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Thoracic Injections
Costovertebral Joint Injection
An in-depth, evidence-based explanation of the costovertebral (and costotransverse) joint injection — an image-guided injection into the joints where the ribs meet the thoracic spine.
Where each rib meets the thoracic spine, it forms small joints — the costovertebral and costotransverse joints. These joints can become a source of pain in the mid-back and around the rib, and they are an under-recognised cause of thoracic pain. A costovertebral joint injection places local anaesthetic, sometimes with steroid, into or around one of these joints under image guidance, to test whether it is responsible for the pain and to try to relieve it. This page explains what the injection involves, when it can be used, and what the evidence shows — while being honest that the evidence here is more limited than for many other spinal injections.
For information only — not medical advice. The content on this page is patient education to help you understand a condition or treatment. It is not a substitute for personalised assessment by a qualified clinician. Always consult your doctor or specialist about your own symptoms, diagnosis, and treatment decisions.
What a costovertebral joint injection is
This injection targets the joints between a rib and the adjacent vertebra. Using image guidance — X-ray, CT or ultrasound — a fine needle is directed to the joint, and local anaesthetic is delivered, often with a small dose of steroid. The local anaesthetic can quickly numb the joint to help confirm whether it is the pain source, while any steroid aims to reduce inflammation over a longer period. Because these joints are small and lie close to the chest, careful image guidance is important for accuracy and safety.
When it can be used
This injection can be considered when mid-back or rib-region pain is thought to arise from the costovertebral or costotransverse joints — for example localised pain near the spine that worsens with certain movements or with breathing, once other causes have been considered. It has both a diagnostic role, helping to confirm the joint as the source, and a therapeutic role, offering a period of relief. It is generally used when thoracic pain is localised and other, more common sources have been assessed.
What the evidence shows
The evidence for costovertebral and costotransverse joint injections is genuinely limited, and it is important to say so. Small studies and technical reports describe the procedure, confirm that these joints can refer pain, and suggest that image-guided injection can provide relief for selected patients, but there are no large trials. As a result, the injection is best regarded as a reasonable, targeted option for carefully selected thoracic pain — useful both to clarify the diagnosis and to provide symptom relief — rather than a treatment backed by strong high-level evidence. Honesty about this uncertainty is part of using it well.
What to expect
The injection is a day-case procedure performed under image guidance. The immediate response to the local anaesthetic is informative, helping to confirm whether the joint is the pain source, while any steroid effect develops over the following days. Depending on the response, the next step may be continued conservative care, a repeat procedure, or consideration of other treatments. Risks are discussed beforehand. Whether this injection is appropriate depends on the individual and is decided with the treating team.
Disclaimer. The information provided on this page is intended for educational purposes only and should not be considered personalised medical advice. Every patient is different, and treatment options, risks, expected recovery and outcomes depend upon an individual's diagnosis, injury pattern, bone health, general health and personal circumstances. Decisions regarding treatment should always be made following consultation with your treating spinal surgeon or healthcare professional.
Evidence & further reading
- —Yoon KB, et al. Clinical effectiveness of ultrasound-guided costotransverse joint injection in thoracic back pain patients. Korean J Pain 2016. (PMID 27413487)
- —Deimel GW, et al. Sonographically guided costotransverse joint injections: a CT-controlled cadaveric feasibility study. J Ultrasound Med 2013. (PMID 24277889)
- —Young BA, et al. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskelet Disord 2008. (PMID 18922181)
- —Ferreira-Silva N, et al. Ultrasound-guided procedures for chronic thoracic back pain: a technical review. J Ultrasound 2024. (PMID 37648900)
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