1
|
Ferreira-Silva N, Worthy L, Ribas R, Ferreira-Dos-Santos G, Bestic J, Hurdle MFB. Ultrasound-guided costovertebral joint injection-technique description and fluoroscopy and computerized tomography combined controlled cadaveric feasibility study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:8-12. [PMID: 37656943 DOI: 10.1093/pm/pnad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES To describe and assess the feasibility of an ultrasound-guided technique for intra-articular injection of the costovertebral joints, in an unembalmed cadaveric specimen, utilizing fluoroscopy and cone beam computerized tomography for confirmation of contrast spread and needle tip position, respectively. METHODOLOGY A single unembalmed cadaveric specimen was obtained. A single interventionist performed the placement of the needles under ultrasound guidance. Contrast dye was then injected through each of the needles under real-time fluoroscopy. Finally, the specimen was submitted to a cone beam computerized tomography with 3-dimensional acquisition and multiplanar reformatting to assess final needle tip position relative to the costovertebral joints. RESULTS In total, 18 spinal needles were placed under ultrasound guidance. Fluoroscopy showed 4 distinct patterns of contrast spread: intra-articular in the costovertebral joint (13 levels in total), epidural (1 level), intra-articular in the facet joint of the target level (3 levels), and undetermined (1 level). Cone-beam computerized tomography confirmed 13 out of 18 needles to be adequately placed in the costovertebral joints (72% of the total) and 5 out of the 18 needles to be misplaced: 3 needles were placed in the facet joint of the target level, and 2 needles were placed in the epidural space. CONCLUSIONS This study suggests that, when performed by experienced interventionists, this technique has an accuracy rate of 72%. Further studies are warranted before these results can be extrapolated to daily clinical practice.
Collapse
Affiliation(s)
- Nuno Ferreira-Silva
- Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, 2720-276 Amadora, Portugal
| | - Lucy Worthy
- Washington and Lee University, Lexington, VA 24450, United States
| | - Rita Ribas
- Department of Anesthesiology, Centro Hospitalar Universitário de Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Guilherme Ferreira-Dos-Santos
- Division of Pain Medicine, Department of Anesthesiology, Reanimation, and Pain Medicine, Hospital Clínic de Barcelona, Barcelona, 08036 Catalonia, Spain
| | - Joseph Bestic
- Department of Radiology, Mayo Clinic, Jacksonville, FL 32224, United States
| | | |
Collapse
|
2
|
Cibulka M, Buck J, Busta B, Neil E, Smith D, Triller R. Intra and inter observer agreement in the mobility assessment of the upper thoracic costovertebral joints. Physiother Theory Pract 2022:1-7. [PMID: 35343374 DOI: 10.1080/09593985.2022.2058439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Determining the mobility of the costovertebral joints might be important in patients with neck-upper thoracic pain. Little research has been performed on observer agreement when assessing the mobility of these joints. PURPOSE The purpose of this study was to determine intra- and inter-observer agreements when assessing costovertebral joint mobility of the upper three ribs in those with and without neck pain and to compare the difference between the Kappa and AC statistic. METHODS Forty-four participants, with and without current neck/upper-thoracic pain, were assessed by two raters. Raters applied a posterior to anterior pressure to the anatomical neck of the first three ribs bilaterally. Mobility was graded: normal, increased, or decreased. An AC1, for nominal data, AC2 for ordinal data, and the Kappa statistics were used to analyze the results. The AC statistics determines chance agreement different than Kappa. RESULTS AC1 showed "moderate to very good" (0.74-1.0) intra-rater reliability, while inter-rater reliability showed "fair to good" agreement (0.51-0.79). Using the AC2 Intra-rater reliability was "very good" and "almost perfect" (AC2: 0.93-1.0), while using the AC2 was "good to very good" and "good to almost perfect" (0.76-0.94). Kappa values for intra-rater reliability ranged from "fair to moderate" (0.38-0.54), while inter-rater reliability ranged from "poor to fair" (-0.10-0.26). CONCLUSION Posterior/anterior pressure is a reliable method to assess the mobility of the upper costovertebral joints. Assessing costovertebral mobility is important when establishing a movement diagnosis in patients with neck/upper thoracic pain.
