Intercostal Neuralgia

What is Intercostal Neuralgia?

Intercostal neuralgia is a condition that causes nerve pain (neuropathic pain) in areas affected by the intercostal nerves, which run along the ribs, chest, or abdomen. This pain is often experienced as sharp, aching, burning, or stabbing, and might be paired with numbness or tingling sensations, known as paresthesia. The pain can come and go or be constant, and it often feels like a band of pain around the chest and back, or follows a specific pattern on the torso (a thoracic dermatomal pattern). The pain can last for a long time, even after the original cause of the problem has gone away.

The typical symptoms are related to the senses, but in severe cases, they can also affect movement. Regardless of what causes the condition, the ways in which pain is transmitted are the same, meaning that treatment approaches often have similarities.

What Causes Intercostal Neuralgia?

There are several ways that the intercostal nerves, which are the nerves located between your ribs, can get damaged and inflamed. The two most common causes of this inflammation and nerve damage, also known as intercostal neuritis or neuralgia, are from damage to the chest wall and nerves from a surgery to the chest (like a lung surgery), and from a reactivated chickenpox virus, or herpes zoster.

In the case of the surgery, sometimes the pain can occur immediately after the operation or can develop over time as a chronic condition called post-thoracotomy pain syndrome (PTPS). With herpes zoster, it can cause intercostal neuritis both when the virus is active and afterwards, where it can lead to a chronic painful condition known as post-herpetic neuralgia (PHN).

While those are the most frequent causes, there are other less common reasons intercostal neuritis might occur. These could include physical injury, damage from medical procedures like placing a chest tube or breast surgery, physical compression due to anatomical changes, pregnancy, inflammation, infection, or even cancer, to list a few possibilities.

Risk Factors and Frequency for Intercostal Neuralgia

Intercostal neuralgia is a broad term that includes various pathologies, making its frequency challenging to measure. About 3 to 22% of patients referred to pain clinics present with thoracic pain, while an estimated 15% of the general population suffer from it. When looking at intercostal neuropathy particularly, one study found 43% of cases were due to surgery, 28% were post-herpetic (following a shingles infection) and the remaining were idiopathic (unknown cause) or related to tumors.

It is worth noting that the condition can cause chronic pain in the abdominal wall, especially for issues located below the T7 level. This could sometimes lead to unnecessary abdominal surgeries. Diagnosing this iteration of intercostal neuritis is tricky as it’s labeled as a diagnosis of exclusion, complicating the estimation of its prevalence.

Post-Thoracotomy Pain Syndrome (PTPS), a specific type of intercostal neuralgia, is characterized by pain persisting along an incision site at least two months after thoracic surgery. Prevalence varies widely, between 25 to 80%, but most studies agree on a mean value in the 50% range. With over 40,000 thoracotomies in the US, this could mean about 20,000 new cases of PTPS per year, showing the significant contribution of PTPS to intercostal neuralgia cases.

Herpes zoster (HZ) normally hits thoracic dermatomes and it’s more prevalent in older age groups and women, affecting them 1.5 times more than men. Overall, about 30% of individuals will get HZ in their lifetime with 10-20% of these developing PHN (postherpetic neuralgia) – a complication of shingles. Notably, a 2015 study showed an annual incidence rate of HZ as 10.46 per 1000 individuals aged 60 or older, even with a vaccine available.

Given that both thoracic surgery and HZ infection are common amongst the elderly, intercostal neuralgia frequently develops within this demographic. However, it can affect anyone who has had damage to their intercostal nerves due to any cause.

Signs and Symptoms of Intercostal Neuralgia

If a patient comes to you with pain in the chest or upper abdomen, it’s extremely important to get a detailed history and physical examination. Pain from intercostal neuralgia, or nerve pain located between the ribs, tends to follow specific patterns. It may appear along the affected nerve path or in a band-like pattern around the ribs, chest, back, or upper abdomen. This pain can feel like a tight, stabbing, aching, or burning sensation, often accompanied by feelings of numbness and tingling.

Pain can often get worse with physical activities or sudden movements like twisting the body, jumping, laughing, coughing, sneezing and even breathing. The pain can be constant or intermittent. Information about past thoracic surgery, trauma, or infection is important, although this condition can occur without any known triggering event.

