Sonographically Guided Costotransverse Joint Injections

Abstract

A Computed Tomographically Controlled Cadaveric Feasibility Studyack pain is a common problem with a lifetime prevalence of approximately 80%. [1][2][3] Although thoracic back pain accounts for only 15% to 20% of all back pain syndromes, the disability incurred by patients with thoracic back pain is equal to that experienced by those with cervical or lumbar spinal pain. [3][4][5] Among symptomatic patients presenting with thoracic pain, multiple potential pain generators have been identified, including but not limited to the thoracic facet joints, costovertebral joints, costotransverse (CTRV) joints, and thoracic intervertebral disks. [5][6][7] Given the high degree of structural integrity of the thoracic spine, there are multiple bony articulations, muscle layers, and ligamentous structures that experience substantial biomechanical stress during daily life. 8,9 The close proximity of these structures and variable 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 intraarticular 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.

The Validation of Ultrasound-Guided Target Segment Identification in Thoracic Spine as Confirmed by Fluoroscopy

“…Then, the transducer was moved medially through the transverse process of T12 and L1 to find the facet joint and then upward to the target segment. Meanwhile, Deimel et al 10) and Marhofer et al 11) described a segment identification method using the spinous process of C7. First, the spinous process of C7 was checked with a transducer, which was moved downward to the spinous process of the target segment.…”

“… 7) Therefore, previous studies on ultrasound-guided thoracic spinal block suggested only the accuracy of contrast material injection at the target facet joint or the paravertebral space as a factor associated with the cause of pain, not the accuracy of target segment identification. 8 9 10) However, with the expanding indications for thoracic spinal nerve block, there has been a growing expectation on favorable results of ultrasound landmark-guided block performed at the definite target segment for conditions, such as facet syndrome associated with thoracic vertebral compression fracture.…”

“…There are two kinds of anatomical landmarks used as a starting point for ultrasound-guided target segment identification in the thoracic vertebra: the 12th rib 8) and the spinous process of C7. 10 11) The aim of this study was to compare the efficacy of the two landmarks for ultrasoundguided target segment identification in the thoracic spine.…”

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

“…All ultrasound-guided CTRV joint injections were performed by one pain physician (K.B.Y.) as previously described by Deimel et al [ 10 ]. For image optimization, we identified the transverse process, CTRV joint, rib, and lung in the same plane ( Fig.…”

“…The costovertebral and CTRV joints also significantly contribute to the stability and movement of the thoracic spine, which is not limited to motion of the ribs [ 6 7 ]. Although the CTRV joints are relatively less studied compared to the thoracic facet joints and intervertebral disks, it has been well established that the CTRV joints may produce clinically significant thoracic back pain [ 1 8 9 10 11 ]. Therefore, we hypothesized that the CTRV joints might be a source of pain and that this treatment could lead to clinical improvements.…”