Skip to main content

Advertisement

SpringerLink
Log in

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

  • Review Paper
  • Published:
Journal of Ultrasound Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

CT:

Computerized tomography

CTJ:

Costotransverse joint

CVJ:

Costovertebral joint

ESP:

Erector spinae Plane

FoV:

Field of view

MBB:

Medial branch block

MRI:

Magnetic resonance imaging

RFN:

Radiofrequency neurotomy

TFJ:

Thoracic facet joint

TP:

Transverse process

US:

Ultrasound

References

  1. Macfarlane GJ (2016) The epidemiology of chronic pain. Pain 157(10):2158–2159. https://doi.org/10.1097/j.pain.0000000000000676

    Article  PubMed  Google Scholar 

  2. Von Korff M, Dworkin SF, Le Resche L, Kruger A (1988) An epidemiologic comparison of pain complaints. Pain 32(2):173–183. https://doi.org/10.1016/0304-3959(88)90066-8

    Article  Google Scholar 

  3. Rubin DI (2007) Epidemiology and risk factors for spine pain. Neurol Clin 25(2):353–371. https://doi.org/10.1016/j.ncl.2007.01.004

    Article  PubMed  Google Scholar 

  4. Linton SJ, Hellsing AL, Halldén K (1998) A population-based study of spinal pain among 35–45-year-old individuals: prevalence, sick leave, and health care use. Spine (Phila Pa 1976) 23(13):1457–1463. https://doi.org/10.1097/00007632-199807010-00006

    Article  CAS  PubMed  Google Scholar 

  5. Briggs AM, Smith AJ, Straker LM, Bragge P (2009) Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord 10:77. https://doi.org/10.1186/1471-2474-10-77

    Article  PubMed  PubMed Central  Google Scholar 

  6. Singer KP, Edmondston SJ (2000) Introduction: the enigma of the thoracic spine. In: Giles LGF, Singer KP (eds) The clinical anatomy and management of thoracic spine pain. Butterworth-Heinemann, Oxford, pp 3–10

  7. Singer KP (2000) Pathology of the thoracic spine. In: Giles LGF, Singer KP (eds) The clinical anatomy and management of thoracic spine pain. Butterworth-Heinemann, Oxford, p 79

  8. Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, Prather H, Press JM (2000) Incidence of intravascular uptake in lumbar spinal injection procedures. Spine (Phila Pa 1976) 25(4):481–486. https://doi.org/10.1097/00007632-200002150-00015

    Article  CAS  PubMed  Google Scholar 

  9. Provenzano DA, Narouze S (2013) Sonographically guided lumbar spine procedures. J Ultrasound Med 32(7):1109–1116. https://doi.org/10.7863/ultra.32.7.1109

    Article  PubMed  Google Scholar 

  10. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ (2016) The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 41(5):621–627. https://doi.org/10.1097/AAP.0000000000000451

    Article  CAS  PubMed  Google Scholar 

  11. De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T (2019) Erector spinae plane block: a systematic qualitative review. Minerva Anestesiol 85(3):308–319. https://doi.org/10.23736/S0375-9393.18.13341-4

    Article  PubMed  Google Scholar 

  12. Forero M, Rajarathinam M, Adhikary S, Chin KJ (2017) Erector spinae plane (ESP) block in the management of post-thoracotomy pain syndrome: a case series. Scand J Pain 17:325–329. https://doi.org/10.1016/j.sjpain.2017.08.013

    Article  PubMed  Google Scholar 

  13. Tulgar S, Ahiskalioglu A, De Cassai A, Gurkan Y (2019) Efficacy of bilateral erector spinae plane block in the management of pain: current insights. J Pain Res 12:2597–2613. https://doi.org/10.2147/JPR.S182128

    Article  PubMed  PubMed Central  Google Scholar 

  14. Yürük D, Akkaya ÖT, Polat ÖE, Alptekin HA (2022) Ultrasound-guided erector spinae plane block and trapezius muscle injection for myofascial pain syndrome. J Ultrasound Med 41(1):185–191. https://doi.org/10.1002/jum.15694

    Article  PubMed  Google Scholar 

  15. Chin KJ, El-Boghdadly K (2021) Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth 68(3):387–408. https://doi.org/10.1007/s12630-020-01875-2

    Article  PubMed  Google Scholar 

  16. Diwan S, Nair A (2020) Is paravertebral-epidural spread the underlying mechanism of action of erector spinae plane block? Turk J Anaesthesiol Reanim 48(1):86–87. https://doi.org/10.5152/TJAR.2019.81226

