What is Intercostal Neuralgia?
Neuralgia is name given to pain occurring in the nerves. This pain usually is triggered without stimulation of pain receptors. There are many types neuralgia, one of which is Intercostal Neuralgia. This is caused due to compression of intercostal nerve in thoracic rib cage or front of the abdominal area. Intercostal Neuralgia is a rare condition in which there is pain along the intercostal nerves. These nerves lie between the ribs and any sort of irritation or pinch of the nerve results in nerve damage followed by symptoms of pain and loss of function of nerve that results in condition known as intercostal neuralgia.
There may be many reasons for compression of this nerve causing intercostal neuralgia. The nerve irritation or pinch is caused by severe contraction of intercostal or abdominal muscles resulting in nerve twist, prolonged abdominal distention, scar tissue formation around nerve following healing of injury or surgical wound, abdominal muscle overuse, irregular curvature of vertebrae like scoliosis and thoracic vertebral disc diseases. A surgery in and around the chest region can also be one of the reasons in which this nerve can be injured. These nerves can get damaged or inflamed due to different infectious diseases like shingles resulting in intercostal neuralgia. The nature of pain is sharp and spasmodic and pain is spread around the ribcage area. The other causes for intercostal neuralgia are pregnancy, rib or abdominal tumor compressing nerve, chest or rib injury and scarring of chest or abdominal wall after chest or abdominal surgery. Shingles may attack nerves in chest and upper back causing pain. Intercostal neuralgia is in few cases preventable and is definitely treatable in most cases.
In some cases, symptoms of intercostal neuralgia can be severe and incapacitating pain resulting in difficulties with moving and breathing. Pain in the ribcage area need not necessarily be from intercostal neuralgia, like in heart attack. So, instant medical attention should be sought if an individual is having unexplained severe pain in ribcage (chest pain), associated with feeling of pressure in the chest, severe dyspnea, or alteration in consciousness.
Pathophysiology of Intercostal Neuralgia
Pain in ribcage may be occurring due to a variety of reasons. When the cause of pain is originating in the intercostal nerves in the chest, then generally the intercostal nerves are the pain generators. These nerves originate from thoracic spinal cord and travel to front of chest and abdominal wall. The 12 intercostal nerves are located under the ribs along with vein and artery. These nerves supply sensory fibers to skin and tissue around ribs and abdomen wall. Motor fibers are connected to muscles of chest wall and abdomen. The pain is sudden and severe when nerve is damaged during surgery, post-trauma or infections like shingles, rarely there may not be definitive cause and symptoms considered idiopathic.
The pathogenesis of acute intercostal neuralgia includes many etiologies like skin infection, muscle injury, dislocation of costochondral joints, damage to costovertebral ligament, post-herpetic neuralgia (shingles) and post-thoracotomy nerve injury. In the case of acute pain, the chemo-sensitive ion channels of receptors attached to intercostal nerve in peripheral tissue and spinal cord get activated by cytokines released from damaged tissue. Activation of these channels results in generation of action potentials that get charged from peripheral nociceptors from chest area to the thoracic spinal cord via intercostal nerves. The pathophysiology of chronic intercostal neuralgia pain is quite complicated. It involves different mechanisms such as peripheral, central, and psychological. In some instances, a structural or inflammatory source can be located, but still there are indeterminate etiologies in many people with primary pain disorders.
Sign and Symptoms of Intercostal Neuralgia
The main symptom of intercostal neuralgia is pain in the ribcage area. This pain associated with intercostal neuralgia can be bilateral, stabbing, sharp, tearing, or aching in nature. The intercostal neuralgia pain is in and around the chest area on either side and may radiate from the back towards the front of chest in a band-like fashion.
Sometimes, pain is felt evenly along the length of ribs. Sometimes, there is pain with breathing, laughing, or sneezing. The pain increases with exertion. Intercostal neuralgia may also be present in an intermittent fashion like acute pain or a dull and constant pain.
Other Symptoms Of Intercostal Neuralgia Are:
- Bilateral pain may radiate to back.
- Pain in the ribs, especially on left side may be mistaken for heart pain or angina.
- Numbness and/or tingling.
- Abdominal pain is a symptom of intercostal neuralgia.
