- Email: [email protected]
Cervical Zygapophysial Joint Innervation
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams Jeffrey R. Conly, Luis D. Baez-Cabrera, Isaac Cohen, Brian F. White, and Michael B. Furman
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
30H
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
TON C2 VB TON
C2-C3 Z JT
C3 VR
C2-C3 Z JT
C3 VB
C3 MB Articular branch
C3 MB Articular branch
C4 VR
C3-C4 Z JT
C4 VB
C4-C5 Z JT C5 VB
C4 MB
C5-C6 Z JT
C5 MB C5-C6 Z JT C6 MB
C6 MB C6-C7 Z JT C7 MB
C6 VB C7 VR
C6-C7 Z JT
C7 VB
C5 VB
C6 VB
C7 MB
C7-T1 Z JT C8 VR
C4 VB
C4-C5 Z JT
C5 MB
C6 VR
C3 VB
C3-C4 Z JT
C4 MB C5 VR
C7 VB
C8 MB T1 VB
A
C2 VB
C7-T1 Z JT C8 MB
T1 VB
B
VI
Fig. 30H.1. Illustration of an idealized cervical spine showing the variable course of cervical medial branches relative to bony landmarks, demonstrating the variability noted in consecutive cadaver dissections. A, Lateral view. Each line represents the nerve course of one cadaver specimen. The variable courses of the third occipital nerve (TON) (i.e., the C3 superficial medial branch) and the C3-C7 medial branches are shown. Note how the variable courses of the TON (blue) and the C3 deep medial branches (black) overlap with each other. Also note that the C5 medial branches course along the middle aspect of the C5 articular pillar, but the other medial branches are located progressively higher on their respective articular pillar as the level progresses further away from the C5 level. Note that the C8 medial branch is illustrated in a lateral view, but not relevant for C8 MB block, which is performed from an adjusted AP view. B, Anteroposterior view. Each dot represents the cross section of one cadaver specimen’s nerve course. The variations in location of the TON are shown as larger open circles, whereas the lower cervical medial branches are shown as smaller solid dots. (TON, C3-C7 figure(s) used and modified with permission from Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophysial joint pain. Neurosurg Q. 1998;8(4):288-308.)
506
A
Right TON
Right GON
Right ear
Lateral aspect of right C1 TP
External occipital protuberance
Right mandible
Posterior tubercle of C1 TP of C2, 3, 4, 5 outlined
C2 spinous process
Right C3, C4, C5, C6, C7, C8 MB Right C5, 6, 7, 8 ventral rami forming brachial plexus Right 1st rib
B Fig. 30 H.2 A and B. Cadaveric dissection of the cervical spine. Image viewed from near AP position with ~10 degrees of right oblique. A, Unlabeled view. Medial branches (MB) are clearly viewed at C3 to C8 levels. Note the relatively larger size of the cervical MB when compared to those in the lumbar spine viewed in the dissection images 15 E.2. The greater occipital nerve (GON) is visible as it emerges inferior to the obliquus capitis inferior muscle, and the third occipital nerve (TON) is visible immediately cephalad to the C3 MB. The posterior tubercle of C1 and the tip of the C2 spinous process are noted in the midline. The C1 to C5 transverse processes (TP) are visible and are located slightly inferior and lateral to the MB of the same level. The location of the lower cervical TP can be approximated by their relation to the visible neurologic structure but are not directly visualized in this view. The right supraclavicular brachial plexus is seen proximal to the level of the trunks and lying above the right first rib. B, Labeled view. Black lines highlight salient osseous structures noted above as well as the waist of the articular pillar at the C4, C5, and C6 levels. Bright yellow lines highlight the position of the GON, TON, C3 – C8 MB. Gold structures are the C5 – C8 ventral rami forming the proximal portion of the brachial plexus. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy 507 Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
VI
Waist of right C4, C5, and C6 articular pillar outlined
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
Right TON
Right GON
Right ear
External occipital protuberance
Lateral aspect of right C1 TP
C4
Right C3, C4, C5, C6, C7, C8 MB
C5
C6 C7
Right 1st rib
C
TP of C2, 3, 4, 5, 6, 7, T1 outlined
D
C8 T1
Right C5, 6, 7, 8 T1 VR forming brachial plexus
VI