    Article  PubMed  Google Scholar 

  17. Celik M, Tulgar S, Ahiskalioglu A et al (2019) Is high volume lumbar erector spinae plane block an alternative to transforaminal epidural injection? Evaluation with MRI. Reg Anesth Pain Med 44:906–907. https://doi.org/10.1136/rapm-2019-100514

    Article  Google Scholar 

  18. Schwartzman A, Peng P, Maciel MA et al (2020) A magnetic resonance imaging study of local anesthetic spread in patients receiving an erector spinae plane block. Can J Anesth 67:942–948. https://doi.org/10.1007/s12630-020-01613-8

    Article  CAS  Google Scholar 

  19. Elsharkawy H, Pawa A, Mariano ER (2018) Interfascial plane blocks: back to basics. Reg Anesth Pain Med 43(4):341–346. https://doi.org/10.1097/AAP.0000000000000750

    Article  PubMed  Google Scholar 

  20. Cornish P (2019) Erector spinae plane block and ‘a cadaveric conundrum.’ Reg Anesth Pain Med 44:269–270. https://doi.org/10.1136/rapm-2018-100066

    Article  Google Scholar 

  21. Barrios A, Camelo J, Gomez J, Forero M, Peng PWH, Visbal K, Cadavid A (2020) Evaluation of sensory mapping of erector spinae plane block. Pain Phys 23(3):E289–E296

    Google Scholar 

  22. Ricci V, Mezian K, Chang K-V, Tarantino D, Güvener O, Gervasoni F, Naňka O, Özçakar L (2023) Ultrasound imaging and guidance for cervical myofascial pain: a narrative review. Int J Environ Res Public Health 20(5):3838. https://doi.org/10.3390/ijerph20053838

    Article  PubMed  PubMed Central  Google Scholar 

  23. Ricci V, Ricci C, Mezian K, Naňka O, Özçakar L (2023) Trapezius muscle and the cutaneous branches of spinal nerves: sonographic/anatomic discussion of myofascial pain and superficial injections. Pain Med 24(3):221–225. https://doi.org/10.1093/pm/pnac125

    Article  PubMed  Google Scholar 

  24. Hurdle MFB, Ferreira-Dos-Santos G, Rosario-Concepcion R, Gil LV, Eldrige JS, Clendenen SR (2021) Counting ribs and thoracic levels under ultrasound: a systematized technical protocol for both posterior and anterior approaches. Reg Anesth Pain Med 46(5):452–454. https://doi.org/10.1136/rapm-2020-102050

    Article  PubMed  Google Scholar 

  25. Manchikanti L, Boswell MV, Singh V, Pampati VS, Damron KS, Beyer CD (2004) Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 5:15. https://doi.org/10.1186/1471-2474-5-15

    Article  PubMed  PubMed Central  Google Scholar 

  26. Manchikanti L, Singh V, Pampati V, Beyer CD, Damron KS (2002) Evaluation of the prevalence of facet joint pain in chronic thoracic pain. Pain Phys 5(4):354–359

    Article  Google Scholar 

  27. Dreyfuss P, Tibiletti C, Dreyer SJ (1994) Thoracic zygapophyseal joint pain patterns. A study in normal volunteers. Spine 19(7):807–811. https://doi.org/10.1097/00007632-199404000-00014

    Article  CAS  PubMed  Google Scholar 

  28. Fukui S, Ohseto K, Shiotani M (1997) Patterns of pain induced by distending the thoracic zygapophyseal joints. Reg Anesth 22:332–336. https://doi.org/10.1016/s1098-7339(97)80007-7

    Article  CAS  PubMed  Google Scholar 

  29. Atluri S, Singh V, Datta S, Geffert S, Sehgal N, Falco FJ (2012) Diagnostic accuracy of thoracic facet joint nerve blocks: an update of the assessment of evidence. Pain Phys 15(4):E483–E496

    Article  Google Scholar 

  30. I. A. F. (2000) Stokes: biomechanics of the thoracic spine rib cage. In: Giles LGF, Singer KP (eds) The clinical anatomy and management of thoracic spine pain. Butterworth-Heinemann, Oxford, pp 45–59

  31. Ebraheim N, Xu R, Ahmad M, Yeasting R (1997) The quantitative anatomy of the thoracic facet and the posterior projection of its inferior facet. Spine 22(16):1811–1817. https://doi.org/10.1097/00007632-199708150-00002

    Article  CAS  PubMed  Google Scholar 

  32. Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson D, Been E, Hershkovitz I (2004) Facet orientation in the thoracolumbar spine: three-dimensional anatomic and biomechanical analysis. Spine (Phila Pa 1976) 29(16):1755–1763. https://doi.org/10.1097/01.brs.0000134575.04084

