The case report by Edlow et al .1is a valuable example of the vascular nature of the C1-C2 facet injection. However, the most valuable picture that would have shown whether the complication that occurred was truly because of an unusual complication of the procedure or whether it was because of simple misplacement of the needle was not included. The anterioposterior view would show how lateral the needle was placed; instead, only the lateral view is provided. The picture of dye spread from the lateral view shows significant spread, much more than what would be expected if the injection occurred purely intraarticular. The classic needle location in an anterioposterior view should show the needle placed in the lateral two-thirds of the joint. Any other picture would explain why this complication occurred. Live fluoroscopy was not used and may have spared this patient from a complication.

Children's Hospital Central California, Madera, California.

Edlow BL, Wainger BJ, Frosch MP, Copen WA, Rathmell JP, Rost NS: Posterior circulation stroke after C1-C2 intraarticular facet steroid injection: Evidence for diffuse microvascular injury. Anesthesiology 2010; 112:1532–5