5 to 1 cm. If resistance is encountered during
the injection, the needle should be repositioned, as the needle may
be in the supraspinatous tendon. This tendon is fragile and could
be damaged by an intra-tendinous injection.
Posterolateral approach to the subacromial bursa.
the Acromioclavicular Joint
The joint space is palpated as a groove or depression between
the acromium and clavicle on the top surface of the shoulder. This
groove is marked, and after sterile preparation and local anesthesia,
a 22-gauge 1½-in. needle is advanced
into the joint space (Figs. 67-2 and 67-7), then 0.5 mL of injectant
is placed into the joint.
Needle approach to the acromioclavicular joint.
The elbow joint
is injected using a lateral approach. The radial humeral joint can
easily be palpated laterally at level of the skin crease of the
The lateral epicondyle of the humerus is the most obvious identifiable
landmark. Identify this with the examining finger and then slide
the finger down the epicondyle until the groove between the epicondyle
and the plateau of the radius is felt. Mark this spot as the needle
entry point (Figs. 67-8 and 67-9). After sterile skin preparation
and cutaneous anesthesia, a 22-gauge 1½-in.
needle is advanced through the needle entry point and advanced to
contact the distal epicondyle. Then walk the needle distally until
it slides off the epicondyle and into the joint space. Advance the
needle 0.5 cm and inject 1 to 2 mL of injectant. If an ulnar paresthesia
is elicited during this block, the needle is too dorsal and a more
volar approach should be used.
Elbow injections. Needle A–Lateral approach
to the elbow joint. Needle B–Olecranon bursa injection.
Lateral approach to the elbow joint injection.
The olecranon bursa is a large bursal sac between the soft tissue
and the olecranon process of the ulna. After sterile skin preparation
and cutaneous anesthesia, a 25-gauge 1- to 1½-in.
needle is advanced in a direction perpendicular to the olecranon
(see Fig. 67-8) until the olecranon surface is contacted. Then the
needle is withdrawn approximately 1 to 2 mm and 1 to 2 mL of injectant
is placed at the site. To avoid a subcutaneous injection, do not
withdraw the needle too far after contacting the olecranon.
Hand and Wrist
(CMC), metacarpophalangeal (MCP), and interphalangeal (IP) joints
commonly are affected by rheumatoid and osteoarthritis flare-ups
and are amenable to injection therapy. The specific joint to be
injected can easily be palpated. For the IP joints, a lateral or
medial approach is used. For the MCP or CMC joints, a dorsal approach
is used. It is best to avoid the more richly innervated volar (palmar)
surface of the hand, as these injections are more painful.
A 27-gauge 1½-in. needle is advanced
into the joint space. It only needs to enter the superficial joint,
just through the capsule (Figs. 67-10 and 67-11). Inject 0.5 mL
of anesthetic-corticosteroid solution.
Hand and wrist injections. Needles A and B–Dorsal
approach to the radiocarpal and ulnocarpal joints. Needle C–Needle
approach to an interphalangeal joint.
Needle approach to the carpometacarpal joint of the thumb.
A dorsal approach to the radiocarpal and ulnocarpal joints is
preferred. These joints can easily be palpated and the needle entry
site marked (Figs. 67-10 and 67-12). Care should be taken to avoid the
extensor tendons. The joint space can be “opened up” slightly
by placing the wrist in 45 degrees of flexion. After sterile skin
preparation and local anesthesia, a 22-gauge 1½-in.
needle is advanced into the joint. Again, the needle should be advanced
into the superficial joint and 1 to 2 mL of solution injected.
Dorsal approach to the wrist joint injection.
hip joint injections usually are performed diagnostically to help
determine if hip arthritis is contributing to a patient’s
pain problem and prognostically to help determine if total hip arthroplasty
would be beneficial.31 The duration of pain relief
after intra-articular corticosteroid hip injection typically is
1 to 3 months in patients with symptomatic osteoarthritis.31,32
The hip joint can be injected from an anterior or lateral approach.
The use of fluoroscopy is highly desirable. A lateral or anterolateral
approach results in a more favorable needle trajectory for joint entry.