    Article  PubMed  Google Scholar 

  33. Fortin JD, McKee MJ (2003) Thoracic facet blocks: bent needle technique. Pain Phys 6(4):513–516

    Article  Google Scholar 

  34. Stulc SM, Hurdle MF, Pingree MJ, Brault JS, Porter CA (2011) Ultrasound-guided thoracic facet injections: description of a technique. J Ultrasound Med 30(3):357–362. https://doi.org/10.7863/jum.2011.30.3.357

    Article  PubMed  Google Scholar 

  35. Lee DG, Ahn SH, Cho YW, Do KH, Kwak SG, Chang MC (2018) Comparison of intra-articular thoracic facet joint steroid injection and thoracic medial branch block for the management of thoracic facet joint pain. Spine (Phila Pa 1976) 43(2):76–80. https://doi.org/10.1097/BRS.0000000000002269

    Article  PubMed  Google Scholar 

  36. Cohen SP, Moon JY, Brummett CM, White RL, Larkin TM (2015) Medial branch blocks or intra-articular injections as a prognostic tool before lumbar facet radiofrequency denervation: a multicenter, case–control study. Reg Anesth Pain Med 40(4):376–383. https://doi.org/10.1097/AAP.0000000000000229

    Article  CAS  PubMed  Google Scholar 

  37. Manchikanti L, Manchinkanti KN, Manchukonda R et al (2006) Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow-up. Pain Phys 9:97–105

    Article  Google Scholar 

  38. Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V, Fellows B (2012) The role of thoracic medial branch blocks in managing chronic mid and upper back pain: a randomized, double-blind, active-control trial with a 2-year follow-up. Anesthesiol Res Pract. https://doi.org/10.1155/2012/585806

    Article  PubMed  PubMed Central  Google Scholar 

  39. Chua WH, Bogduk N (1995) The surgical anatomy of thoracic facet denervation. Acta Neurochir (Wien) 136(3–4):140–144. https://doi.org/10.1007/BF01410616

    Article  CAS  PubMed  Google Scholar 

  40. Ishizuka K, Sakai H, Tsuzuki N, Nagashima M (2012) Topographic anatomy of the posterior ramus of thoracic spinal nerve and surrounding structures. Spine (Phila Pa 1976) 37(14):E817–E822. https://doi.org/10.1097/BRS.0b013e31824b65ea

    Article  PubMed  Google Scholar 

  41. Koutp A, Sadoghi P, Petritsch J, Skias C, Grechenig P, Andrianakis A, Feigl GC (2022) Anatomic-topographic investigation of the branches of the dorsal ramus of thoracic spinal nerves. Pain Med 23(11):1869–1874. https://doi.org/10.1093/pm/pnac072

    Article  PubMed  Google Scholar 

  42. Wahezi SE, Alexeev E, Georgy JS, Haramati N, Erosa SA, Shah JM, Downie S (2018) Lumbar medial branch block volume-dependent dispersion patterns as a predictor for ablation success: a cadaveric study. PMR 10(6):616–622. https://doi.org/10.1016/j.pmrj.2017.11.011

    Article  Google Scholar 

  43. Cohen SP, Bhaskar A, Bhatia A et al (2020) Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, International Working Group. Reg Anesth Pain Med 45(6):424–467. https://doi.org/10.1136/rapm-2019-101243

    Article  PubMed  PubMed Central  Google Scholar 

  44. Fruth SJ (2006) Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther 86(2):254–268

    Article  PubMed  Google Scholar 

  45. Sanzhang C, Rothschild BM (1993) Zygapophyseal and costovertebral/costotransverse joints: an anatomic assessment of arthritis impact. Br J Rheumatol 32:1066–1071. https://doi.org/10.1093/rheumatology/32.12.1066

    Article  CAS  PubMed  Google Scholar 

  46. Lau LS, Littlejohn GO (1987) Costotransverse joint injection description of technique. Australas Radiol 31(1):47–49. https://doi.org/10.1111/j.1440-1673.1987.tb01781.x

    Article  CAS  PubMed  Google Scholar 

  47. Young BA, Gill HE, Wainner RS, Flynn TW (2008) Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskelet Disord 9:140. https://doi.org/10.1186/1471-2474-9-140

    Article  PubMed  PubMed Central  Google Scholar 

  48. Del Chiaro A, Ciampi B, Franzoni F, Miccoli M, Galletti S, Stella SM (2022) Inflammatory disease of the costotransverse joints: US evaluation in 15 symptomatic patients. J Ultrasound 25(2):167–175. https://doi.org/10.1007/s40477-021-00589-5

