Abstract
Whereas most other causes of chest wall pain are musculoskeletal, the pain of intercostal neuralgia is neuropathic. As with costosternal joint pain, Tietze’s syndrome, and rib fractures, many patients who suffer from intercostal neuralgia seek medical attention because they believe they are having a heart attack. If the subcostal nerve is involved, gallbladder disease may be suspected. The pain of intercostal neuralgia is the result of damage to or inflammation of the intercostal nerves. The pain is constant and burning, and it may involve any of the intercostal nerves, as well as the subcostal nerve of the twelfth rib. The pain usually begins at the posterior axillary line and radiates anteriorly into the distribution of the affected intercostal or subcostal nerves, or both. Deep inspiration or movement of the chest wall may slightly increase the pain of intercostal neuralgia, but to a much lesser extent than with musculoskeletal causes of chest wall pain.
Keywords
chest wall pain, chest pain, Tietze’s syndrome, devil’s grip, noncardiogenic chest pain, intercostal neuralgia, intercostal neuritis, acute herpes zoster, zoster sine, herpete, fracture rib
ICD-10 CODE G54.8
Keywords
chest wall pain, chest pain, Tietze’s syndrome, devil’s grip, noncardiogenic chest pain, intercostal neuralgia, intercostal neuritis, acute herpes zoster, zoster sine, herpete, fracture rib
ICD-10 CODE G54.8
The Clinical Syndrome
Whereas most other causes of chest wall pain are musculoskeletal, the pain of intercostal neuralgia is neuropathic. As with costosternal joint pain, Tietze’s syndrome, and rib fractures, many patients who suffer from intercostal neuralgia seek medical attention because they believe they are having a heart attack. If the subcostal nerve is involved, gallbladder disease may be suspected. The pain of intercostal neuralgia is the result of damage to or inflammation of the intercostal nerves. The pain is constant and burning, and it may involve any of the intercostal nerves, as well as the subcostal nerve of the twelfth rib. The pain usually begins at the posterior axillary line and radiates anteriorly into the distribution of the affected intercostal or subcostal nerves, or both ( Fig. 63.1 ). Deep inspiration or movement of the chest wall may slightly increase the pain of intercostal neuralgia, but to a much lesser extent than with musculoskeletal causes of chest wall pain.
Signs and Symptoms
Physical examination generally reveals minimal findings unless the patient has a history of previous thoracic or subcostal surgery or cutaneous evidence of herpes zoster involving the thoracic dermatomes. Unlike patients with musculoskeletal causes of chest wall and subcostal pain, those with intercostal neuralgia do not attempt to splint or protect the affected area. Careful sensory examination of the affected dermatomes may reveal decreased sensation or allodynia. When motor involvement of the subcostal nerve is significant, the patient may complain that his or her abdomen bulges outward.
Testing
Plain radiographs are indicated for all patients who present with pain thought to be emanating from the intercostal nerve, to rule out occult bony disorders, including tumor ( Fig. 63.2 ). If trauma is present, radionuclide bone scanning may be useful to exclude occult fractures of the ribs or sternum. Based on the patient’s clinical presentation, additional testing may be indicated, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Computed tomography of the thoracic contents is indicated if an occult mass is suspected ( Fig. 63.3 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.