The patient is placed supine on the fluoroscopy table with the
hip internally rotated (toes and knees pointed inward). The needle
entry point is just anterior and cephalad to the greater trochanter
(Fig. 67-13). Using fluoroscopy, the needle is directed medially
and slightly cephalad (Figs. 67-13 and 67-14). The joint capsule
is quite thick and easily identified with the needle. The needle
is advanced just through the capsule. Aspirate to be sure the needle
has not entered the femoral vessels. Two milliliters of radiopaque
contrast can be injected to confirm placement. This is followed
by placing 2 to 3 mL of injectant into the joint.
Hip injections. Needle A–Needle orientation
and trajectory for lateral approach to the hip joint. Needle B–Lateral
approach to the trochanteric bursa injection. Needle C – Approach
to the iliopsoas bursa injection.
Hip joint injection. Needle placement for the lateral
approach to the hip joint. The white arrows outline the margin of
The trochanteric bursa is a large bursal sac located between
the lateral surface of the greater trochanter and the overlying
iliotibial band (see Fig. 67-13). It is a common cause of lateral
thigh pain and responds well to local anesthic-corticosteroid injection.33
The injection is performed by placing the patient in a lateral
position with the symptomatic side up (Fig. 67-15). The area of
maximal trochanteric tenderness is marked. After sterile skin preparation
and cutaneous anesthesia, a 22- or 25-gauge 2½-
to 3½-in., needle is directed perpendicular
to the trochanter and advanced until bone is contacted. Then the
needle is withdrawn 3 to 5 mm and 3 to 5 mL of solution is injected.
Needle approach for the trochanteric bursa injection.
The iliopsoas bursa is the largest bursa in the body and lies
between the iliopsoas muscle and the anterior hip capsule (see Fig.
67-13). It is a common but often overlooked cause of groin pain.34,35 There
may be direct communication between the bursa and the joint.
The injection is performed with the patient supine. The needle
entry site is just below the inguinal ligament and 1 to 2 cm lateral
to the neurovascular bundle (femoral artery pulsation) to avoid
needle trauma to the femoral nerve and vessels (see Fig. 67-13).
After sterile skin preparation and anesthesia, a 22-gauge 3½-in.
needle is advanced perpendicular to the skin and advanced until
the anterior bone of the acetabulum is contacted. The needle is
then withdrawn 3 to 5 mm, and after careful aspiration, 3 to 5 mL
of solution is injected. If blood is aspirated, or a femoral nerve
paresthesia occurs during needle placement, re-direct the needle
1 to 2 cm laterally. Be sure to check the patient for femoral nerve
anesthesia prior to allowing ambulation.
knee joint injection can be valuable diagnostically to help determine
the contribution of the joint versus periarticular structures in
a patient with knee pain. It can be therapeutic in patients with
rheumatoid arthritis by suppressing pain and inflammation in an
acute flare-up.36 It can provide short-term relief
(2 to 4 weeks) in patients with symptomatic osteoarthritis.37 This
will allow time for affected patients to participate in an appropriate
Knee joint injection can be performed using either an anterior
or a medial approach. For the more commonly used medial approach,
the patient is placed supine with the leg straight or slightly flexed.
The needle entry site is identified and marked as follows. The medial
border of the inferior patella is identified. The needle entry site
is 1 cm medial to this (Figs. 67-16 and 67-17). After skin preparation
and local anesthesia, a 1½- to 2-in.
22-gauge needle is advanced to contact the medial edge of the patella.
Then it is walked off the patella and advanced between the patella
and the medial femoral condyle and 2 to 3 mL of solution is injected.
Knee injections. Needle A–Approach to the patellar
bursa. Needle B–Anterior approach to intra-articular knee
joint injection. Needle C–Medial approach to intra-articular
knee joint injection. Needle D–Approach to the anserine
Medial approach to intra-articular knee joint injection.
The marked circle outlines the patella and the lines outline the
For an anterior approach, the patient is seated with the knee
flexed. The needle entry point is marked on the anterior surface
of the knee as a point just below the inferior pole of the patella
and just medial to the inferior patella tendon (Figs. 67-16 and 67-18). After sterile preparation and skin anesthesia, a 1½-in.