Fig. 30 H.2 C and D cont’d Cadaveric dissection of cervical spine images viewed from lateral position. Wires have been placed in close approximation to the C3, C4, C5, and C6 MB. C, Unlabeled view. A wire is also placed near the TON; however, note that the wire placement has migrated to a position superior to the actual anatomic course of the TON additionally, the wire has an exaggerated cephalad angulation relative to the anatomic position of the TON. GON is seen emerging from beneath the obliquus capitis inferior muscle and the lateral aspect of C1 TP is seen directly below the ear. The C3 – T1 level ventral rami (VR) can be seen extending anteriorly with the C5 – T1 levels forming the brachial plexus. The first rib is seen in the lower aspect of the image. D, Labeled view. Black lines highlighting osseous structures in the lateral view. TP are prominently visible at the C1 and C2 levels and can also be seen at lower cervical levels; black lined ovals highlight the lateral projection of the C1 – T1 TP. Lateral margin of the facet joints at the C3-C4, C4-C5, and C5-C6 levels are visible highlight with black lines over the joint margin. Lower level cervical facet joints are not directly visible, but their location can be inferred by the position of visualized neurologic structures. Yellow lines demonstrate the C3 – C8 MB and the GON and TON. Green lines highlight the positon of wires placed along the C3, C4, and C5, MB. Gold colored structures are C3 – T1 level ventral rami. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
508
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
E
C2
Right TON nerve course shown with the blue line
C3
VI
Wires over MB C3 C4 C5 C6
C4
C5
C6
F
C7
Fig. 30 H.2 E-H cont’d Fluoroscopic images of the cadaveric dissection viewed above in Fig. 30 H.2 A-D. Lateral (E and F) and AP (G and H) fluoroscopic views are presented with wire segments placed along the course of the medial branches at the C3 – C6 levels. E and F. Lateral views, E, unlabeled and, F, labeled. This view is a fluoroscopic image of the cadaveric view seen in Fig. 30 H.1. E (unlabeled) and F (labeled). Black lines outline the vertebral bodies of C2 – C7. Green lines highlight the wires placed along the course of the C3 – C6 MB. No wire is shown along the TON in E. A blue line represents the TON course in F. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME. 509
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
G
C2 Right TON nerve course shown with the blue line
VI
C3
C4
Wires over MB C3 C4 C5 C6
C5
C6
H Fig. 30 H.2 G-H cont’d This view is a fluoroscopic image of the cadaveric view seen in Fig. 30 H.1. G (unlabeled) and H (labeled). Black lines outline the articular pillars of C2 – C6. Green lines highlight the wires placed along the course of the C3 – C6 MB. No wire is shown along the TON in EG. A blue line represents the TON course in H. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME. 510
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
C3 C3 C4 C5
C4
C6 C5 A
C6
B
C3
C2
VI
C4 C3
C
C4
D
Fig. 30H.3. A-B C3-6 medial branch block. A, Lateral and, B, AP demonstrate suggested targets for C3 through C6 medial branch blocks. An anatomic validation study by Barnsley1 demonstrated that blocking a single point for the C3-6 medial branches (centroid of the articular pillar) is sufficient to encompass all the known locations of the C3-6 medial branches. Third occipital nerve and C7 medial branch blocks require different and multiple block points, given the different bony anatomy and greater cephalocaudal variability in location relative to the C3-6 medial branches. C-D Third occipital nerve block. C, Lateral and, D, AP demonstrate suggested targets for the third occipital nerve. Three block points along the vertical bisector of the C2-3 joint are required to encompass all known locations of the third occipital nerve as it winds around the lateral aspect of the C2-3 joint: (1)apex of the C3 SAP, (2)base of C2-3 foramen, and ( 3) in between the above two points. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
511
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
C5
C6
C5 C6
E
C7
C7
F
VI
Fig. 30 H.3 E-F cont’d E-F C7 medial branch block. E, Lateral and, F, AP demonstrate suggested targets for the C7 medial branch. The C7 medial branch crosses either the C7 SAP or proximal aspect of the C7 transverse process; hence two block points are recommended. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
512
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
A
B
VI
C Fig. 30H.4. Illustration and model of an idealized cervical spine with radiofrequency electrode positioning and cervical medial branch (MB) lesion sites for the third occipital nerve through C8 MBs based on the variable course of the cervical MBs relative to bony landmarks. The target “zone” for neurotomy is demonstrated as pink region based on and extrapolated from known MB anatomy demonstrated and referenced in Fig. 30H.1 as well as “zones” described in SIS Guidelines.2 A, Anteroposterior view. B, Lateral view. C, Oblique view. (For a high-resolution version of these images, go to www.expertconsult.com.)
513
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
References 1. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophysial joint pain. Reg Anes 18:343:1993.
VI
2. Bogduk N. Editor. Practice Guidelines for Spinal Diagnostic and Treatment Procedures (Second Edition). Hinsdale, IL: International Spine Intervention Society, 2014.
