What is intercostal neuralgia?
Intercostal neuralgia is nerve pain due to injury or inflammation of an intercostal nerve. The term “intercostal” refers to the location between two ribs. There are 12 intercostal nerves each of which originate in the thoracic spinal cord and travel to the front of the chest wall along the lower border of each rib.
A significant number of patients who suffer from intercostal neuralgia first seek medical attention because they believe they are suffering a heart attack. If the subcostal nerve is involved, patients may believe they are suffering from gallbladder disease.
Causes of intercostal neuralgia and post-thoracotomy syndrome
Causes of intercostal neuralgia include direct nerve injury which may accompany a rib fracture or as an after effect of surgery (specifically, a thoracotomy). The nerve is often involved in cases of shingles where the herpes zoster (chickenpox) virus is reactivated causing a painful, burning, and blistering rash in a band-like distribution across the chest. As many as 15% of people with shingles develop postherpetic neuralgia where significant disabling pain remains even after the rash has resolved (see photo).
Thoracotomy procedures involve an approach between the rib cage for any number of reasons. This could be for a tumor resection, scoliosis procedure, infection, etc. At times the surgery itself is a success, however, the patient ends up with chronic rib cage pain due to irritation of the intercostal nerves.
Signs and symptoms of intercostal neuralgia
The main symptom of intercostal neuralgia is pain in the rib cage area which may wrap around the chest in a band-like pattern. The pain is often described as stabbing, sharp, spasm-like, tearing, tender, aching or gnawing.
Analgesics such as non-steroidal anti-inflammatory drugs are the first-line treatment. The application of heat and cold may provide symptomatic relief. Topical creams containing capsaicin are recommended. Lidoderm is a patch that contains the topical anesthetic, lidocaine. It is applied directly to the affected area.
If these therapies do not adequately control the patient’s pain, a tricyclic antidepressant may be beneficial. These include drugs such as amitriptyline (Elavil), desipramine (Norpramin), or nortriptyline (Pamelor). If a tricyclic antidepressant proves ineffective, anticonvulsants are the next pharmacologic treatment of choice. They include drugs such as gabapentin (Neurontin), carbamazepine (Tegretol), pregabalin (Lyrica), and gabapentin enacarbil (Horizant). Many people require narcotic medication (oxycodone or morphine) for pain control.
A TENS unit may provide pain relief and simply involves placing foam pads over the painful area with mild electrical impulses going through them into the skin. It can provide excellent pain relief.
Interventional Pain Treatments
An intercostal nerve block with local anesthetic and corticosteroid offers short-term therapeutic relief and serves as a diagnostic test for intercostal neuralgia. The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The steroid starts working in about 3 to 5 days and its effects can last for several days to a few months. The injections are done about one week apart and only if needed.
Intercostal nerve blocks can also predict how a patient will respond to chemical neurolytic blocks. A good response usually means the patient will benefit from neurolytic procedures as well. Fluoroscopic guidance improves the accuracy of these blocks and minimizes complications. Alcohol and phenol are the preferred agents for neurolytic procedures because they cause axonal degeneration within minutes and effectively interrupt the central transmission of pain impulses.
Chemical neurolysis can result in immediate and total pain relief in select patients. Complications include unintended spread of alcohol or phenol to the root cuff, epidural space or cerebrospinal fluid.
Intercostal nerve blocks and chemical neurolysis should be considered for refractory neuralgic pain due to intercostal nerve injury from rib fracture or post-thoracotomy and for refractory postherpetic neuralgia.
For those suffering from postherpetic neuralgia, post-thoracotomy syndrome or pain after a rib fracture, then an intercostal nerve block may be the answer. As an absolute last resort, a spinal cord stimulator may be a great option to obtain pain relief and avoid chronic pain and depression.
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Ho, A.M.-H., Karmakar, M.K. (2012). Intercostal nerve block The New York School of Regional Anesthesia [online]. Available at: http://www.nysora.com/peripheral_nerve_blocks/nerve_stimulator_techniques/3098-Intercostal-Nerve-Block.html
Williams, E.H., Williams, C. G., Rosson, G.D., Heitmiller, R.E., Dellon, A.L. (2008). Neurectomy for treatment of intercostal neuralgia. Annals of Thoracic Surgery, 85: pp. 1766-70.