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Intercostal neuralgia , or thoracalgia , is pain that is felt along the passage of the nerve and is localized in the intercostal space. It may also be accompanied by other uncomfortable sensations - numbness, burning.
Causes of intercostal neuralgia
There are many sources that cause intercostal neuralgia. This can be external (poisoning with heavy metals, medications) and internal intoxication. The latter are usually associated with diseases in neighboring organs and tissues (pleurisy, spinal diseases).
Pain in the intercostal space is often caused by diffuse pathologies of the nervous system - hormonal spondylopathy, polyradiculoneuritis, multiple sclerosis, as well as infections such as tuberculosis and herpes zoster.
Often this symptom occurs due to spinal pathology, injuries, allergies .
Metabolic disorders and hypoxia of nervous tissue are promoted by anemia, diabetes mellitus, alcohol intoxication, hepatitis, malabsorption and decreased concentrations of B vitamins, atherosclerosis and hypertension.
As a rule, intercostal neuralgia, the symptoms of which everyone should know, develops under the influence of several factors. It is characteristic that it is never diagnosed in children. We can say that this is a disease of people mainly in the middle and older age categories.
Symptoms
The main symptom of intercostal neuralgia is pain in the ribs, which has an acute burning character, sometimes dull. The pain can develop in paroxysms or appear periodically. During attacks, the pain can be intense and intensify with coughing, sneezing, and body movements. The pain is usually localized in the area of the lower ribs and can radiate to the shoulder or arm, which often makes such attacks of pain similar to cardialgia. Pain with intercostal neuralgia from pain in the heart in the more constant nature of the pain intensity, and in the absence of changes in the cardiovascular system (changes in pulse, pressure). In addition, cardiogenic pain does not increase with trunk movement and there is no local tenderness in the rib area. Pain during intercostal neuralgia may be accompanied by vegetative manifestations (pallor or redness of the skin, sweating), fasciculations of muscle groups, impaired sensitivity in the area of pain (numbness). Palpation of the area of paravertebral points in the intercostal spaces in the area of attachment of the ribs to the sternum can be painful. Sometimes pain with intercostal neuralgia can radiate to the lower back and simulate renal colic.
How to treat intercostal neuralgia?
Since this symptom develops against the background of a large number of different diseases, the doctor must accurately identify the cause of its occurrence and prescribe adequate treatment.
Intercostal neuralgia sometimes simulates an attack of heart pain, but discomfort appears predominantly in the left half of the chest; moreover, it does not depend on breathing or movement and does not occur with external palpation.
The most advanced diagnostics are now possible using the most modern research methods, such as computed tomography and magnetic resonance imaging. These techniques make it possible to detect neoplasms, signs of changes in the brain and spinal cord, and damage to internal organs with high accuracy.
During the acute period, the patient should strictly observe a rest regime. It is necessary to limit sudden movements, physical activity, and body turns. Sitting should be avoided. You need to lie on a flat and level surface. You can apply sand in bags, pepper patch, or a heating pad, that is, dry heat, to the painful area. To enhance the thermal effect, you can tie yourself with a scarf made of natural wool.
Intercostal neuralgia - symptoms and treatment
Physical examination is usually minimal unless the patient has a history of chest surgery (thoracic or subcostal surgery) or herpes zoster. It is preferable to conduct the examination of the thoracic spine with the patient in a sitting position and include examination at rest and palpation of the vertebrae and paravertebral structures. Provocation of pain by passive forward rotation, flexion, reverse flexion, and lateral flexion in particular may indicate that the pain is of spinal origin.[9]
As a rule, during the examination, the patient tilts the torso in the healthy direction, thus reducing the pressure on the affected intercostal nerve. If several nerves are damaged, a neurologist, upon examination, can determine an area of decreased or loss of sensitivity in certain areas of the skin of the body.
If the pain is localized in the heart area, differential diagnosis is carried out with diseases of the cardiovascular system (for example, angina pectoris, which, unlike MPH, is relieved by taking nitroglycerin). MRNs provoke movements in the chest and palpation of the intercostal spaces. Angina pectoris is characterized by a painful attack of a compressive nature, it is provoked by physical activity, and it is not associated with turning the body, sneezing, etc. To exclude coronary heart disease, you need to perform an ECG and, if necessary, refer the patient for a consultation with a cardiologist.
If the lower intercostal nerves are affected, the pain syndrome is similar to diseases of the gastrointestinal tract (gastritis, gastric ulcer, acute pancreatitis). It should be noted that with stomach diseases, the pain is usually longer and less intense and is usually associated with food intake. Pancreatitis is characterized by girdle pain of a bilateral nature.
To exclude pathology of the gastrointestinal tract, it is advisable to conduct additional examinations: analysis of pancreatic enzymes in the blood, gastroscopy, etc. If intercostal neuralgia occurs as a symptom of thoracic radiculitis, then painful paroxysms occur against the background of constant dull pain in the back, which decreases when the spine is unloaded in a horizontal position.