- Loss of appetite.
- Pain in arms and/or shoulders. Referral pain on left side of shoulder joint and arm is often mistaken for heart pain or angina.
Some Of The More Serious Symptoms Characteristic Of A Life-Threatening Condition Are:
- One of the symptoms of intercostal neuralgia is chest or rib pain with radiation to left arm, shoulder, and back.
- Chest pressure with tightness or tearing sensation in chest.
- Persistent cough producing yellowish-green phlegm.
- Breathing difficulties can be a sign and symptoms of intercostal neuralgia.
- Acute abdominal pain.
- Acute pain in chest with breathing or coughing is yet another sign and symptoms of intercostal neuralgia.
- Sudden confusion, dizziness or change in level of consciousness.
- Paralysis and atrophy of muscles.
Causes and Risk Factors of Intercostal Neuralgia
Intercostal neuralgia can be caused due to a variety of conditions affecting intercostal nerve like infection, inflammation, trauma, or diseases of lungs and chest wall. One of the most common cause of intercostal neuralgia is an injury caused during surgical procedure. Most thoracic surgery involves spreading of the ribs with metal retractor and during retraction intercostal nerve, which lies underneath the nerve can get pinch or crushed resulting in damage to intercostal nerves.
Some of the Causes of Intercostal Neuralgia are:
- Injured chest or rib can cause intercostal neuralgia.
- Entrapment of intercostal nerves.
- Degeneration of the nerves can also cause intercostal neuralgia.
- Neuritis or inflammation of nerve cause by infection like post herpetic neuralgia.
- Pregnancy, which causes rib cage to expand in order to make room for fetus.
- Strain to the muscles and ligaments of chest wall, shoulders and back.
- Rib infections or osteomyelitis of rib can irritate intercostal nerve.
- Surgical procedure in and around the thoracic cavity can lead to intercostal neuralgia.
- Intercostal neuralgia can be caused due to tumors around the chest or abdomen pressing on intercostal nerves.
Some of the Risk Factors for Intercostal Neuralgia are:
- Varicella Zoster infection.
- Participation in sporting activities involving great speed like skiing, snowboarding, football, etc., puts you at risk for sustaining intercostal neuralgia.
- Trauma due to motor vehicle accidents resulting in injury to ribs and intercostal nerves.
Treatment for Intercostal Neuralgia
- Depending on cause of pain associated with intercostal neuralgia, a treatment plan is designed. Intercostal neuralgia can also resolve on its own, but generally requires treatment.
- Sometimes in patients where intercostal pain is frequently recurring, the specific portion of nerve causing pain needs to be destroyed. The treatment is known as "Selective Radiofrequency or Cryo Nerve Ablation."
- In cases where the nerve is entrapped in an abdominal scar, then the suture needs to be excised in order to treat intercostal neuralgia.
- Medications like neuropathic pain medications (Neurontin, Lyrica) and Capsaicin cream help in relieving pain associated with intercostal neuralgia.
- TENS unit also helps.
- Epidural injections and sleeve injection of nerve root can also be given to treat intercostal pain.
- Intercostal nerve blocks using local anesthetic or corticosteroid may be given around the affected intercostal nerve.
- NSAIDs help in calming down pain and reducing inflammation.
- Antidepressant medications for intercostal neuralgia help in calming down nerve pain. Antihistamines are used for relief of itching. Antiviral medications reduce the severity and duration of symptoms.
- Corticosteroids help in reducing risk of postherpetic neuralgia.
- Other treatments for intercostal neuralgia include cold therapy, acupuncture, and yoga etc.
- Lifestyle modifications such as driving safely and wearing protective gears like helmets and padding when participating in high impact sports can help in the prevention of intercostal neuralgia.
- Vaccination to prevent infection like chickenpox, herpes zoster, and shingles helps to prevent viral infection, which may cause intercostal neuralgia.
Investigations to Diagnose Intercostal Neuralgia
- Detailed neurological examination in done to identify the cause of pain.
- Pain questionnaire.
- Blood examination to rule out lung infection and heart failure.
- Electrocardiogram and echocardiogram rule out angina.
- Radiological studies like x-ray or MRI rule out fracture of rib and lung diseases.
- Consultation with a pulmonologist.