Costovertebral Joint Injection

Indications and Clinical Considerations

The costovertebral joint can serve as a source of pain that often may mimic pain of pulmonary origin. The costovertebral joint is a true joint and is susceptible to the development of arthritis, including osteoarthritis, rheumatoid arthritis, psoriatic arthritis, Reiter syndrome, and, in particular, ankylosing spondylitis ( Fig. 109.1 ). The joint is often traumatized during acceleration–deceleration injuries and blunt trauma to the chest and to the dorsal spine. With severe trauma, the joint may sublux or dislocate. Overuse or misuse can also result in acute inflammation of the costovertebral joint, which can be quite debilitating. The joint is also subject to invasion by tumor either from primary malignancies, including lung cancer, or from metastatic disease as well as infection ( Fig. 109.2 ).

Physical examination reveals that the patient will attempt to splint the affected joint or joints by splinting that area of the back to avoid flexion, extension, or lateral bending of the spine. The patient may retract the scapulae in an effort to gain relief of the pain emanating from this joint. The costovertebral joint may be tender to palpation and feel hot and swollen if acutely inflamed. The patient may also report a clicking sensation with movement of the joint.

Plain radiographs are indicated for all patients with pain thought to be emanating from the costovertebral joint to rule out occult bony disease, including tumor. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging of the joint is indicated if primary joint disease or infection is suspected ( Figs. 109.3 and 109.4 ) The injection technique presented later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The costovertebral joint is a synovial plane-type joint with an actual synovial cavity ( Fig. 109.5 ). Articulation occurs between the ribs and the vertebrae. The joint is composed of 2 elements that articulate with the vertebrae: the head of the ribs and the costotransverse joint. The head of each individual rib articulates with the superior facet of its corresponding vertebral body as well as the inferior facet of the vertebral body just above it. The head of the rib also articulates with the intervertebral disk that is interposed between the 2 adjacent vertebral bodies. These articulations are supported by the radiate and intra-articular ligaments.

The costotransverse joint is made up of the articulation of the tubercle and its adjacent vertebral body. The joint is supported and strengthened by the superior and lateral costotransverse ligaments ( Fig. 109.6 ).