Collapse
Affiliation(s)
- Michael Cibulka
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| | - Justin Buck
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| | - Bria Busta
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| | - Erika Neil
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| | - Drake Smith
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| | - Reece Triller
- Physical Therapy Program, Maryville University, St. Louis, MO, USA
| |
Collapse
|
3
|
Krasin E, Schermann H, Snir N, Tudor A, Behrbalk E. A Quick and Comprehensive Guide to Differential Diagnosis of Neck and Back Pain: a Narrative Review. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:232. [PMID: 36320816 PMCID: PMC9610337 DOI: 10.1007/s42399-022-01321-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
The list of diagnostic options when approaching a patient with axial pain is impressively complex. Many offer limited diagnostic workups, but we could not find a truly comprehensive diagnostic guide to assist in the diagnostic evaluation. In this short paper, we briefly described a long list of medical conditions, each of which can manifest as back or neck pain, and whose prevalence ranges from common to very rare. We then proposed an algorithm for classifying them into subgroups. Further referral to diagnostic tests and specialist consultations, after assignment to one of those subgroups, could save time and unnecessary tests. We believe that this review and the proposed diagnostic algorithm can be valuable for medical education and for use in the primary care setting for the diagnostic evaluation of any type of back or neck pain in all patient groups.
Collapse
Affiliation(s)
- Elisha Krasin
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haggai Schermann
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adrian Tudor
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Behrbalk
- Department of Orthopedic Surgery at Hillel Yaffe Medical Center, Hadera, Israel, affiliated with the Rappaport Faculty of Medicine, Technion, Haifa, Israel
| |
Collapse
|
4
|
Investigation of reaction force magnitude and orientation during supine thoracic thrust manipulation applied to intervertebral and costovertebral regions. Musculoskelet Sci Pract 2020; 49:102217. [PMID: 32861370 DOI: 10.1016/j.msksp.2020.102217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/09/2020] [Accepted: 06/30/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Spinal manipulative techniques are commonly used in manual therapies but quantified descriptive and reliability data are lacking considering supine thoracic thrust manipulation. OBJECTIVES The purpose of this study is to explore and compare kinetic parameters during supine thoracic thrust manipulation performed at two different thoracic regions. Intra-rater task repeatability and influence of practitioners were estimated. DESIGN Exploratory and agreement study. METHODS Kinetic parameters were assessed by examining reaction force magnitude and orientation (on the basis of the zenithal angle) using force platforms. Manipulative procedure (consisting in the application of 3 preloads followed by one thrust adjustment) at both intervertebral and costovertebral region was performed by different practitioners at three sessions. Application of thrust was allowed for experienced practitioners only. Preload force, peak force magnitude and vector force orientation were compared between anatomical sites, sessions and practitioners, and bias with limit of agreement were estimated. RESULTS Repeatability analysis showed that practitioners achieved similar preload and peak force independent of the session, with comparable force orientation. Differences between practitioners were observed for preload and peak force but not regarding the zenithal angle during the thrust phase. CONCLUSIONS The present study is the first that explores kinetic parameters for supine thoracic thrust manipulation applied on two different regions of the thorax. Results confirm consistency of performance among practitioners for supine manipulative techniques at intervertebral and costovertebral region. While task repeatability was confirmed, several differences were observed between practitioners. Further investigations would examine velocity, acceleration and potential neurophysiological effect of such manipulative technique.
Collapse
|
5
|
Saker E, Graham RA, Nicholas R, D'Antoni AV, Loukas M, Oskouian RJ, Tubbs RS. Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine. Cureus 2016; 8:e874. [PMID: 27994992 PMCID: PMC5154401 DOI: 10.7759/cureus.874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Few studies have examined the costovertebral joint and its ligaments in detail. Therefore, the following review was performed to better elucidate their anatomy, function and involvement in pathology. Standard search engines were used to find studies concerning the costovertebral joints and ligaments. These often-overlooked ligaments of the body serve important functions in maintaining appropriate alignment between the ribs and spine. With an increasing interest in minimally invasive approaches to the thoracic spine and an improved understanding of the function and innervation of these ligaments, surgeons and clinicians should have a good working knowledge of these structures.
