Target: Exit of intervertebral neuroforamen, just below the upper pedicle (foraminal roof)

Procedure:

• - Patient in supine position
  - Use of a traction strap for shoulder lowering
  - Axial scan from C4 to Th1 (i.v. contrast is optional) to locate the neuroforamen and the anterior lying vertebral artery
  - Lateral approach just behind or through the sternocleidomastoid muscle
  - CT fluoroscopy-guided direct puncture from skin to roof of neuroforamen with a 22 or 25 G needle
  - Placement of needle tip on the anterior aspect of the bony facet
  - Steroid injection followed by a controlateral decubitus for 5 minutes
  - The procedure should be painless. If radiculopathy increases when approaching the neuroforamen (in case of severe inflammation), the procedure should be stopped and steroid injection should be performed at the level where pain appears. A second infiltration should be programmed 3 weeks later
  

Danger:

• -Vertebral artery perforation : beginners should always use a target slice where the vertebral artery is protected by bone at the level of the transverse foramen
• -To avoid risk of nerve root injury at the foraminal exit, always place the needle tip in the upper half of the foramen (roof). Cervical nerve roots always emerge at the lower half