To analyze the condition of the spine, an X-ray of the thoracic region is performed, and if an intervertebral hernia is suspected, an MRI of the spine is performed.
MRN occurs in some lung diseases (atypical pneumonia, pleurisy, lung cancer).
When diagnosing intercostal neuralgia, one should keep in mind syringomyelia, meningoradiculitis, intradural tumors, as well as referred pain from internal organs – Hed’s area.[2]
Tablets for intercostal neuralgia
Of the medications that alleviate the course of this disease, the first place goes to analgesics (analgin, sedalgin) and non-steroidal drugs (ibuprofen, piroxicam, indomethacin), which have anti-inflammatory properties. They should be taken regularly for pain prevention purposes, without waiting for a new attack to occur.
Drugs that belong to the group of muscle relaxants (tizanidine or baclofen) help not only eliminate pain, but also relieve muscle spasms in the area of injury. Medicines in this group must be used with caution, especially for people driving and associated with work involving a high concentration of attention.
To relieve nervous tension, you can take sedatives. Be sure to carry out vitamin therapy . Complexes containing daily dosages of B .
Intercostal neuralgia with unbearable pain can be successfully relieved with lidocaine or novocaine blockades . These procedures are usually performed in specialized centers. But in particularly severe cases of the disease, the prescription of steroids, usually prednisone, is indicated.
A good effect is achieved when physiotherapeutic methods . They include UV irradiation of the corresponding paravertebral region, electrophoresis with lidocaine, especially in the acute period. When the phase transitions from acute to subacute, darsonvalization, microwave therapy, and phonophoresis are prescribed. Reflexology is widely used for this pathology.
Causes of postherpetic neuralgia
Once a person has had chickenpox, the virus remains in the body for life. With age, the immune system weakens (particularly from taking medications or chemotherapy) and the virus can become more active, resulting in shingles.
Damage to nerve endings during rashes leads to postherpetic neuralgia. When damaged, nerve fibers cannot send signals from the skin to the brain as they normally do. Instead, they transmit amplified signals, and the patient feels excruciating pain that can last for months or even years.
Surgical treatment of trigeminal neuralgia
Patient Sh., 63 years old, was admitted to the 1st neurological department on June 7, 2015.
Upon admission, complaints of paroxysmal, burning, high-intensity pain in the area of the right cheek, chin, ear on the right, in the area of the upper and lower teeth, pain in the temporomandibular joint on the right, with aggravation during talking, eating (chewing), washing, with periodic increases in pain in the form of “lumbago”, hypersalivation (more at night), worsening night sleep due to pain.
History: In the spring of 2011, neuropathic pain first appeared in the zones of innervation of the II and III branches of the right trigeminal nerve. Treatment was carried out, including a course of Finlepsin and Lyrica, and IRT procedures and magnetic therapy were also started, which were canceled after MRI revealed a falx meningioma in the frontal region. The pain syndrome regressed within 3 months.
In the spring of 2014, the pain syndrome relapsed. The examination revealed an increase in anti-VZV IgG (421.2 mU/ml, when the norm is less than 150). Anti-VZV IgM (negative). There were no skin rashes and he denied any history of H.zoster. She underwent 2 courses of treatment with hydrocortisone in tablet form (in April and July 2014), a course of Valtrex, Famvir, and Cycloferon. Dynamics after therapy: increase in anti-VZV IgG titer (496.4 mU/ml), anti-VZV IgM (negative). The pain syndrome regressed after half a year.
For a long time in 2014, she was engaged in dental prosthetics.
The real deterioration of the condition began in mid-May 2015, when facial pain resumed, increasing in intensity, “shooting”, limiting household activity. During the study, the titer of anti-VZV IgG continues to increase - 571.7 mU/ml), anti-HSV (types 1 and 2) IgG is detected - 23.5 (positive), anti-HSV (types 1 and 2) IgM - negative, anti-EBV IgG-EBNA (white caps.) – 385.0 U/ml (positive), anti-EBV IgM-VCA (white caps.) <10 (negative), anti-EBV IgG-VCA (white caps.) (positive ). I started taking Valtrex, Cycloferon, Famvir, Lyrica. I couldn’t sleep at night because of the pain. Hospitalized on an emergency basis.
History: surgical interventions: NAM for endometriosis, takes hormonal therapy (in gel form); appendectomy. In 2009 - a circular facelift.
As a child, she suffered from chickenpox, mumps, and rubella; did not suffer from frequent ARVI; in adulthood - double lacunar tonsillitis.
Photos provided upon admission:
CT scan of the TMJ with functional tests and multiplanar reconstructions dated November 26, 2014: Condition after secondary partial edentia, after prosthetics. CT picture of degenerative changes in the right TMJ with signs of subluxation during a functional test.
MRI of the TMJ dated 12/15/14: MR signs of TMJ asymmetry. Picture of partial reducible dislocation of the right TMJ. Severe degenerative changes in the right articular disc. MRI signs of osteoarthritis and synovitis of the right TMJ. MRI signs of functional overload of the superior head of the right lateral pterygoid muscle.