Collapse
Affiliation(s)
- Erfanul Saker
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
| | - Rachel A Graham
- Department of Anatomy, The Sophie Davis School of Biomedical Education
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
| | - Rod J Oskouian
- Neurosurgery, Complex Spine, Swedish Neuroscience Institute
| | | |
Collapse
|
6
|
Dedrick GS, Sizer PS, Sawyer BG, Brismeè JM, Smith MP. Immunohistochemical study of human costotransverse joints: A preliminary investigation. Clin Anat 2011; 24:741-7. [PMID: 21400610 DOI: 10.1002/ca.21137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 11/16/2010] [Accepted: 12/30/2010] [Indexed: 11/05/2022]
Abstract
The human costotransverse joint (CTJ) is the articulation between the posterior tubercle of the ribs with the first through tenth costal facet of the thoracic transverse processes. While the CTJ is well defined anatomically and considered a synovial joint, the human CTJ as a pain generating structure is controversial and not supported from a histological perspective. The objective of the present study was to investigate the histological pain producing properties of CTJ capsule tissue. Ten micron cross-sections at each level (1-10) were stained with H & E or immunostained with antisera against Substance P (SP), calcitonin-gene-related peptide (CGRP), and neuropeptide Y (NPY). Immunoreactivity was confirmed for SP, CGRP, and NPY within the CTJ tissue samples of two unembalmed male cadavers. The presence of previously mentioned neuropeptides suggests that human CTJ is capable of producing pain through somatic and autonomic nervous systems. Therefore, clinicians should consider the CTJ as a differential diagnostic possibility when examining and treating painful thoracic conditions.
Collapse
Affiliation(s)
- G S Dedrick
- Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | | | | | | |
Collapse
|
7
|
Clinical presentation and chiropractic treatment of Tietze syndrome: A 34-year-old female with left-sided chest pain. J Chiropr Med 2011; 10:60-3. [PMID: 22027210 DOI: 10.1016/j.jcm.2010.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 09/21/2010] [Accepted: 10/21/2010] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The purpose of this case report is to describe the clinical presentation and chiropractic management of Tietze syndrome. CLINICAL FEATURES A 34-year-old woman presented with unexplained left-sided chest pain. Electrocardiogram and radiographs were taken at a medical emergency department to rule out cardiovascular and pulmonary causes, and pain medication did not relieve her pain. Physical examination showed tenderness on palpation and swelling of the second and third chondrosternal joints, as well as thoracic joint dysfunction. Heart and lung pathology was ruled out, and chondrosternal joint swelling was present, Tietze syndrome was diagnosed. INTERVENTION AND OUTCOME A treatment plan aimed at restoring normal thoracic and rib joint movement and decreasing inflammation of the chondrosternal joints resulted in lower pain levels. Treatment consisted of diversified high-velocity, low-amplitude chiropractic manipulation; activator technique; and cryotherapy. CONCLUSION Chiropractic management of Tietze syndrome was successful in reducing pain levels in this patient's case.
Collapse
|
8
|
Van der Wall H, Lee A, Magee M, Frater C, Wijesinghe H, Kannangara S. Radionuclide Bone Scintigraphy in Sports Injuries. Semin Nucl Med 2010; 40:16-30. [DOI: 10.1053/j.semnuclmed.2009.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
9
|
Passmore SR, Dunn AS. Positive patient outcome after spinal manipulation in a case of cervical angina. ACTA ACUST UNITED AC 2009; 14:702-5. [DOI: 10.1016/j.math.2009.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 02/23/2009] [Accepted: 03/23/2009] [Indexed: 10/20/2022]
|
10
|
Immunohistochemical and histological study of human uncovertebral joints: a preliminary investigation. Spine (Phila Pa 1976) 2009; 34:1257-63. [PMID: 19455000 DOI: 10.1097/brs.0b013e31819b2b5d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A descriptive cadaveric study. OBJECTIVE To investigate the anatomy and innervation of the uncovertebral joint to determine if it is synovial in nature and capable of generating pain. SUMMARY OF BACKGROUND DATA There is controversy with regard to the anatomic and histological makeup of the uncovertebral interface with some authors considering it a joint and others disc tissue. No research has investigated the presence of pain generating neurotransmitters within the uncovertebral cartilaginous and capsular tissue. METHODS Tissue from uncovertebral capsule and cartilage was harvested for each uncovertebral surface starting at the C2-C3 to the C6-C7 cervical segment. The tissue was placed in 4% paraformaldehyde fixative, then dehydrated and embedded in paraffin. Ten micron sections were cut through the tissue blocks and mounted on slides. The tissue was rehydrated and either stained with hematoxylin and eosin (H and E) or immunostained with antisera against protein gene product 9.5 (PGP 9.5), substance P (SP), neuropeptide Y (NPY), and calcitonin gene-related peptide (CGRP). RESULTS The sample consisted of 2 unembalmed fresh male human cadavers of a mean age of 83 years. Chondrocytes and synoviocytes were identified at the capsular tissue of each uncovertebral interface from C2-C3-C6-C7. Immunoreactivity for PGP 9.5, SP, CGRP, and NPY was observed at all uncovertebral interface levels in capsular tissue. CONCLUSION The presence of both synoviocytes and chondrocytes has been recorded in the present study, suggesting that the uncovertebral interface is synovial in nature. Immunoreactivity to PGP 9.5, SP, CGRP, and NPY indicates the presence of nerve fibers from both the somatic and autonomic nervous systems. These findings suggest that the uncovertebral joints are potential pain generators in the cervical spine.
