Intercostal neuralgia is a lesion of intercostal nerves, accompanied by acute pain syndrome. It is characterized by paroxysmal shooting or burning pain in one or more intercostals, going from the vertebral column to the sternum. Diagnosis is based on complaints and an objective examination of the patient, to exclude / detect pathology of the spine and internal organs, an additional examination is carried out using radiography, CT, endoscopy of the gastrointestinal tract. The main directions of therapy are etiotropic, anti-inflammatory, neuroprotective and physiotherapeutic treatment.
General information
Intercostal neuralgia is a pain syndrome associated with damage to intercostal nerves of any etiology (due to infringement, irritation, infection, intoxication, hypothermia, etc.). Intercostal neuralgia can occur in people of different ages, including children. Most often it is noted in adults. The most common intercostal neuralgia is caused by osteochondrosis of the spine with radiculopathy or thoracic disc herniation, as well as caused by herpes zoster. In some cases, intercostal neuralgia acts as a “signal” of serious diseases of the structures forming the chest, or organs located inside it (for example, pleurisy, tumors of the spinal cord, chest and mediastinum). In addition, left-sided intercostal neuralgia can mimic cardiac pathology. Due to the variety of etiology of intercostal nerve neuralgia, the management of patients is not limited to clinical neurology, and often requires the participation of related specialists — vertebrologists, cardiologists, oncologists, pulmonologists.
Anatomy of intercostal nerves
Intercostal nerves are mixed, contain motor, sensory (sensitive) and sympathetic fibers. They originate from the anterior branches of the spinal roots of the thoracic segments of the spinal cord. There are 12 pairs of intercostal nerves in total. Each of the nerves passes in the intercostal space below the edge of the corresponding rib. The nerves of the last pair (Th12) pass under the 12 ribs and are called subcostal. In the area from the exit from the spinal canal to the costal corners, the intercostal nerves are covered by the parietal pleura.
Intercostal nerves innervate the muscles and skin of the chest, the anterior wall of the abdomen, the mammary gland, the costal-diaphragmatic part of the pleura, the peritoneum lining the antero-lateral surface of the abdominal cavity. The sensitive branches of neighboring intercostal nerves branch and connect to each other, providing cross innervation, in which a skin area is innervated by one main intercostal nerve and partially above and below the underlying nerve.
Causes
The lesion of the intercostal nerves may be inflammatory in nature and may be associated with previous hypothermia or an infectious disease. The most common neuralgia of infectious etiology is intercostal neuralgia in herpes infection, the so-called herpes zoster. In some cases, nerve damage is associated with their injury with bruises and fractures of the ribs, other chest injuries, spinal injuries. Neuralgia can occur due to compression of nerves by intercostal muscles or back muscles with the development of musculotonic syndromes associated with excessive physical exertion, work with an uncomfortable posture, reflex impulses in the presence of pleurisy, chronic vertebrogenic pain syndrome.
Various diseases of the spine (thoracic spondylosis, osteochondrosis, intervertebral hernia) often cause irritation or compression of intercostal nerves at the place of their exit from the spinal canal. In addition, the pathology of intercostal nerves can be associated with the dysfunction of the rib-vertebral joints with arthrosis or post-traumatic changes of the latter. Factors predisposing to the development of intercostal nerve neuralgia are chest deformities and spinal curvature.
In some cases, intercostal neuralgia occurs as a result of nerve compression by a growing benign tumor of the pleura, a neoplasm of the chest wall (chondroma, osteoma, rhabdomyoma, lipoma, chondrosarcoma), an aneurysm of the descending thoracic aorta. Like other nerve trunks, intercostal nerves can be affected when exposed to toxic substances, hypovitaminosis with vitamin B deficiency.
Symptoms
The main symptom is a sudden unilateral penetrating acute pain in the chest (thoracalgia), running along the intercostal space and encircling the patient’s torso. Patients often describe it as a “lumbago” or “passage of an electric current.” At the same time, they clearly indicate the spread of pain along the intercostal space from the spine to the sternum. At the beginning of the disease, thoracalgia may be less intense in the form of tingling, then the pain usually increases, becomes unbearable. Depending on the location of the affected nerve, pain can radiate to the scapula, heart, epigastric region. Pain syndrome is often accompanied by other symptoms (hyperemia or pallor of the skin, local hyperhidrosis) caused by damage to the sympathetic fibers that make up the intercostal nerve.
Recurrent pain paroxysms are characteristic, lasting from a few seconds to 2-3 minutes. During an attack, the patient freezes and holds his breath while inhaling, since any movements, including a respiratory excursion of the chest, cause increased pain. Fearing to provoke a new pain paroxysm, during the intercalative period, patients try to avoid sharp turns of the trunk, deep sighs, laughter, coughing, etc. In the period between pain paroxysms along the intercostal space, paresthesia may occur — subjective sensitive sensations in the form of tickling, crawling goosebumps.