22-gauge needle is advanced perpendicular to the skin until bone
is contacted. The needle is then withdrawn 0.5 cm and 2 to3 mL of
solution is injected.
Anterior approach to knee joint injection. The “x” represents
the needle entry site for the medial approach.
The prepatellar bursa lies between the patella and the overlying
soft tissue. Prepatellar bursitis is a common cause of localized
knee pain and responds well to local injection and rest.38 Local
injection is not much more than a trigger point injection. After
skin preparation and local anesthesia, a 25-gauge needle is advanced
until it contacts the patella (see Fig. 67-16). Then it is withdrawn
2 to 3 mm and 1 to 2 mL of solution is injected.
The anserine bursa lies between the medial knee joint and the
pes anserinus (tendons of the semitendinous, graclis, and sartorius
muscles). Anserine bursitis is a common cause of medial knee pain
and it responds well to injection therapy.39
The injection technique is quite simple and is similar to a trigger
point injection. The area of maximal tenderness is identified over
the medial tibial plateau and marked. After skin preparation and anesthesia,
a 25-gauge 1- to 1½-in. needle is advanced
until bone is contacted (see Fig. 67-16). The needle is withdrawn
2 to 3 mm and 1.0 mL of solution is injected.
The ankle joint
is entered from an anterior approach to enter the joint between
the tibia and the talus. The patient is positioned supine with the
leg‐foot angle placed at 90 degrees. The point of entry is just
medial to the anterior tibial and extensor hallicis longus tendons
on a line drawn between the medial and lateral malleoli (Figs. 67‐19
and 67‐20). These tendons can be easily identified by having the
patient dorsiflex the foot and great toe. After skin preparation
and anesthesia, a 1‐in. 22-gauge needle is advanced directly posteriorly
until bone is contacted. The needle is then walked inferiorly until
it slips between the tibia and talus. One to two milliliters of
solution is injected. Joints between the tarsal bones are best injected
by using fluoroscopic guided injection.40
Foot and ankle injections. Needle A-Anterior approach
to ankle joint injection. Needle B–Metatarsophalangeal
Anterior approach to ankle joint injection. The two parallel
lines represent the anterior tibialis and extensor hallicus longus
The injection technique for metatarsal phalangeal and interphalangeal
joints is exactly the same as the techniques described for the IP
and MCP joints on the hand (see Fig. 67-19). Again, a lateral or
dorsal approach is usually favored over the more painful plantar
In patients with acute spondyloarthropathies, an inflammatory
sacroiliac component may be present. More often, sacroiliac joint
pain occurs as a result of injury. Diagnostic sacroiliac injections
are considered an important part of the diagnostic workup for mechanical
low back pain because history and physical examination are notoriously
Sacroiliac joint injection can be performed with or without the
use of fluoroscopy; however, when fluoroscopy is not used, there
is a significant rate of failure to enter the joint. Therefore,
if the block is being performed for diagnostic reasons, fluoroscopy
or CT guidance should be used.
The patient is placed in the prone position. The sacroiliac joint
is most accessible to injection at the most caudal or inferior portion
of the joint.42,43 Attempts to enter the synovial
cavity of the joint at the middle and cranial or superior portions
of the joint have a higher failure rate.
Using fluoroscopy, or by palpation, the posterior superior iliac
spine (PSIS) is identified. The needle entry site is approximately
1 cm below the PSIS (Fig. 67-21A and 21B). After skin preparation
and local anesthesia, a 22-gauge 2½-
to 3½-in. needle is advanced through
the above mentioned entry site toward the joint. The correct needle
angle is typically 20 to 30 degrees laterally from the sagittal
plane. Upon initial entry, the needle will traverse through the
thick and tough posterior sacroiliac ligament (Fig. 67-22). The needle
must be advanced through this ligament to reach the synovial joint
cavity. This joint cavity may be obliterated or replaced by fibrous
tissue in some patients. If fluoroscopy is used, 1 to 2 mL of radiopaque
contrast can be injected to confirm an intra-articular dye patter
(Fig. 67-23). This is followed by an injection of 1 to 2 mL of the
diagnostic or therapeutic injectant.
(A) Needle placement for sacroiliac joint injection.
Small arrows outline the posterior superior iliac spine (PSIS).