Collapse
|
11
|
Ian Rabey M. Costochondritis: Are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures. ACTA ACUST UNITED AC 2008; 13:82-6. [PMID: 17360222 DOI: 10.1016/j.math.2006.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Revised: 11/16/2006] [Accepted: 12/19/2006] [Indexed: 11/19/2022]
Affiliation(s)
- Martin Ian Rabey
- St. Sampson's Medical Centre, Grandes Maisons Road, St. Sampson's, Guernsey, GY2 4JS Great Britain, UK.
| |
Collapse
|
12
|
Bussières AE, Taylor JA, Peterson C. Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders. J Manipulative Physiol Ther 2008; 31:33-88. [DOI: 10.1016/j.jmpt.2007.11.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Revised: 09/28/2007] [Accepted: 10/14/2007] [Indexed: 01/29/2023]
|
13
|
Aspegren D, Hyde T, Miller M. Conservative Treatment of a Female Collegiate Volleyball Player with Costochondritis. J Manipulative Physiol Ther 2007; 30:321-5. [DOI: 10.1016/j.jmpt.2007.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 01/01/2007] [Accepted: 01/02/2007] [Indexed: 11/29/2022]
|
14
|
Polkinghorn BS, Colloca CJ. Chiropractic management of chronic chest pain using mechanical force, manually assisted short-lever adjusting procedures. J Manipulative Physiol Ther 2003; 26:108-15. [PMID: 12584509 DOI: 10.1067/mmt.2003.8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To discuss a case involving a patient with chronic chest pain, dyspnea, and anxiety. Although resistant to previous treatment regimens, the condition responded favorably to chiropractic manipulation of the costosternal articulations. CLINICAL FEATURES A 49-year-old man had chronic chest pain, dyspnea, and anxiety for over 4 months. The severity of the condition gradually progressed to the point of precluding the patient's active employment and most physical activity. Prior efforts to treat the condition had met with failure. INTERVENTION AND OUTCOME The patient received mechanical force, manually assisted short-lever chiropractic adjustment of the thoracic spine and, in particular, the costosternal articulations. Adjustments were by means of an Activator Adjusting Instrument II. The patient responded favorably to the intervention, obtaining prompt relief from his symptoms. Sustained chiropractic care rendered over a 14-week period resulted in complete resolution of the patient's previously chronic condition, with recovery maintained at 9-month follow-up. CONCLUSIONS Certain types of chest pain may have their etiology in a subluxation complex involving the costosternal articulation. Although the possibility of myocardial involvement must be considered with all patients whose symptoms include chest pain, a musculoskeletal involvement, including costosternal subluxation complex, may be the underlying cause of the symptoms in certain patients. When this is the case, chiropractic adjustment may provide an effective mode of treatment. Further study in an academic research venue is merited to investigate the role that conservative chiropractic care can provide for patients with chest pain.
Collapse
|
15
|
Abstract
This case study describes the process of examination, re-examination, and intervention for a collegiate runner with mechanical thoracic pain preventing athletic participation and limiting daily function. Unimpaired function fully returned in less than 3 weeks with biweekly sessions to re-establish normal and painfree thoracic mechanics via postural hygiene, exercise, mobilization, and manipulation. The outcome of this case study supports the original hypothesis that the pattern of impairments was in fact responsible for the functional limitations and disability in this athlete. At the time of publication the athlete was without functional limitations and had fully returned to competitive sprinting for the university track team.
Collapse
Affiliation(s)
- G P Austin
- Department of Physical Therapy and Human Movement Science, Sacred Heart University Sports Medicine and Rehabilitation Center, Fairfield, Connecticut, USA.
| | | |
Collapse
|
16
|
Affiliation(s)
- S J Horton
- School of Physiotherapy, University of Otago, Dunedin, New Zealand.
| |
Collapse
|