During the physical examination, patients might describe an extreme sensitivity to light touch and increased pain response to pin-prick, often described as stabbing or burning. Also, patients might experience numbness in an area that corresponds to the nerves affected. Muscular contractions and skin discoloration above the painful area, as well as loss of sensitivity over said area, are signs of nerve damage. Tests that put pressure on or stretch the affected nerve can bring about the pain.

There are specific signs that might be present in patients suffering from intercostal neuralgia. For example, Schepelmann’s sign involves increased pain when the patient bends their torso towards the side of pain. Other signs might include Carnett’s sign in the case of Abdominal Cutaneous Nerve Entrapment (ACNE) syndrome where the pain gets worse when the abdominal muscles are engaged like during a partial sit-up.

If there is a history of past thoracic surgery, the details including the reason for the surgery, when it was carried out, and any complications, should be reviewed. After thoracic surgery, patients typically describe the pain as burning or stabbing in one or two nearby nerve paths that correspond to the surgical site.

The physical examination should also involve a detailed assessment of any surgical scars and the painful area. Similar patterns of pain can be noticed from blunt or penetrating chest injuries. For patients with a history of herpes zoster, commonly known as shingles, they might have had previous outbreaks or have been immunosuppressed. The physical examination might show a rash in the area where the nerves are affected or possible scarring in cases of chronic (Post Herpetic Neuralgia) pain. Other important factors that can affect nerve pain include pregnancy, childbirth, autoimmune diseases, cancer, and disorders related to metabolism and nutrition.

Testing for Intercostal Neuralgia

If you’re experiencing pain around the ribs, you may be diagnosed with a condition called ‘intercostal neuralgia’. To identify whether you have this condition, your doctor will first take a look at your medical history and conduct an examination. They may also give you a ‘nerve block’ to see if this relieves your pain as a way of confirming the condition.

In some instances, your doctor might decide to use imaging techniques. If you’ve experienced any type of damage or injury in the area, they may want to take an X-ray or conduct a CT scan to check for any signs of damage like broken ribs or something trapped in the area which could be compressing the nerve.

If you are a cancer patient who has undergone a surgery to remove a cancer from your chest, your doctor might want to use CT or MRI scanning. This is because chest pain in such cases could mean the cancer is returning or spreading, and they would want to ensure this is not the case.

In certain scenarios, your doctor might also use a technique called electromyography to study the nerves around your ribs and determine how well they’re functioning. If you have conditions like herpes zoster (shingles), which presents as a painful rash often in a strip of skin known as a dermatome, your doctor can diagnose it simply by examining the rash in most cases. Although, if your case is not typical, they may need to have a skin sample analyzed or conduct a PCR test, a type of lab test to detect viruses.

It’s also highly important to make sure your pain isn’t caused by other conditions related to your heart, lungs, or digestive system. Therefore, further testing or specialist referrals may be needed. If you’re experiencing upper stomach pain, your doctor might order an ultrasound or a CT scan, or refer you to a specialist to rule out problems with your internal organs. Sometimes, a slipped disc in your upper back can cause similar symptoms, and can be confirmed or ruled out by running an MRI scan of that area.

Treatment Options for Intercostal Neuralgia

Intercostal neuralgia, a type of nerve pain in the ribs, can be caused by many different things, so treatment can vary. However, the main goal of treatment is often the same: to reduce the pain you’re feeling. If we can identify what’s causing the pain, the first step is to try and ease it. For example, if chronic coughing is making the pain worse, then cough medicine could help.

Key to treating this condition is preventing it from becoming a long-term issue. This involves easing the immediate pain while also addressing the underlying cause. For instance, if you’re about to have chest surgery, your doctor may plan to control the pain using injections to block nerves and a variety of strong painkillers (analgesic agents). This could reduce the chances of you developing post-thoracotomy pain syndrome (PTPS), a chronic pain condition following chest surgery. Traditionally, a type of injection called a thoracic epidural is used before surgery, although other types, like a paravertebral nerve blockade, might also be effective.