Large arrow is at the first sacral foramen. (B) Skeletal model showing
corresponding landmarks. Small arrows again outline the PSIS. Large
arrow is at the first sacral foramen.
Diagram of sacroiliac injection.
Contrast spread following sacroiliac injection.
If fluoroscopy is not used then a larger volume is injected in
order to improve the likelihood of spread to the joint. To obtain
the greatest chance of joint entry, it is best to direct the needle
down to the sacrum and then walk the needle laterally until the
needle contact changes from bone to the tough ligamentous tissue.
Because the injectant may spread to a variety of adjacent structures, including
muscles, ligaments, and sacral nerve roots following an injection
done without imaging guidance, diagnostic inferences should not
be made following such a procedure.
cervical facet injections are performed to diagnosis and treat a
variety of neck pain problems. Anatomically, the first cervical
facet joint, the atlantoaxial or C1-2 joint is markedly
different from the remaining five cervical facet joints and the
cervical-thoracic facet joint. This joint is responsible for the
majority of axial rotation in the normal cervical spine. Accordingly,
suboccipital pain with rotation of the head to the left or right
often is indicative of C1-2 joint pathology.
The C1-2 joint may be injected using a lateral or posterior
approach.44–47 Because the vertebral artery
courses along the lateral edge of the joint, the posterior approach
is preferred. The patient is positioned prone on the fluoroscopy
table and the fluoroscopy beam is positioned in a posteroanterior
(PA) projection (Fig. 67-24). Because the teeth and jaw frequently project
over the upper cervical spine, it is usually necessary to have the
patient open the mouth. Once a clear view of the joint is obtained
by adjusting the fluoroscopy column, the entry point is marked,
sterilized, and anesthetized. Then a 3½-in.
22- or 25-gauge needle is advanced directly toward the joint with
the target being the junction of the lateral one third and the medial
two thirds of the joint. The needle is advanced to contact the boney
edge of the joint at C2. The needle is then walked off
the bone into the joint and advanced no more than 1 to 2 mm. Intra-articular
placement is confirmed by the injection of 0.25 to 0.5mL of radiopaque
dye suitable for myelography (e.g., iopamidol). An appropriate arthrogram
should be identifiable (Fig. 67-25) and there should not be any
intravascular uptake or spread to the spinal axis. This is followed
by the injection of a mixture of 0.25 mL of anesthetic (recommend
1% lidocaine) and 0.25 mL of corticosteroid. The C2 nerve
root runs across the posterior surface of the joint (Fig. 67-26).
If a paresthesia is obtained during needle placement, it is advisable
to choose a slightly different trajectory. It is usually best to
make the initial needle puncture sight slightly more caudad.
Patient positioning for posterior cervical facet joint
C1-2 facet joint injection. Fluoroscopic view
was obtained with the mouth wide open. The right C1-2 joint
is clearly visualized and contrast outlines the left C1-2 joint.
The relationship of the vertebral artery and C2 nerve
root to the C1-2 joint are illustrated in this oblique
view of the cervical spine.
Potential complications include intravascular injection, spinal
axis injection, needle trauma to the nerve root or spinal cord,
and vascular injury. Since most injectable corticosteroids are particulate,
it is theoretically possible for a particulate cerebral embolism
The C2-3 through C6-7 joints can be injected
using a posterior approach or a lateral approach.48,49 The
posterior approach is safer but technically more difficult due to
the marked cephalocaudal angulation of the joints. The lateral approach
is technically easier but more risky as the advancing needle can
pass through the joint and into the spinal canal. This can be prevented
by frequent PA and lateral fluoroscopic views.
For the posterior approach the patient is prone and the neck
is slightly flexed (see Fig. 67-24). The fluoroscopy column is adjusted
to identify the target joint(s). The needle entry site should be marked
one level below the target joint. This will allow angulation of
the needle at an angle that will facilitate entry into the cephalocaudal
oriented cervical facet joints. A 3½-in.
