Costovertebral and costotransverse joint injection results and follow-up

Twenty to thirty minutes after the procedure, the patient will be asked to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the area injected is the main source of the patient’s upper back pain. On occasion, patients may feel numb or a slightly weak/odd feeling for a few hours after the injection. This may last several hours, but the patient should be able to function safely, if proper precautions are taken.

On the day of the injection, patients are advised to avoid doing any strenuous activities, unless instructed by their physician. The patient should not drive the day of the injection unless approved by the treating physician. If sedation was used, the patient should not drive for 24 hours after the procedure. Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and before the cortisone starts to take effect. If the area is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief.

On the day after the procedure, patients may return to their regular pre-injection level of activity. When the pain is improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to gradually increase activities over one to two weeks to avoid recurrence of pain.

Patients may continue to take their regular pain medicine after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection so that the diagnostic information obtained is accurate. Patients may also be referred for physical therapy or manual therapy, and this may be an appropriate time for the patient to have manipulation, while the numbing medicine from the injection is effective and/or over the next several weeks while the cortisone is working.

The patient may begin to notice longer lasting pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient’s upper back pain and other symptoms.

Ideally, patients will record the levels of pain relief in a ‘pain diary’ for the week following the injection. A pain diary is helpful to clearly inform the treating physician of the injection results and in planning future tests and/or treatment, as needed.

Potential risks and complications
As with all invasive medical procedures, there are potential risks associated with costovertebral and costotransverse joint injections. However, in general the risk is low, and complications are rare. Potential risks include:

Allergic reaction. Usually an allergy to x-ray contrast or steroid; rarely to local anesthetic.
Infection. Minor infections occur in less than 1% to 2% of all injections. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders.
Nerve or spinal cord damage or paralysis. While very rare, damage can occur from direct trauma from the needle, or secondarily from infection, bleeding resulting in compression, or injection into an artery causing blockage.
Punctured lung (pneumothorax). This complication is uncommon, but at times requires that a small catheter be placed in the chest wall to re-inflate the lung.

In addition to risks from the injection, some patients will experience side effects from the steroid medication, such as:

Transient flushing with a feeling of warmth (‘hot flashes’) for several days
Fluid retention, weight gain, or increased appetite
Elevated blood pressure
Mood swings, irritability, anxiety, insomnia
High blood sugar—diabetic patients should inform their primary care physicians about the injection prior to their appointment
Transient decrease in immunity
Cataracts—a rare result of excessive and/or prolonged steroid usage
Severe arthritis of the hips or shoulders (avascular necrosis)—a rare result of excessive and/or prolonged steroid usage

Costovertebral and costotransverse joint injections should not be performed on patients who are taking blood thinners (Coumadin), aspirin or other antiplatelet drugs (e.g. Ticlid, Plavix). Baby aspirin (81mg) may be an exception, depending upon the specific injection and the physician’s discretion. Costovertebral and costotransverse joint injections should not be performed on patients who have a local or systemic bacterial infection, are pregnant (if fluoroscopy is used), or have bleeding problems. Patients should also let their doctor know of any allergies they have to medications that may be used for the procedure.

By: Ray Baker, MD
September 24, 2004