Your doctor might suggest an intercostal nerve blockade, a procedure to specifically block the nerves that are causing your pain in the rib area. This, along with other pain management methods, including anti-inflammatory drugs, anticonvulsants to stop seizures, and transcutaneous electrical nerve stimulation (TENS) – a therapy that uses mild electric currents can help control your pain.

If your nerve pain is due to herpes zoster, a viral infection also known as shingles, it might be prevented or minimized with vaccination. Antiviral medication can lessen the severity and duration of pain by preventing the virus from multiplying. Corticosteroids, anti-inflammatory drugs, and antidepressants might also offer some relief.

For long-term intercostal neuralgia, regardless of the cause, some medications, including NSAIDs, anticonvulsants, like gabapentin and pregabalin, and specific antidepressants, may help. Topical medications – those you apply to the skin, such as a capsaicin patch or lidocaine, can also be useful. TENS therapy might also be considered, although its effectiveness isn’t entirely certain.

Interventional techniques like intercostal nerve blocks can be beneficial in both diagnosing and treating intercostal neuralgia. If these blocks provide pain relief but only for a short time, the next step may be a neurolytic intercostal nerve block, which uses a chemical (phenol or alcohol) to destroy the nerve and provide longer-lasting relief.

In some cases, physical manipulation of the thoracic spine might help relieve nerve irritation. Additionally, physical therapy, psychotherapy, and acupuncture can be effective and work in combination with medicines or interventional treatments.

More invasive treatments, including surgical removal of the nerve, are rare due to the risks involved and the potential for long-term sensory problems. Nevertheless, they might be considered in severe cases.

It’s worth noting that the pain from intercostal neuralgia can lead to a sedentary lifestyle, as activity might increase discomfort. Therefore, a holistic approach considering both physical therapy and psychological support may yield the best results.

If you’re experiencing pain in the chest area, the causes can be numerous and diverse. The source of the pain can generally be traced back to either a traumatic incident (like an injury) or non-traumatic causes. This can then be further divided into musculoskeletal/neuropathic (related to your muscles, bones, and nerves) and visceral (related to your internal organs).

If the pain is stemming from an injury, it’s necessary to investigate certain possibilities. Here are some potential causes:

Bone fracture, particularly of the ribs.
Damage to the muscles and cartilage between the ribs.
A vertebral compression fracture, which is a type of spine injury.
Damage to internal organs due to the injury, which might result in conditions like aortic dissection, pulmonary contusion (bruised lungs), and hemo/pneumothorax (air or blood in the space around your lungs).

For chest pain not caused by an injury, both musculoskeletal/neuropathic and visceral sources should be considered. Some common examples are:

Pleurisy or inflammation of the tissues that line the lungs and chest cavity.
Costochondritis, an inflammation of the cartilage in the rib cage.
Tietze syndrome, a rare inflammatory disorder.
Cancers that originated or spread to your chest or spine.
Radiculopathy, or pinched nerve in the spine.
Pulmonary embolism, which is a blockage in one of the lung’s arteries.
Myocardial infarction, commonly known as a heart attack.
Aortic dissection, a serious condition involving a tear in the heart’s main artery.

Finally, if your chest pain extends to the upper abdomen, your healthcare provider might wish to rule out causes related to your digestive system.

What to expect with Intercostal Neuralgia

The future outcome of intercostal neuralgia, a condition characterized by pain that follows the path of the intercostal nerves, can be unpredictable. Some patients have seen their symptoms go away over a period of time, even without medical treatments. However, some may experience long-lasting pain that can considerably affect their quality of life.

Research indicates that up to 5% of patients may develop severe, long-lasting symptoms that disrupt their daily lives after undergoing surgery in the chest area. According to one study, the number of patients reporting post-thoracic surgery pain gradually decreased over several years, with 57% reporting pain 7 to 12 months after surgery, 36% after 4 to 5 years, and 21% after 6 to 7 years. In this group, around 40% reported limitations in daily activity due to pain. Typically, patients who experience this type of pain have limitations in physical function and lower quality of life.

