Thoracic costotransverse joint pain patterns: a study in normal volunteers

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

Facet joint disorders: from diagnosis to treatment

One of the most common sources of spinal pain syndromes is the facet joints. Cervical, thoracic, and lumbar facet joint pain syndromes comprise 55%, 42%, and 31% of chronic spinal pain syndromes, respectively. Common facet joint disorders are degenerative disorders, such as osteoarthritis, hypertrophied superior articular process, and facet joint cysts; septic arthritis; systemic and metabolic disorders, such as ankylosing spondylitis or gout; and traumatic dislocations. The facet pain syndrome from osteoarthritis is suspected from a patient's history (referred pain pattern) and physical examination (tenderness). Other facet joint disorders may cause radicular pain if mass effect from a facet joint cyst, hypertrophied superior articular process, or tumors compress the dorsal root ganglion. However, a high degree of morphological change does not always provoke pain. The superiority of innervating nerve block or direct joint injection for diagnosis and treatment is still a controversy. Treatment includes facet joint injection in facet joint osteoarthritis or whiplash injury provoking referred pain or decompression in mass effect in cases of hypertrophied superior articular process or facet joint cyst eliciting radicular pain. In addition, septic arthritis is treated using a proper antibiotic, based on infected tissue or blood culture. This review describes the diagnosis and treatment of common facet joint disorders.

[Method of manual-physical correction in the treatment of hypertensive disease and normalization of psychoneurological status in patients with degenerative-dystrophic processes of the musculoskeletal system]

There are some non-communicable diseases (NCD) associated with arterial hypertension (AHT) that are cured after recovery from AHT. Recently confirmed the theory of centralized aerobic-anaerobic energy balance compensation (TCAAEBC) originated some NCDs with the obstructions of arterial blood flow access to the rhomboid fossa. For some sergeants, this has already been demonstrated. Since neurological NCDs are similarly considered by TCAAEBC, it is logical to analyze dynamics of such musculoskeletal neurological problem as isolated musculoskeletal chest pain (IMCP) in connection with the therapy based on TCAAEBC. We retrospectively evaluated the medical records of adult patients with AHT, simultaneously suffering from IMCP. All these patients underwent complex treatment including manual techniques that restore arterial blood flow to the rhomboid fossa, followed by therapy that strengthens the muscular corset primarily of the cervical region. This, in addition to the normalization of AHT, led to a decrease in the musculoskeletal pain syndrome. The dynamic of pain was recorded according to four questionaries - Oswestry Disability Index (ODI) Hospital Anxiety and Depression Scale (HADS), Numerical Rating Scale (NRS), and the Quality-of-life assessment questionnaire (SF-12). The collected data were analyzed with the Wilcoxon signed-rank test, which confirms the recovery of the patients from both AHT and IMCP.

Intra and inter observer agreement in the mobility assessment of the upper thoracic costovertebral joints

BACKGROUND

Determining the mobility of the costovertebral joints might be important in patients with neck-upper thoracic pain. Little research has been performed on observer agreement when assessing the mobility of these joints.

PURPOSE

The purpose of this study was to determine intra- and inter-observer agreements when assessing costovertebral joint mobility of the upper three ribs in those with and without neck pain and to compare the difference between the Kappa and AC statistic.

METHODS

Forty-four participants, with and without current neck/upper-thoracic pain, were assessed by two raters. Raters applied a posterior to anterior pressure to the anatomical neck of the first three ribs bilaterally. Mobility was graded: normal, increased, or decreased. An AC1, for nominal data, AC2 for ordinal data, and the Kappa statistics were used to analyze the results. The AC statistics determines chance agreement different than Kappa.

RESULTS

AC1 showed "moderate to very good" (0.74-1.0) intra-rater reliability, while inter-rater reliability showed "fair to good" agreement (0.51-0.79). Using the AC2 Intra-rater reliability was "very good" and "almost perfect" (AC2: 0.93-1.0), while using the AC2 was "good to very good" and "good to almost perfect" (0.76-0.94). Kappa values for intra-rater reliability ranged from "fair to moderate" (0.38-0.54), while inter-rater reliability ranged from "poor to fair" (-0.10-0.26).

CONCLUSION

Posterior/anterior pressure is a reliable method to assess the mobility of the upper costovertebral joints. Assessing costovertebral mobility is important when establishing a movement diagnosis in patients with neck/upper thoracic pain.

