I have seen a lady with degenerative TMJ disease of both joints, grade III, more left that right. She is using a mouth guarding (dental splint) at night to allay frictional burden but she is still complaining of ongoing pain and has asked, actually begged, for an intraarticular injection. Could anyone share with me the image-guided (fluoro) technique that is to be used. I have not found any references with directions to follow, images or anything worth reading/seeing. Thank you in advance.
TM joint pain
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I usually do these in the exam room without fluoro, although I have heard of them being done under CT guidance. If you can do mandibular and maxillary nerve blocks w/o fluoro then I don't see why you need fluoro for a more shallow structure like the TMJ.
I usually have them open and close their mouth a few times to identify the relationship between the zygomatic arch and the condyle. You can do the injection anteriorly or posteriorly.
Posterior - have them open their mouth wide. Use a bite block to keep it propped open. Palpate the space above and behind the condylar head just below the zygoma and insert a 25g or 27g needle. You often feel a pop when you enter the joint. Aspirate to be sure you aren't in a vessel. I inject a mix of 0.25 cc 1% lidocaine and 0.25 cc of kenalog, total volume 0.5 cc. The advantage of this approach is that by going posterior you are unlikely to hit the disk. The disadvantage is that structures like the superficial temporal artery/vein and mandibular nerve run nearby.
For the anterior approach the mouth should be closed but the jaws should not be clenched. I target the space between the anterior condyle and the zygoma. The disk is in this area so if you encounter any resistance to injection stop. There should be no resistance if you are in the joint space. If you go too deep you can hit the maxillary artery or nerve.
I usually use a TB syringe so I can't go very deep. I wouldn't use more than a 1/2" needle. Warn the patient that they might have bruising afterward because behind that area it's pretty vascular.
BTW, a good treatment for nocturnal bruxism is a TCA. Some people push amitriptyline to pretty high doses, with the endpoint being the patient decides to find another doctor.
I usually have them open and close their mouth a few times to identify the relationship between the zygomatic arch and the condyle. You can do the injection anteriorly or posteriorly.
Posterior - have them open their mouth wide. Use a bite block to keep it propped open. Palpate the space above and behind the condylar head just below the zygoma and insert a 25g or 27g needle. You often feel a pop when you enter the joint. Aspirate to be sure you aren't in a vessel. I inject a mix of 0.25 cc 1% lidocaine and 0.25 cc of kenalog, total volume 0.5 cc. The advantage of this approach is that by going posterior you are unlikely to hit the disk. The disadvantage is that structures like the superficial temporal artery/vein and mandibular nerve run nearby.
For the anterior approach the mouth should be closed but the jaws should not be clenched. I target the space between the anterior condyle and the zygoma. The disk is in this area so if you encounter any resistance to injection stop. There should be no resistance if you are in the joint space. If you go too deep you can hit the maxillary artery or nerve.
I usually use a TB syringe so I can't go very deep. I wouldn't use more than a 1/2" needle. Warn the patient that they might have bruising afterward because behind that area it's pretty vascular.
BTW, a good treatment for nocturnal bruxism is a TCA. Some people push amitriptyline to pretty high doses, with the endpoint being the patient decides to find another doctor.
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Mister Mixasxkdisdkhgsksjs (or the pain doctor formally known as GRBK),
Can you post a fluoro shot of the posterior approach?
Can you post a fluoro shot of the posterior approach?