Globally, there is approximately a 30% chance of getting the Herpes Zoster (HZ) virus, commonly known as shingles, during a person’s lifetime. Most cases of shingles occur in people over the age of 50 and/or those with weakened immune system. After a person gets shingles, they have a 5 to 30% chance of developing Postherpetic Neuralgia (PHN). PHN is a complication of shingles, which is characterized by chronic nerve pain. People at higher risk of getting PHN include older individuals, those experiencing preliminary symptoms (prodrome), people with severe rash, and those experiencing uncontrolled pain during the shingles infection. Patients who still have pain six months after diagnosis are much more likely to experience chronic pain lasting several months to years. PHN pain can limit daily activities, disturb sleep, and may lead to depression.

Possible Complications When Diagnosed with Intercostal Neuralgia

Intercostal neuralgia can lead to several complications. One significant problem of acute intercostal neuralgia negatively impacts the respiratory system. This can strongly contribute to mortality (death) in elderly patients, especially after surgery, or in those with a weak immune system and multiple health conditions. Furthermore, the persistent pain can have significant effects on psychological and physical health, challenging to manage. Besides, the treatment options also come with certain risks.

Treatment using epidural analgesia comes with multiple risks like spinal cord injury, accidental puncture of the dural sheath that surrounds the spinal cord, unintended disruption of the sympathetic nervous system, unusually low blood pressure, feeling nauseous or vomiting, inability to urinate, infections, and possibility of bleeding, to only list a few.

Moreover, regional treatments that focus on a specific part of the body can also be risky. These risks often include damage to the nerves or nearby structures, and poisoning resulting from local anesthetic (pain relief) medication.

All drugs used for treatment have known side effects and can possibly react with other medications you may be taking.

Particularly, opioids (strong pain relievers) are infamous for their unique risks. These include addiction, respiratory problems and misuse of the drugs. These complications constitute a challenge in taking care of patients with intercostal neuralgia.

Potential Risks:

Effect on respiratory system
Psychological and physical health issues due to chronic pain
Risks associated with epidural analgesia like spinal cord injury, accidental puncture of the dural sheath, hypotension etc.
Risks from regional treatments including nerve damage and local anesthetic toxicity
Possible side effects and interactions of pharmacological treatments
Unique risks associated with opioids like addiction and misuse

Preventing Intercostal Neuralgia

People with a condition called intercostal neuritis are at risk of experiencing long-term, or chronic, pain in the muscles between the ribs. This risk is higher for people who have had an injury or surgery in the chest area, or those who have had a condition called herpes zoster (HZ)— also known as shingles.

Some of these risk factors can be managed. For example, getting a vaccine can help prevent shingles. This vaccine is recommended by the Centers for Disease Control and Prevention (CDC) for all at-risk individuals, such as people aged 60 and over, especially women and those with weakened immune systems. So, if you fall into these categories, it’s crucial to consider getting the shingles vaccine.

If a person does get shingles, it’s important to seek prompt medical treatment. Antiviral medicines and pain management can reduce the risk of developing further complications such as postherpetic neuralgia (PHN), a painful condition that can follow shingles.

This information encourages family doctors to teach their patients about the advantages of both the shingles vaccine and quick treatment if shingles does occur. This can help reduce the number and severity of postherpetic neuralgia (PHN) cases. Therefore, doctors ought to know the signs and symptoms of intercostal neuralgia pain and be able to share and offer patients different treatment options.

Moreover, the development of post-thoracotomy pain syndrome (PTPS), a condition that can cause chronic pain after chest surgery, can be lessened by using effective pain relief methods before and after surgery. This could involve regional anesthesia techniques such as an epidural or paravertebral blocks where medication is administered near the spine to numb a large area of the body, along with appropriate drug therapy.

Frequently asked questions

Intercostal neuralgia is a condition that causes nerve pain in areas affected by the intercostal nerves, which run along the ribs, chest, or abdomen. The pain is often sharp, aching, burning, or stabbing, and may be accompanied by numbness or tingling sensations.

About 3 to 22% of patients referred to pain clinics present with thoracic pain, while an estimated 15% of the general population suffer from it.