Inflammatory disease of the costotransverse joints: US evaluation in 15 symptomatic patients

The costotransverse joints (CTJs) are small arthrodial joints which articulate with the costal tuberosity on the transverse process of the thoracic vertebrae. CTJs are composed of oval-shaped facets with a major axis, vertical at the upper vertebrae and almost horizontal at the lower vertebrae. This position explains the different movements of the ribs: the cranial ribs move on the sagittal plane and the caudal ribs on the transverse plane. Movements in directions other than these usual CTJ spatial planes can cause inflammation resulting in a stinging pain in the space between the scapula and thoracic spine. We studied 15 subjects with paravertebral pain compatible with CTJ pathology. Mean age was 29 years, 11 females/4 males. In 12 patients, the non-dominant limb was affected. US imaging was carried out using linear 12 MHz and 9 MHz probes. Scanning was performed following the long axis of the rib (transverse plane) and the short axis (sagittal plane). Sagittal scanning is the method of choice for detection of possible joint effusion and comparison with undamaged joints above and below. US identified joint effusion correlating with the site of pain in all patients. Thickening of the posterior costotransverse capsular ligament was detected in six patients mainly affecting the first thoracic vertebrae. Power Doppler showed intraarticular hypervascularization in four patients. US imaging should be performed as a first-line examination in the evaluation of patients with stinging pain in the paravertebral region. US evidence of effusion within the joints is a sure sign of involvement of these structures.

Osteoartrose costovertebral: Diagnóstico diferencial raro de dorsalgia no paciente jovem. Relato de caso

The differential diagnosis of dorsal thoracic pain can be a challange due to the proximity of the dorsal column to vital organs as well as to its unique anatomy, innervation, and rib joint. The patterns of referred visceral pain require, in most cases, extensive complementary diagnostic tests in order to exclude severe conditions. Referred pain patterns often result in numerous and expensive visceral workups in order to exclude serious conditions, and costovertebral joint osteoarthritis is usually only considered when the origin of the pain remains unexplained. The authors present the case of a 40-year-old man with disabling dorsal pain due to isolated costovertebral osteoarthrosis. The symptomatology was controlled after injection of methylprednisolone guided by computed tomography. This clinical case aims to describe the clinical presentation of a rare entity that should be considered in the differential diagnosis of back pain.

Investigation of reaction force magnitude and orientation during supine thoracic thrust manipulation applied to intervertebral and costovertebral regions

BACKGROUND

Spinal manipulative techniques are commonly used in manual therapies but quantified descriptive and reliability data are lacking considering supine thoracic thrust manipulation.

OBJECTIVES

The purpose of this study is to explore and compare kinetic parameters during supine thoracic thrust manipulation performed at two different thoracic regions. Intra-rater task repeatability and influence of practitioners were estimated.

DESIGN

Exploratory and agreement study.

METHODS

Kinetic parameters were assessed by examining reaction force magnitude and orientation (on the basis of the zenithal angle) using force platforms. Manipulative procedure (consisting in the application of 3 preloads followed by one thrust adjustment) at both intervertebral and costovertebral region was performed by different practitioners at three sessions. Application of thrust was allowed for experienced practitioners only. Preload force, peak force magnitude and vector force orientation were compared between anatomical sites, sessions and practitioners, and bias with limit of agreement were estimated.

RESULTS

Repeatability analysis showed that practitioners achieved similar preload and peak force independent of the session, with comparable force orientation. Differences between practitioners were observed for preload and peak force but not regarding the zenithal angle during the thrust phase.

CONCLUSIONS

The present study is the first that explores kinetic parameters for supine thoracic thrust manipulation applied on two different regions of the thorax. Results confirm consistency of performance among practitioners for supine manipulative techniques at intervertebral and costovertebral region. While task repeatability was confirmed, several differences were observed between practitioners. Further investigations would examine velocity, acceleration and potential neurophysiological effect of such manipulative technique.

Increased 99mTc MDP activity in the costovertebral and costotransverse joints on SPECT-CT: is it predictive of associated back pain or response to percutaneous treatment?

PURPOSE

Pain related to costovertebral and costotransverse joints is likely an underrecognized and potentially important cause of thoracic back pain. On combined single-photon emission computed tomography and computed tomography (SPECT-CT), increased technetium-99m methylene diphosphonate (99mTc MDP) activity at these articulations is not uncommon. We evaluated whether this activity corresponds with thoracic back pain and whether it predicts response to percutaneous injection.

