Thoracic back pain can be as severe and disabling as pain originating from the cervical or lumbar spine, with potential sources including zygapophysial, costovertebral, and costotransverse joints, as well as intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the past two decades, ultrasound has gained traction in interventional spinal procedures due to its unique ability to visualize soft tissues like muscle layers, pleura, nerves, and blood vessels, all while providing real-time needle tracking. Unlike traditional fluoroscopy, ultrasound significantly reduces radiation exposure for both patients and clinicians, making it a safer option for certain spinal interventions. However, ultrasound does have limitations, such as in epidural injections (both interlaminar and transforaminal approaches) and intradiscal injections, where it is generally less effective than fluoroscopy.
This technical review focuses on five thoracic spinal injections that can be effectively guided by ultrasound. For each procedure, we outline its clinical applications, the relevant topographic anatomy, and detailed technical steps, supplemented by illustrations. The procedures discussed include: (1) erector spinae plane block, which targets pain in the thoracic spine by blocking nerves along the erector spinae muscles; (2) intra-articular injections in the thoracic zygapophyseal (facet) joints to reduce localized pain; (3) thoracic medial branch blocks, which interrupt nerve signals in the medial branches of the dorsal rami; (4) costotransverse joint injections, designed to alleviate pain at the costotransverse joints; and (5) costovertebral joint injections for pain related to the articulation between ribs and vertebrae. Each technique benefits from ultrasound’s precise visualization and needle guidance capabilities, highlighting its growing role in thoracic pain management.