Signs and symptoms of Intercostal Neuralgia include: - Pain in the chest or upper abdomen, following specific patterns along the affected nerve path or in a band-like pattern around the ribs, chest, back, or upper abdomen. - Tight, stabbing, aching, or burning sensation in the affected area. - Feelings of numbness and tingling. - Increased pain with physical activities or sudden movements like twisting the body, jumping, laughing, coughing, sneezing, and even breathing. - Constant or intermittent pain. - Extreme sensitivity to light touch. - Increased pain response to pin-prick, described as stabbing or burning. - Numbness in an area corresponding to the affected nerves. - Muscular contractions and skin discoloration above the painful area. - Loss of sensitivity over the painful area. - Pain brought about by tests that put pressure on or stretch the affected nerve. - Specific signs such as Schepelmann's sign (increased pain when bending the torso towards the side of pain) and Carnett's sign (worsening pain when engaging the abdominal muscles). - History of past thoracic surgery, with pain described as burning or stabbing in nearby nerve paths corresponding to the surgical site. - Blunt or penetrating chest injuries can cause similar patterns of pain. - History of herpes zoster (shingles) with possible rash or scarring in the affected nerve area. - Other factors that can affect nerve pain include pregnancy, childbirth, autoimmune diseases, cancer, and disorders related to metabolism and nutrition.

There are several ways that intercostal neuralgia can occur, including damage to the chest wall and nerves from surgery, reactivation of the chickenpox virus (herpes zoster), physical injury, medical procedures, physical compression, inflammation, infection, and even cancer.

Other conditions that a doctor needs to rule out when diagnosing Intercostal Neuralgia include: - Conditions related to the heart - Conditions related to the lungs - Conditions related to the digestive system - Slipped disc in the upper back - Pleurisy or inflammation of the lung and chest tissues - Costochondritis, an inflammation of the rib cage cartilage - Tietze syndrome, a rare inflammatory disorder - Cancers originating or spreading to the chest or spine - Radiculopathy or pinched nerve in the spine - Pulmonary embolism, a blockage in the lung's arteries - Myocardial infarction or heart attack - Aortic dissection, a tear in the heart's main artery

To properly diagnose Intercostal Neuralgia, a doctor may order the following tests: 1. Medical history review and physical examination 2. Nerve block to see if it relieves pain 3. Imaging techniques such as X-ray or CT scan to check for damage or compression of the nerve 4. CT or MRI scanning for cancer patients to check for cancer recurrence or spreading 5. Electromyography to study nerve function 6. Skin sample analysis or PCR test to detect viruses in cases of atypical presentations 7. Ultrasound or CT scan for ruling out problems with internal organs 8. MRI scan to confirm or rule out a slipped disc in the upper back These tests help the doctor identify the underlying cause of the pain and determine the most appropriate treatment approach.

Intercostal neuralgia can be treated in various ways depending on the underlying cause. The main goal of treatment is to reduce the pain experienced by the patient. Treatment options include identifying and addressing the cause of the pain, such as using cough medicine for chronic coughing. Preventing the condition from becoming long-term is also important, which may involve controlling pain with injections and strong painkillers before chest surgery. Intercostal nerve blocks, anti-inflammatory drugs, anticonvulsants, transcutaneous electrical nerve stimulation (TENS), and vaccination for viral infections like shingles can also be used. Medications like NSAIDs, anticonvulsants, and specific antidepressants may help in long-term cases. Interventional techniques like nerve blocks and physical therapy, psychotherapy, and acupuncture can also be effective. Invasive treatments, such as surgical removal of the nerve, are rare and considered in severe cases. A holistic approach that includes physical therapy and psychological support is recommended for the best results.

The side effects when treating Intercostal Neuralgia can include: - Effect on respiratory system - Psychological and physical health issues due to chronic pain - Risks associated with epidural analgesia like spinal cord injury, accidental puncture of the dural sheath, hypotension etc. - Risks from regional treatments including nerve damage and local anesthetic toxicity - Possible side effects and interactions of pharmacological treatments - Unique risks associated with opioids like addiction and misuse

The prognosis for intercostal neuralgia can vary. Some patients may see their symptoms go away over time without medical treatment, while others may experience long-lasting pain that significantly affects their quality of life. Research indicates that up to 5% of patients may develop severe, long-lasting symptoms that disrupt their daily lives after undergoing chest surgery. Additionally, patients with post-thoracic surgery pain may experience limitations in physical function and lower quality of life.

A pain specialist or a neurologist.

Chest Pain Nerve Health