22- or 25-gauge needle is advanced into the joint under fluoroscopic
guidance. Intra-articular placement is confirmed with PA and lateral
fluoroscopy by injecting 0.25 to 0.5 mL of contrast. After proper
needle placement is confirmed, and following negative aspiration,
a mixture of 0.25 mL of anesthetic plus 0.25 to 0.50 mL of corticosteroid
For the lateral approach, the patient may be positioned prone,
lateral, or even supine. Lateral positioning usually is preferred
by the patient and is convenient for the physician (Fig. 67-27).
The target joint is identified and marked using fluoroscopy. Following
sterile preparation and local anesthesia, a 1½-
to 2½-in. 25-gauge needle is advanced
to contact bone at the inferior edge of the joint. The needle is walked
off the bone and advanced 2 to 3 mm into the joint (Fig. 67-28A
and Fig. 67-29). Posteroanterior fluoroscopy is used to confirm
that the needle is in the lateral one third of the joint (Fig. 67-28B).
The needle is withdrawn slightly if the tip is beyond the lateral
one third of the joint. Injection is performed as described for
the posterior approach.
Patient positioning for lateral cervical facet joint
(A) Lateral fluoroscopic view of lateral approach to
C4-5 facet joint. (B) Posteroanterior fluoroscopic view
of lateral approach to the C4-5 facet joint. Needle is
not advanced beyond the lateral one third of the joint. (Both figures:
Courtesy of the International Spinal Injection Society).
Lateral approach to the C4-5 facet joint.
Complications and side effects from cervical facet blocks include
intravascular injection, spinal axis injection, joint trauma, nerve
root and spinal cord trauma, infection, and side effects from the injected
Thoracic fact joint pain is not a common clinical problem. The
thoracic facet joints are not as prone to arthritic involvement
as are the cervical and lumbar facet joints. The most common cause of
thoracic facet pain is trauma.
Like the lower cervical facets, the thoracic facets have a marked
cephalocaudal angulation. The average angle of incline from the
horizontal plane is 60 degrees in the mid-thoracic region. Accordingly,
the technique for thoracic facet injection is very similar to the
posterior approach to the cervical facet joint.50
The patient is placed prone and the fluoroscopy tube is angled
in order to get the best view of the target joint. The needle entry
site is one to two segments below the target joint to allow angulation of
the needle to facilitate joint entry (Fig. 67-30A and 30B). The
remainder of the technique is as described for posterior cervical
Posteroanterior fluoroscopic view of thoracic facet joint
injection. (B) Lateral fluoroscopic view of thoracic facet joint
injection. (Reproduced, with permission, from Dreyfuss P, Tibiletti
C, Dreyer S. Thoracic zygapophyseal joint pain patterns: a study
in normal volunteers. Spine 1994;9:807-811.)
Because of the prevalence of low back pain, lumbar facet injection
is one of the most commonly performed pain management procedures.
Intra-articular facet injections can be performed for diagnostic
or therapeutic purposes.51–53 Because
of the oblique orientation of the lumbar facet joints, especially
the lower two levels, it often is helpful to position the patient
in a slightly oblique position with the side to be injected rotated
up 30 to 45 degrees (Fig. 67-31).
Patient positioning for lateral approach to lumbar facet
With the patient appropriately positioned, the target joint is
identified with fluoroscopic guidance and the skin is marked. It
is best to identify the level by starting at the lumbosacral junction
and then working up to the thoracolumbar junction. It is not unusual
to have lumbosacral anomalies. To make communication between practitioners
clear, it is important to specify the presence of any abnormalities
and how it influences the counting and reporting of the level or
After sterile preparation and local anesthesia, a 22-gauge needle
is advanced under fluoroscopic guidance toward the target joint.
A 3½-in. needle will be long enough
for most patients; however, the larger patient may require a 5-
or 6-in. needle. The needle is advanced until it contacts the boney
edge of the facet joint. The needle is then walked off the bone
to slip into the facet joint.
In patients with severe osteoarthritis, the joint space may be
narrowed to the point that needle entry is not possible. A periarticular
injection can be performed in this situation for therapeutic purposes
but a periarticular injection will be of minimal diagnostic value.
Following needle entry into the joint, the needle is advanced 2
to 3 mm. Because the lumbar facet joint surfaces are curved, it
is often not possible to advance more than 2 to 3 mm. Intra-articular
position is confirmed by injecting 0.5 mL of contrast suitable for
intrathecal injection (e.g., iopamidol). A typical lumbar facet
arthrogram is shown in Figure 67-32.
