FAQs on Intercostal Neuralgia & Postthoracotomy Syndrome


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.Best AZ Pain Doctors

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.

Medical management

TENS unit2Analgesics 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.Pain Clinic Phoenix

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.

Pain clinic PhoenixFor 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.

Arizona Pain Specialists has 7 Valley locations with Double Board Certified doctors accepting over 50 insurances. This includes workers compensation, personal injury, PPO’s, some HMO’s, Medicare, Medicaid and Self Pay.

As the top AZ pain centers, Arizona Pain has won the Patients Choice Award 5 years in a row! Call (602) 507-6550 for the top Phoenix pain management treatment.


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.

An overview of Botox treatment for migraines


A migraine refers to a specific type of headache: this headache is a unilateral (one sided), pulsating, or throbbing headache that lasts anywhere from two to four hours, and can be Botox for Migrainesassociated with an “aura” of associated symptoms, such as nausea, vomiting, photophobia (sensitivity to light), and transient neurological symptoms.

This pain is typically recurring, and can be associated with specific triggers that the patient can identify. The headache from migraine is also aggravated by external stimuli, such as loud sounds, bright lights, and physical activity.

Migraine affects a significant portion of the global population, going as high as 15 percent in some estimates. The prevalence among women (19 percent) is significantly higher than that among men (11 percent).

Migraine Specialist PhoenixThe cause of migraine has many theories. Some researchers point to the increased excitability of the cerebral cortex and abnormal firing of pain neurons in the trigeminal nucleus. Changes in serotonin levels have also been observed, and these can cause spasms and dilations of the blood vessels in the brain, causing the headache. Hormonal changes, food, environment, and emotional stressors have also been implicated in triggering migraine.

Typically, migraine is managed using medications, such as painkillers. There is a stepwise progression in painkillers, with non-steroidal anti-inflammatory drugs (NSAIDs) being prescribed prior to opioid analgesics. Prophylactic medication with topimarate, propranolol, metoprolol and sodium valproate have been shown to reduce the frequency and severity of attacks for those with chronic migraine.

One of the more recent novel interventions for treatment of migraine is the injection of Botulinum toxin type A, or “botox” as it is colloquially known. Botox is a purified form of neurotoxin that is produced by the bacterium Clostridium botulinum, which works by interfering in the transmission of signals between the nerve and muscle. Botox causes local Migraine clinic Phoenixmuscle paralysis, and its use in dermatologic procedures to smooth out wrinkles is widely known.

Researchers have found that injections with Botulinum toxin are effective in reducing the frequency of headaches, as well as significantly improving the patient’s quality of life. This seems to be the best application for Botox, as it has not been shown to be better than placebo in the treatment of acute headaches.

The injections have been proven to be generally well tolerated by patients, with neck pain appearing in 9 percent of patients. Other side effects of the injections include itching, pain in the injection site, as well as muscle aching, tightness, or spasms.

It is still not understood how botulinum toxin provides effective reduction in the frequency and severity of migraines. There have been several theories offered, and these include:Pain clinic Phoenix

  • Botulinum toxin causes local muscle paralysis. This relaxation of the muscles around the head may reduce blood pressure within the brain. It may also decrease muscular spasm, a possible cause of the headache.
  • Botulinum toxin may interfere with the ability of the nerves to send pain signals
  • Botulinum toxin may directly interfere with the transmission of signals that triggers an attack of migraine

Botox works, however, it should be reserved until initial therapy with oral medications has failed.

The top headache specialists in AZ are with Arizona Pain Specialists. The Board Certified pain management doctors in Arizona at the practice provide both medical and interventional treatments. This includes occipital blocks, Botox for migraines, abortive and preventive medications.

Over 50 insurances are accepted at any of the 7 Arizona Pain locations. Call (602) 507-6550 for schedule you or a loved one right away!


Lin KH, Chen SP, Fuh JL, Wang YF, Wang SJ. Efficacy, safety, and predictors of response to botulinum toxin type A in refractory chronicmigraine: a retrospective study. J Chin Med Assoc. 2014 Jan;77(1):10-5. doi: 10.1016/j.jcma.2013.09.006.

Reddy DS. The pathophysiological and pharmacological basis of current drug treatment of migraine headache. Expert Rev Clin Pharmacol. 2013 May;6(3):271-88. doi: 10.1586/ecp.13.14.

Shao YF, Zhang Y, Zhao P, et al. Botulinum toxin type a therapy in migraine: preclinical and clinical trials. Iran Red Crescent Med J. 2013 Oct;15(10):e7704. doi: 10.5812/ircmj.7704.

Chiropractic Treatment for Neck Pain Relief


Chiropractic treatment is done without the use of modern medicine in most instances. The reasoning behind chiropractic treatment is that when there is proper alignment of musculoskeletal structures andNeck pain Phoenix especially the spine, then chronic back and neck pain will often go away.

How Chiropractic Treatment for Neck Pain Relief Works

Since it is already clear that no medication is involved with chiropractic treatment, it is important that we take a look at how it works. Chiropractors in Phoenix usually use “hands-on” kinds of treatment to manipulate the muscles and align them.

This ensures that if the chronic pain was a result of incorrectly aligned muscles, then when they get back in place, the pain goes away. This is generally a very effective method of treatment and it involves very little pain if any at all.

Benefits of Chiropractic Treatment for Neck Pain Relief

Recent studies have shown that spinal manipulation given by Phoenix chiropractors is generally an effective and safe way of treating chronic Neck pain specialist Phoenixneck and back pain naturally. Since it does not require the use of any medication, there is no need for you to worry about side effects or pain coming back when you are through with the drugs.

These are just some of the benefits of getting treatment for neck pain from a Phoenix chiropractor. Other benefits may include keeping a record of your ailment and response to treatment so that your doctor knows how to help if anything goes wrong.

Arizona Pain Specialists offers chiropractic treatment at all seven locations, with exceptional pain relief coming from the  therapies offered. This is often performed in conjunction with the Phoenix pain management doctor treatment which may include medical or intreventional pain treatment.

The pain doctors in Arizona are Board Certified and Award Winning, with the chiropractic doctors providing over an 85% success rate for back and neck pain. Call (602) 507-6550 today!