514
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
30H
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
TON C2 VB TON
C2-C3 Z JT
C3 VR
C2-C3 Z JT
C3 VB
C3 MB Articular branch
C3 MB Articular branch
C4 VR
C3-C4 Z JT
C4 VB
C4-C5 Z JT C5 VB
C4 MB
C5-C6 Z JT
C5 MB C5-C6 Z JT C6 MB
C6 MB C6-C7 Z JT C7 MB
C6 VB C7 VR
C6-C7 Z JT
C7 VB
C5 VB
C6 VB
C7 MB
C7-T1 Z JT C8 VR
C4 VB
C4-C5 Z JT
C5 MB
C6 VR
C3 VB
C3-C4 Z JT
C4 MB C5 VR
C7 VB
C8 MB T1 VB
A
C2 VB
C7-T1 Z JT C8 MB
T1 VB
B
VI
Fig. 30H.1. Illustration of an idealized cervical spine showing the variable course of cervical medial branches relative to bony landmarks, demonstrating the variability noted in consecutive cadaver dissections. A, Lateral view. Each line represents the nerve course of one cadaver specimen. The variable courses of the third occipital nerve (TON) (i.e., the C3 superficial medial branch) and the C3-C7 medial branches are shown. Note how the variable courses of the TON (blue) and the C3 deep medial branches (black) overlap with each other. Also note that the C5 medial branches course along the middle aspect of the C5 articular pillar, but the other medial branches are located progressively higher on their respective articular pillar as the level progresses further away from the C5 level. Note that the C8 medial branch is illustrated in a lateral view, but not relevant for C8 MB block, which is performed from an adjusted AP view. B, Anteroposterior view. Each dot represents the cross section of one cadaver specimen’s nerve course. The variations in location of the TON are shown as larger open circles, whereas the lower cervical medial branches are shown as smaller solid dots. (TON, C3-C7 figure(s) used and modified with permission from Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the cervical medial branches: a validated treatment for cervical zygapophysial joint pain. Neurosurg Q. 1998;8(4):288-308.)
506
A
Right TON
Right GON
Right ear
Lateral aspect of right C1 TP
External occipital protuberance
Right mandible
Posterior tubercle of C1 TP of C2, 3, 4, 5 outlined
C2 spinous process
Right C3, C4, C5, C6, C7, C8 MB Right C5, 6, 7, 8 ventral rami forming brachial plexus Right 1st rib
B Fig. 30 H.2 A and B. Cadaveric dissection of the cervical spine. Image viewed from near AP position with ~10 degrees of right oblique. A, Unlabeled view. Medial branches (MB) are clearly viewed at C3 to C8 levels. Note the relatively larger size of the cervical MB when compared to those in the lumbar spine viewed in the dissection images 15 E.2. The greater occipital nerve (GON) is visible as it emerges inferior to the obliquus capitis inferior muscle, and the third occipital nerve (TON) is visible immediately cephalad to the C3 MB. The posterior tubercle of C1 and the tip of the C2 spinous process are noted in the midline. The C1 to C5 transverse processes (TP) are visible and are located slightly inferior and lateral to the MB of the same level. The location of the lower cervical TP can be approximated by their relation to the visible neurologic structure but are not directly visualized in this view. The right supraclavicular brachial plexus is seen proximal to the level of the trunks and lying above the right first rib. B, Labeled view. Black lines highlight salient osseous structures noted above as well as the waist of the articular pillar at the C4, C5, and C6 levels. Bright yellow lines highlight the position of the GON, TON, C3 – C8 MB. Gold structures are the C5 – C8 ventral rami forming the proximal portion of the brachial plexus. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy 507 Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
VI
Waist of right C4, C5, and C6 articular pillar outlined
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
Right TON
Right GON
Right ear
External occipital protuberance
Lateral aspect of right C1 TP
C4
Right C3, C4, C5, C6, C7, C8 MB
C5
C6 C7
Right 1st rib
C
TP of C2, 3, 4, 5, 6, 7, T1 outlined
D
C8 T1
Right C5, 6, 7, 8 T1 VR forming brachial plexus
VI
Fig. 30 H.2 C and D cont’d Cadaveric dissection of cervical spine images viewed from lateral position. Wires have been placed in close approximation to the C3, C4, C5, and C6 MB. C, Unlabeled view. A wire is also placed near the TON; however, note that the wire placement has migrated to a position superior to the actual anatomic course of the TON additionally, the wire has an exaggerated cephalad angulation relative to the anatomic position of the TON. GON is seen emerging from beneath the obliquus capitis inferior muscle and the lateral aspect of C1 TP is seen directly below the ear. The C3 – T1 level ventral rami (VR) can be seen extending anteriorly with the C5 – T1 levels forming the brachial plexus. The first rib is seen in the lower aspect of the image. D, Labeled view. Black lines highlighting osseous structures in the lateral view. TP are prominently visible at the C1 and C2 levels and can also be seen at lower cervical levels; black lined ovals highlight the lateral projection of the C1 – T1 TP. Lateral margin of the facet joints at the C3-C4, C4-C5, and C5-C6 levels are visible highlight with black lines over the joint margin. Lower level cervical facet joints are not directly visible, but their location can be inferred by the position of visualized neurologic structures. Yellow lines demonstrate the C3 – C8 MB and the GON and TON. Green lines highlight the positon of wires placed along the C3, C4, and C5, MB. Gold colored structures are C3 – T1 level ventral rami. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