    Article  PubMed  Google Scholar 

  49. Yoon KB, Kim SH, Park SJ, Moon JA, Yoon DM (2016) Clinical effectiveness of ultrasound-guided costotransverse joint injection in thoracic back pain patients. Korean J Pain 29(3):197–201. https://doi.org/10.3344/kjp.2016.29.3.197

    Article  PubMed  PubMed Central  Google Scholar 

  50. Oda I, Abumi K, Lü D, Shono Y, Kaneda K (1996) Biomechanical role of the posterior elements, costovertebral joints, and rib cage in the stability of the thoracic. Spine 21(12):1423–1429. https://doi.org/10.1097/00007632-199606150-00005

    Article  CAS  PubMed  Google Scholar 

  51. Watkins R IV, Watkins R III, Williams L, Ahlbrand S, Garcia R, Karamanian A, Sharp L, Vo C, Hedman T (2005) Stability provided by the sternum and rib cage in the thoracic spine. Spine 30(11):1283–1286. https://doi.org/10.1097/01.brs.0000164257.69354.bb

    Article  PubMed  Google Scholar 

  52. Bogduk N (2002) Innervations and pain patterns of the thoracic spine. In: Grant R (ed) Physical therapy of the cervical and thoracic spine. Churchill Livingstone, New York, p 77

  53. Deimel GW, Hurdle MF, Murthy N, Cartwright JA, Smith J, Pingree MJ (2013) Sonographically guided costotransverse joint injections: a computed tomographically controlled cadaveric feasibility study. J Ultrasound Med 32(12):2083–2089. https://doi.org/10.7863/ultra.32.12.2083

    Article  PubMed  Google Scholar 

  54. Nathan H, Weinberg H, Robin GC et al (1964) The costovertebral joints, anatomical-clinical observations in arthritis. Arthritis Rheum 7:228–240. https://doi.org/10.1002/art.1780070306

    Article  CAS  PubMed  Google Scholar 

  55. Gundersen A, Borgstrom H, McInnis KC (2021) Trunk injuries in athletes. Curr Sports Med Rep 20(3):150–156. https://doi.org/10.1249/JSR.0000000000000819

    Article  PubMed  Google Scholar 

  56. Goldthwait JE (1940) The rib joints. N Engl J Med 223:568–573. https://doi.org/10.1056/nejm194010102231503

    Article  Google Scholar 

  57. Arroyo JF, Jolliet P, Junod AF (1992) Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain. Postgrad Med J 68(802):655–659. https://doi.org/10.1136/pgmj.68.802.655

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Afonso JR, Soares D, Lopes DB, Matos RM, Pinto RP (2021) Costovertebral osteoarthritis: rare differential diagnosis of back pain in young patients. Rev Bras Ortop (São Paulo) 57(2):345–347. https://doi.org/10.1055/s-0040-1722587

    Article  PubMed  Google Scholar 

  59. Groen GJ, Baljet B, Boekelaar AB, Drukker J (1987) Branches of the thoracic sympathetic trunk in the human fetus. Anat Embryol (Berl) 176(4):401–411. https://doi.org/10.1007/BF00310082

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

The authors did not receive any direct or indirect financial benefits for the publication of this manuscript—Level 0.

Author information

Author notes

  1. Nuno Ferreira-Silva and Rita Ribas shared first authorship.

Authors and Affiliations

  1. Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal

    Nuno Ferreira-Silva

  2. Department of Anesthesiology, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal

    Rita Ribas

  3. Department of Pain Medicine, Mayo Clinic, Jacksonville, FL, USA

    Mark Friedrich B. Hurdle, Sahil Gupta & Steven R. Clendenen

  4. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA

    Steven R. Clendenen

  5. Division of Pain Medicine, Department of Anesthesiology, Reanimation, and Pain Medicine, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain

    Guilherme Ferreira-Dos-Santos

Authors
  1. Nuno Ferreira-Silva
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rita Ribas
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mark Friedrich B. Hurdle
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sahil Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Steven R. Clendenen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Guilherme Ferreira-Dos-Santos
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nuno Ferreira-Silva.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Consent to publish

The authors affirm that the human volunteers provided informed consent for the publication of the US images in Figs. 2B, 3B, 4B, D, 5B,C.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ferreira-Silva, N., Ribas, R., Hurdle, M.F.B. et al. Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review. J Ultrasound 27, 1–11 (2024). https://doi.org/10.1007/s40477-023-00825-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40477-023-00825-0

Keywords

Search

Navigation