(A) Posterolateral approach to the lumbar facet joint.
(B) Posterolateral fluoroscopic view of lumbar facet joint injection
It is not unusual for the facet capsule to have small fenestrations.
It is possible that the injectant may spread to contiguous structures
including the epidural space or intervertebral foramen. It is important
to identify such spread during the contrast injection, if the injection
is being used for diagnostic purposes, as spread to the epidural
space or adjacent nerve root would limit the diagnostic utility
of the injection. Figure 67-33 is an example of contrast spreading
from the L5S1 facet joint to the adjacent S1 nerve
root. Arthrography is followed by the diagnostic or therapeutic
injection. Typically, 0.25 to 0.50 mL of anesthetic is mixed with
0.25 to 0.50 mL of corticosteroid for each joint.
L5S1 facet injection with contrast.
The injectant has spread beyond the ventral aspect of the joint,
to surround the first sacral nerve root in this patient with previous
lumbar spine surgery.
Complications following facet joint injection are uncommon and
include intravascular injection, spinal injection, infection, and
needle trauma to the joint or adjacent nerve root.
The pain related to costovertebral and costotransverse joints
usually is unilateral, beginning in a paravertebral location and
often radiates in a banklike fashion around the thorax.54,55 The
pain is described as aching and burning, and is usually worse in
the morning. It is also worsened by deep inspiration, coughing,
and twisting or rotation of the torso.
The injection is performed with fluoroscopy guidance to minimize
the risk of pneumothorax. The patient is placed in the prone position,
and the lateral tip of the transverse process of the level in question
is identified. The skin is entered just cephalad and lateral to
this point, with a 25-gauge 3½-in. needle
directed medially, usually approximately 3 cm from midline. The
needle is advanced approximately 3 to 4 cm until contact is made
with the vertebral body, which indicates that the needle tip is
in the intertransverse space. The needle tip placement is then adjusted
cephalad or caudad until it lies within the joint, or pierces the
articular capsule. At this point, 0.5 to 1 mL of local anesthetic
and/or depot steroid is injected.
Pneumothorax is the most feared complication of this block, although
the incidence should be low with proper technique and fluoroscopic
Costosternal joint pain can be post-traumatic or inflammatory
in nature. The costosternal joints are synovial joints; however,
the joint space can be obliterated or replaced by fibrous tissue.
The patient is placed supine and the affected joint (or joints)
is identified by palpation. Fluoroscopy is not helpful as the costosternal
joints are not identifiable with plain x-ray films or fluoroscopy.
The joint space is usually identifiable by palpating a groove between
the costal cartilage and the sternum. Once identified, the affected
joint is injected with 0.5 to 1.0 mL of local anesthetic and/or
corticosteroid using a 25-gauge 1-in. needle (see Fig. 67-2).
The patient is placed in the supine position, and the gap between
the medial end of the clavicle and the sternum is palpated. The
joint is entered with a 25-gauge 1-in. needle and 1 mL of local anesthetic
and/or depot steroid is injected (see Fig. 67-2). There
should be little resistance to injection. If resistance is encountered,
the needle tip is most likely in the meniscal cartilage and should
be withdrawn slightly or repositioned until the injectant flows
If posterior sternoclavicular pain is suspected, the posterior
ligament of the sternoclavicular joint may be injected. There are
two ways to approach this ligament. With the patient in the supine position,
a slightly longer 25-gauge needle may be passed completely through
the joint, until ligamentous resistance is felt, and then 1 mL of
local anesthetic and/or depot steroid is injected around
the ligament. The alternate approach is to enter the skin above
the superior aspect of the clavicle, and walk the needle off the
posterior aspect of the clavicle in a slightly medial direction. Again,
the injection is carried out as described above.
With both costosternal and sternoclavicular joint injections,
care must be taken to have the needle enter the skin perpendicularly
in order to diminish the possibility of pneumothorax. With sternoclavicular
joint injections, there is also the possibility of puncture of the
subclavian artery or vein with a misplaced needle. Careful attention
to technique and use of short (e.g., ½ in.)
needles should minimize these complications.