508
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
E
C2
Right TON nerve course shown with the blue line
C3
VI
Wires over MB C3 C4 C5 C6
C4
C5
C6
F
C7
Fig. 30 H.2 E-H cont’d Fluoroscopic images of the cadaveric dissection viewed above in Fig. 30 H.2 A-D. Lateral (E and F) and AP (G and H) fluoroscopic views are presented with wire segments placed along the course of the medial branches at the C3 – C6 levels. E and F. Lateral views, E, unlabeled and, F, labeled. This view is a fluoroscopic image of the cadaveric view seen in Fig. 30 H.1. E (unlabeled) and F (labeled). Black lines outline the vertebral bodies of C2 – C7. Green lines highlight the wires placed along the course of the C3 – C6 MB. No wire is shown along the TON in E. A blue line represents the TON course in F. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME. 509
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
G
C2 Right TON nerve course shown with the blue line
VI
C3
C4
Wires over MB C3 C4 C5 C6
C5
C6
H Fig. 30 H.2 G-H cont’d This view is a fluoroscopic image of the cadaveric view seen in Fig. 30 H.1. G (unlabeled) and H (labeled). Black lines outline the articular pillars of C2 – C6. Green lines highlight the wires placed along the course of the C3 – C6 MB. No wire is shown along the TON in EG. A blue line represents the TON course in H. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME. 510
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
C3 C3 C4 C5
C4
C6 C5 A
C6
B
C3
C2
VI
C4 C3
C
C4
D
Fig. 30H.3. A-B C3-6 medial branch block. A, Lateral and, B, AP demonstrate suggested targets for C3 through C6 medial branch blocks. An anatomic validation study by Barnsley1 demonstrated that blocking a single point for the C3-6 medial branches (centroid of the articular pillar) is sufficient to encompass all the known locations of the C3-6 medial branches. Third occipital nerve and C7 medial branch blocks require different and multiple block points, given the different bony anatomy and greater cephalocaudal variability in location relative to the C3-6 medial branches. C-D Third occipital nerve block. C, Lateral and, D, AP demonstrate suggested targets for the third occipital nerve. Three block points along the vertical bisector of the C2-3 joint are required to encompass all known locations of the third occipital nerve as it winds around the lateral aspect of the C2-3 joint: (1)apex of the C3 SAP, (2)base of C2-3 foramen, and ( 3) in between the above two points. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
511
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
C5
C6
C5 C6
E
C7
C7
F
VI
Fig. 30 H.3 E-F cont’d E-F C7 medial branch block. E, Lateral and, F, AP demonstrate suggested targets for the C7 medial branch. The C7 medial branch crosses either the C7 SAP or proximal aspect of the C7 transverse process; hence two block points are recommended. Cadaveric specimens and dissection provided courtesy of Professor Frank Willard and the Anatomy Department at the University of New England College of Osteopathic Medicine, Biddeford, ME.
512
Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
A
B
VI
C Fig. 30H.4. Illustration and model of an idealized cervical spine with radiofrequency electrode positioning and cervical medial branch (MB) lesion sites for the third occipital nerve through C8 MBs based on the variable course of the cervical MBs relative to bony landmarks. The target “zone” for neurotomy is demonstrated as pink region based on and extrapolated from known MB anatomy demonstrated and referenced in Fig. 30H.1 as well as “zones” described in SIS Guidelines.2 A, Anteroposterior view. B, Lateral view. C, Oblique view. (For a high-resolution version of these images, go to www.expertconsult.com.)
513
Chapter 30H Cervical Zygapophysial Joint Innervation: Anatomy, Dissections, and Lesion Zone Diagrams
References 1. Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophysial joint pain. Reg Anes 18:343:1993.
VI
2. Bogduk N. Editor. Practice Guidelines for Spinal Diagnostic and Treatment Procedures (Second Edition). Hinsdale, IL: International Spine Intervention Society, 2014.
514