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Counting ribs and thoracic levels under ultrasound: a systematized technical protocol for both posterior and anterior approaches
  1. Mark Friedrich B Hurdle1,
  2. Guilherme Ferreira-Dos-Santos2,
  3. Raul Rosario-Concepcion3,
  4. Laura V Gil4,
  5. Jason S Eldrige1 and
  6. Steven R Clendenen4
  1. 1Department of Pain Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
  2. 2Department of Physical Medicine and Rehabilitation, Central Lisbon University Hospital Centre, Lisboa, Portugal
  3. 3Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
  4. 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
  1. Correspondence to Dr Guilherme Ferreira-Dos-Santos, Physical Medicine and Rehabilitation, Central Lisbon University Hospital Center, 1050-099 Lisboa, Portugal; guilhermesantos{at}


Over the last two decades, the clinical applications of diagnostic and interventional ultrasound have expanded rapidly. When analyzing the chest wall and thoracic region, ultrasound has previously been shown to reliably identify chest wall pathologies like rib fracture and slipping rib syndrome, as well as having fundamentally changed perioperative management and patient outcomes after the emergence of point-of-care ultrasound. In addition, ultrasound guidance has recently become more popular for multiple blocks in the field of regional anesthesia and pain medicine. In this technical report, we systematize an ultrasound-guided protocol for counting ribs and thoracic levels for both posterior and anterior approaches, which does not require level confirmation by fluoroscopy. With this protocol, we hope to create an effective educational resource to support physicians from any specialty background as they engage in point-of-care ultrasound applications in the thoracic region.

  • diagnostic techniques and procedures
  • education
  • emergency medicine
  • regional anesthesia
  • ultrasonography

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  • MFBH and GF-D-S are joint first authors.

  • Contributors MFBH is the first author and the interventionist who appears performing the technique in the videos. MFBH and GF-D-S were responsible for original research and description of the technique. Additionally, they drafted the original manuscript together. RR-C and LVG provided intellectual input to the first version of the manuscript, helped in the recording and editing of the videos and pictures for the manuscript. JE and SRC reviewed the entire manuscript and were responsible for the final written version of the main document, submitted for consideration for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.