In herpetic infection, intercostal neuralgia is accompanied by skin rashes that appear on the 2nd-4th day of thoracalgia. The rash is localized on the skin of the intercostal space. It consists of small pink spots, which then transform into vesicles, drying out with the formation of crusts. Itching is typical, occurring even before the appearance of the first elements of the rash. After the resolution of the disease, temporary hyperpigmentation remains at the site of the rash.
Diagnostics
A neurologist can establish the presence of intercostal nerve neuralgia based on characteristic complaints and examination data. The patient’s antalgic posture attracts attention: in an effort to reduce the pressure on the affected intercostal nerve, he tilts the trunk to the healthy side. Palpation in the affected intercostal space provokes the appearance of a typical pain paroxysm, trigger points are detected at the lower edge of the corresponding rib. If several intercostal nerves are affected, a zone of decrease or loss of sensitivity of the corresponding area of the trunk skin can be determined during a neurological examination.
The clinical differentiation of pain syndrome is important. So, when pain is localized in the cardiac region, it is necessary to differentiate them from the pain syndrome in cardiovascular diseases, primarily from angina pectoris. Unlike the latter, intercostal neuralgia is not stopped by taking nitroglycerin, it is provoked by movements in the chest and palpation of intercostal spaces. In angina pectoris, the pain attack is compressive in nature, provoked by physical exertion and is not associated with torso turns, sneezing, etc. In order to unambiguously exclude coronary heart disease, an ECG is performed for the patient, if necessary, a cardiologist’s consultation is indicated.
When the lower intercostal nerves are affected, the pain syndrome can mimic diseases of the stomach (gastritis, gastric ulcer) and pancreas (acute pancreatitis). Stomach pathology is characterized by a longer and less intense pain paroxysm, usually associated with eating. With pancreatitis, shingles are also observed, but they are usually bilateral in nature, associated with food. In order to exclude the pathology of the gastrointestinal tract, additional examinations may be prescribed: determination of pancreatic enzymes in the blood, gastroscopy, etc. If intercostal neuralgia occurs as a symptom of thoracic sciatica, then pain paroxysms occur against the background of constant dull back pain, which decreases when unloading the spine in a horizontal position. To analyze the state of the spine, an X—ray of the thoracic region is performed, if an intervertebral hernia is suspected, an MRI of the spine is performed.
Intercostal neuralgia can be observed in some lung diseases (atypical pneumonia, pleurisy, lung cancer). To exclude / detect such pathology, chest X—ray is performed, and if there are indications, computed tomography is performed.
Treatment
Complex therapy is carried out aimed at eliminating causal pathology, relieving thoracalgia, restoring the affected nerve. One of the main components is anti-inflammatory therapy (piroxicam, ibuprofen, diclofenac, nimesulide). With severe pain syndrome, drugs are administered intramuscularly, therapy is supplemented by therapeutic intercostal blockades with the introduction of local anesthetics and glucocorticosteroids. An auxiliary tool in the relief of pain syndrome is the appointment of sedatives that reduce pain by increasing the threshold of excitability of the nervous system.
Etiotropic therapy depends on the genesis of neuralgia. Thus, antiviral agents (famciclovir, acyclovir, etc.), antihistamines and topical application of antiherpetic ointments are indicated for herpes zoster. In the presence of musculotonic syndrome, muscle relaxants (tizanidine, tolperizone hydrochloride) are recommended. With compression of the intercostal nerve at the exit from the spinal canal due to osteochondrosis and displacement of the vertebrae, mild manual therapy or spinal traction can be performed, aimed at relieving compression. If nerve compression is caused by a tumor, surgical treatment is considered.
In parallel with etiotropic and anti-inflammatory therapy, neurotropic treatment is carried out. Intramuscular administration of B vitamins and ascorbic acid is prescribed to improve the functioning of the affected nerve. Drug therapy is successfully complemented by physiotherapy procedures: ultraphonophoresis, magnetotherapy, UHF, reflexotherapy. With herpes zoster, local UFO is effective on the area of rashes.
Prognosis and prevention
In general, with adequate treatment, intercostal nerve neuralgia has a favorable prognosis. Most patients have a complete recovery. In the case of herpetic etiology of neuralgia, its relapses are possible. If intercostal neuralgia is persistent and does not respond to therapy, you should carefully reconsider the idea of its etiology and examine the patient for the presence of a herniated intervertebral disc or a tumor process.
Preventive measures are timely treatment of diseases of the spine, prevention of its curvature, adequate therapy of chest injuries. The best protection against herpes infection is a high level of immunity, which is achieved by a healthy lifestyle, hardening, moderate physical activity, outdoor recreation.