METHODS

All 99mTc MDP SPECT-CT spine examinations completed at our institution from March 2008 to March 2014 were retrospectively reviewed to identify those with increased 99mTc MDP activity in the costovertebral or costotransverse joints. The presence of corresponding thoracic back pain, percutaneous injection performed at the relevant joint(s), and response to injection were recorded.

RESULTS

A total of 724 99mTc MDP SPECT-CT examinations were identified. Increased 99mTc MDP activity at costovertebral or costotransverse joints was reported in the examinations of 55 patients (8%). Of these, 25 (45%) had corresponding thoracic back pain, and nine of 25 patients (36%) underwent percutaneous injection of the joint(s) with increased activity. At clinical follow-up two days to 12 weeks after injection, one patient (11%) had complete pain relief, two (22%) had partial pain relief, and six (67%) had no pain relief.

CONCLUSION

The findings suggest that increased activity in costovertebral and costotransverse joints on 99mTc MDP SPECT-CT is only variably associated with the presence and location of thoracic back pain; it does not predict pain response to percutaneous injection.

Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine

Few studies have examined the costovertebral joint and its ligaments in detail. Therefore, the following review was performed to better elucidate their anatomy, function and involvement in pathology. Standard search engines were used to find studies concerning the costovertebral joints and ligaments. These often-overlooked ligaments of the body serve important functions in maintaining appropriate alignment between the ribs and spine. With an increasing interest in minimally invasive approaches to the thoracic spine and an improved understanding of the function and innervation of these ligaments, surgeons and clinicians should have a good working knowledge of these structures.

T4 syndrome - A distinct theoretical concept or elusive clinical entity? A case report

T4 syndrome has existed as a clinical concept for more than three decades and it has been identified as a source of upper extremity (UE) symptoms. This case report explores the clinical reasoning in the diagnoses and management of a patient with symptoms consistent with T4-type syndrome and critically discusses the concept of T4 syndrome using recent research to help explain the clinical presentation. Manual therapy treatment focused on stimulation of the sympathetic ganglia, decreasing local upper thoracic pain and UE referral pattern noted during passive examination. The successful outcomes included immediate and lasting symptom relief after upper thoracic spinal manipulation. Although treatment has been based on the theory that mechanical thoracic dysfunction can produce sympathetic nervous system (SNS) referred pain, the role the sympathetic reflexes potentially plays on the referral symptoms to the UE presently remains unclear.

Common causes of dyspnoea in athletes: a practical approach for diagnosis and management

Key points

Educational aims

Dyspnoea during exercise is a common chief complaint in athletes and active individuals. It is not uncommon for dyspnoeic athletes to be diagnosed with asthma, “exercise-induced asthma” or exercise-induced bronchoconstriction based on their symptoms, but this strategy regularly leads to misdiagnosis and improper patient management. Dyspnoea during exercise can ultimately be caused by numerous respiratory and nonrespiratory conditions, ranging from nonpathological to potentially fatal in severity. As, such it is important for healthcare providers to be familiar with the many factors that can cause dyspnoea during exercise in seemingly otherwise-healthy individuals and have a general understanding of the clinical approach to this patient population. This article reviews common conditions that ultimately cause athletes to report dyspnoea and associated symptoms, and provides insight for developing an efficient diagnostic plan.

Dyspnoea, fatigue and underperformance are often interrelated symptoms in athletes, and may have various causeshttp://ow.ly/4nsYnk

Clinical Effectiveness of Ultrasound-guided Costotransverse Joint Injection in Thoracic Back Pain Patients

Because of its anatomical location and function, the costotransverse (CTRV) joint can be a source of thoracic back pain. In this retrospective observational study, we evaluated the clinical effectiveness of the CTRV joint injection in thoracic back pain patients with suspected CTRV joint problems. We enrolled 20 thoracic back pain patients with localized tenderness that was provoked by the application of pressure on the affected CTRV joints. We injected it with 0.5 ml of a ropivacaine and triamcinolone mixture at each level. The mean pre-injection pain score decreased by 37.9% (7.2 ± 1.5 to 4.5 ± 1.7, P < 0.001) two weeks after CTRV joint injection. In addition, 70% of patients reported an excellent or good level of satisfaction. We demonstrated that an ultrasound-guided injection of the CTRV joint reduced patients' pain scores and led to a high level of satisfaction at short-term follow-ups in patients with suspected CTRV joint problems.

