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

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.

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.

Chinese Association for the Study of Pain: Experts consensus on ultrasound-guided injections for the treatment of spinal pain in China (2020 edition)

Spinal pain (SP) is a common condition that has a major negative impact on a patient’s quality of life. Recent developments in ultrasound-guided injections for the treatment of SP are increasingly being used in clinical practice. This clinical expert consensus describes the purpose, significance, implementation methods, indications, contraindications, and techniques of ultrasound-guided injections. This consensus offers a practical reference point for physicians to implement successfully ultrasound-guided injections in the treatment of chronic SP.

Morphometric analysis of the costal facet of the thoracic vertebrae

Various studies have examined morphometric features of the vertebrae to understand the functional aspects of the spine. Geometric analysis of vertebral zygapophyseal facets has also been related to functional and clinical aspects of the spine, but no quantitative investigation of the costotransverse joint facet is found in the literature. The costal facet geometry may partly determine the mechanical interaction between the rib cage and spine for trunk stabilization during functional tasks and during breathing. Therefore, the present study proposes a method for estimating the 3D geometric features of the costal facets of the first 10 thoracic vertebrae (Th1-Th10). Series of landmarks (95 ± 43) were placed on 258 costal facets from a sample of 14 asymptomatic individuals to determine their 3D location and orientation. The relative location of the costal facet was used to investigate symmetry and asymmetry components of the overall vertebrae shape variation among thoracic levels using 3D geometric morphometric methods. Results showed significant variation in sagittal orientation (inclination angle) between levels with a gradual cephalic orientation in the lower levels. No significant difference was observed on transverse orientation (declination angle). The shape of the costal facet was flatter at Th1 and from Th5 to Th10 and more concave from Th2 to Th4. An average difference of 7° between right and left facet orientation in both sagittal and transverse plane was demonstrated. Asymmetry of costal facet relative location was also detected and significantly influenced by the thoracic level. Nevertheless, location and orientation of the costal facets seem to be independent features of vertebrae morphology.