Costotransverse and Costovertebral Joint Injections

Rib dysfunction syndromes may cause one or a combination of the following symptoms: upper back pain, arm pain, pain between the ribs, and/or generalized upper back area discomfort. Patients with upper back pain and the above symptoms may be candidates for a costotransverse or costovertebral joint injection to both help diagnose the condition and provide pain relief. It is important to note that these injections should not be considered a cure for upper back pain: rather, the goal is to help patients get enough pain relief in order to be able to progress with their rehabilitation program.

Costotransverse and costovertebral joint injections both involve carefully injecting medication into the small joints where the ribs join with the spine in the upper back. These injections are types of pain blocks and may also be referred to as a costovertebral block or a costotransverse block.

Costotransverse and costovertebral joint injections are used to both confirm a diagnosis that these joints are the source of the patient's upper back pain as well as to provide pain relief.

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  • Diagnostic goals: by placing numbing medicine into the joint, the amount of immediate pain relief that the patient experiences will help confirm or deny the joint as a source of the upper back pain. If complete pain relief is achieved while the joints are numb it means that these joints are likely the source of patient’s upper back pain and other symptoms, and if not, then there is likely another pain generator. If partial pain relief is obtained, then the joints may be part of the problem.
  • Pain relief function: along with the numbing medication, time release cortisone is also injected into these joints. The cortisone helps reduce any inflammation, which usually surrounds the painful joints in the upper back. Reducing inflammation in the upper back area can often provide long term pain relief.

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These injections are typically done by a pain management specialist, such as an anesthesiologist, physiatrist, radiologist, or other medical specialist with advanced training (which may include board certification in pain medicine and pain management).

Anatomy of the Upper Back and Costovertebral and Costotransverse Joints

At each level of the thoracic spine (the upper back), the ribs are attached to the corresponding vertebrae (the bony building blocks of the spine) on the right side and left side with small joints. The rib joints from the second to the tenth vertebrae in the upper back comprise costotransverse and costovertebral joints that are located in the back of the vertebrae. These joints provide stability to the upper back and chest wall. The joints are supported by ligaments, which add strength to the junction of bones and limit the motion of the joints in the upper back.

Costotransverse and Costovertebral Injection Procedure

Costovertebral and costotransverse joint injections, as with many spinal injections, should only be performed using fluoroscopy (live X-ray). Fluoroscopy allows for guidance in properly placing the needle into the target, and helps avoid injury to adjacent structures.

The injection procedure includes the following steps:

  • An IV line may be placed so that relaxation medicine can be given, as needed.
  • The patient lies on an X-ray table and the skin over the mid-back is well cleaned with an antiseptic solution.
  • The physician numbs a small area of skin with local anesthetic, which may sting for a few seconds.
  • The physician uses X-ray guidance (fluoroscopy) to direct a very small needle into the joint. Several drops of contrast dye are then injected to confirm that the medicine only goes into the joint.
  • Following this confirmation, a mixture of small amount of numbing medicine (anesthetic) and anti-inflammatory (steroid) will then be slowly injected into the joint in the upper back.

The procedure usually takes approximately 15-30 minutes, followed by about 30-45 minutes of recovery time at the clinic.

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Written by Ray M. Baker, MD