Primary spontaneous pneumothorax presenting to a chiropractic clinic as undifferentiated thoracic spine pain: a case report

OBJECTIVE

To present a case of primary spontaneous pneumothorax presenting to a chiropractic clinic as undifferentiated thoracic spine pain.

CLINICAL FEATURES

A tall thin 25-year-old male anxiously presented to a chiropractic clinic with six days of sudden unexplained left thorax pain. His breathing was laboured and his dry cough aggravating. After assessment a high clinical suspicion of primary spontaneous pneumothorax prevailed.

INTERVENTION AND OUTCOME

The patient was referred to hospital for further investigation and primary spontaneous pneumothorax was confirmed on chest radiograph. He underwent immediate tube thoracostomy to drain the air from his pleural space and to re-inflate his lung. After three days the tube was removed. By two weeks the lung had returned to full size. No recurrences have occurred to date.

CONCLUSIONS

Primary spontaneous pneumothorax is a medical emergency in the presence of shortness of breath. The focus of treatment is to drain air from the pleural linings and to prevent recurrences. In less severe cases, patients may believe they have thoracic spine pain and seek manual therapy care. This case highlights the important role chiropractors have as primary contact health care providers.

Canine thoracic costovertebral and costotransverse joints: three case reports of dysfunction and manual therapy guidelines for assessment and treatment of these structures

The costovertebral and costotransverse joints receive little attention in research. However, pain associated with rib articulation dysfunction is reported to occur in human patients. The anatomic structures of the canine rib joints and thoracic spine are similar to those of humans. As such, it is proposed that extrapolation from human physical therapy practice could be used for the assessment and treatment of the canine patient with presumed rib joint pain. This article presents 3 case studies that demonstrate signs of rib dysfunction and successful treatment using primarily physical therapy manual techniques. General assessment and select treatment techniques are described.

Sonographically guided costotransverse joint injections: a computed tomographically controlled cadaveric feasibility study

OBJECTIVES

The primary purpose of this study was to describe and validate a novel sonographically guided costotransverse (CTRV) joint injection technique.

METHODS

The bilateral T3-T10 CTRV joints of an unembalmed cadaveric specimen were localized using a 12-3-MHz linear array transducer. A 22-gauge, 2.5-in spinal needle was directed into the CTRV joint using an in-plane, lateral-to-medial approach under direct sonographic guidance. After needle placement, 3-dimensional computed tomographic (CT) images were obtained to assess the locations of the needle tips. This step was followed by injection of an iodinated contrast agent and repeated CT to assess the contrast flow pattern. An experienced musculoskeletal radiologist reviewed the CT images and assessed the accuracy of the injections (intra- or extra-articular). For intra-articular injections, a quantitative assessment of the percentage of injectate within the joint was performed.

RESULTS

A total of 16 sonographically guided CTRV joint injections were completed on a single torso-pelvis specimen. Using our technique, 11 of 16 sonographically guided CTRV joint injections (68.8%) placed the contrast agent into the target joint. Quantitative analysis of the arthrograms showed 6 of 11 intra-articular injections (54.5%) with greater than 50% injectate within the joint capsule.

CONCLUSIONS

To our knowledge, this study is the first to determine the feasibility of sonographically guided CTRV joint injections. Overall, 68.8% of injection attempts produced acceptable CTRV joint arthrograms, which compares favorably to a previously reported 76% accuracy rate for fluoroscopically guided CTRV joint injections. Although these injections are technically challenging, the use of sonographic guidance to perform CTRV joint injections is feasible and warrants further investigation to establish its role in the management of patients presenting with thoracic pain syndromes.

Immunohistochemical study of human costotransverse joints: A preliminary investigation

The human costotransverse joint (CTJ) is the articulation between the posterior tubercle of the ribs with the first through tenth costal facet of the thoracic transverse processes. While the CTJ is well defined anatomically and considered a synovial joint, the human CTJ as a pain generating structure is controversial and not supported from a histological perspective. The objective of the present study was to investigate the histological pain producing properties of CTJ capsule tissue. Ten micron cross-sections at each level (1-10) were stained with H & E or immunostained with antisera against Substance P (SP), calcitonin-gene-related peptide (CGRP), and neuropeptide Y (NPY). Immunoreactivity was confirmed for SP, CGRP, and NPY within the CTJ tissue samples of two unembalmed male cadavers. The presence of previously mentioned neuropeptides suggests that human CTJ is capable of producing pain through somatic and autonomic nervous systems. Therefore, clinicians should consider the CTJ as a differential diagnostic possibility when examining and treating painful thoracic conditions.