MRI of cerebral vessels dated 06/04/14: no pathological changes in the main arteries and veins of the brain were detected.
MRI of the brain dated 06/03/14: a picture of a space-occupying falx formation in the frontal region (12*10 mm), most likely meningiomas. Fine-focal changes in the brain substance of a vascular nature.
CT scan of the skull bones dated November 7, 2014: no bone-destructive or space-occupying formations of the upper and lower jaw were detected. Condition after secondary partial adentia, after prosthetics. CT picture of degenerative changes in the right TMJ. Signs of a space-occupying formation in the area of the falx of the frontal region of the brain, most likely meningioma. Local thickening of the left frontal bone (exostosis? Compact osteoma?)
Objectively: The condition is satisfactory. The skin is of normal color. There are no rashes in the area where the pain is localized and in the area of the ear canal on the right. There is no swelling. In the lungs there is vesicular breathing, no wheezing. NPV up to 14 per minute. Heart sounds are muffled, rhythmic, heart murmurs cannot be heard, heart rate is 62 per minute. Blood pressure 120/80 mm Hg. Art. The abdomen is soft, painless on palpation, there are no symptoms of peritoneal irritation, peristalsis can be heard. The liver does not protrude from under the edge of the costal arch. Controls pelvic functions.
Neurological status: Conscious, contactable, oriented. There is no decrease in background mood. There are no meningeal signs. Palpebral fissures D=S. Pupils D=S. Photoreactions are live. Movement of the eyeballs is not limited. There is no nystagmus. There are no violations of superficial sensitivity on the face. Pain is provoked by palpation of the exit point of the 2nd branch of the trigeminal nerve on the right. The face is symmetrical. Swallowing and phonation are not impaired. Tongue in the midline. There are no paresis. Tendon reflexes are of medium vivacity, D=S. No sensory disturbances were detected. Romberg's posture is unsteady. Coordinator tests are performed satisfactorily on both sides.
In the tests - moderate leukocytosis: 11.38 10e9 /l (N: 4-9), without a shift in the formula; ESR acceleration: 20 mm/hour
ECG: Sinus rhythm with heart rate 76/min. Horizontal position of the EOS.
X-RAY examination of the chest organs : No recent focal and infiltrative changes were detected.
Consulted with an infectious disease specialist: there is no evidence of an acute infectious process or signs of a persistent viral infection. The condition can be regarded as postherpetic trigeminal neuralgia. The existing increase in the titer of antibodies to VZV and EBV is of an anamnestic nature (previous infection). Active antiviral therapy is not indicated. Complex therapy is necessary to correct neuropathic pain syndrome.
The dentist suggested possible compression of the terminal branches of the second branch of the trigeminal nerve by a foreign body (filling material) at the apex of the 1.4 tooth, which was confirmed by CT scan of the upper jaw.
When performing a high-field MRI of the brain, a formation measuring up to 13 mm (meningioma) is determined in the projection of the anterior parts of the falx. During a targeted examination of the trunk, a vein with a blood flow diameter of up to 2 mm is adjacent to the lower parts of the right trigeminal nerve, slightly deforming them in the area of the grubber notch. Picture of meningioma of the anterior parts of the falx. MRI signs of neurovascular conflict of the right trigeminal nerve (see Fig. 1)
Thus, the polyetiological genesis of the pain syndrome was revealed:
- Postherpetic neuropathy
- formation of trigeminal pain syndrome due to irritation of the second branch of the trigeminal nerve from the periphery (as a result of contact with filling material),
- trigeminal neuralgia due to compression of the nerve root by the vein in the area of the cerebellopontine angle,
- The influence of falx meningioma could not be excluded.
With EEG: Epileptiform activity and signs of interhemispheric asymmetry at the time of the study were not recorded either in the background recording or during afferent tests.
Considering the possibility of the formation of trigeminal pain syndrome both due to irritation of the second branch of the trigeminal nerve from the periphery (as a result of contact with filling material), and trigeminal neuralgia due to compression of the nerve root by the vein in the area of the cerebellopontine angle, surgical treatment for both nosologies is indicated. A decision was made on a staged intervention: first of all, cystectomy with resection of the apex of the 14th tooth, then microvascular decompression of the trigeminal nerve root on the right.
The patient received treatment: no-spa + analgin + novocaine + relanium; Perfalgan IV, Tramal, Milgamma IM, Lyrica, Valtrex, Amitriptyline, Augmentin, Glycine, PC-Merz, Hydrocortisone, Cycloferon, Femivir, Finlepsin in the table. During the treatment, moderate positive dynamics were noted in the form of a decrease in the intensity of the frequency of painful paroxysms: the patient could talk and eat.
A surgical intervention was performed - cystectomy with resection of the apex of the 1.4 tooth. The course of the postoperative period was smooth, fluctuations in the pain syndrome were noted, and after a week there was a persistent increase. Finlepsin was added to therapy at a dose of 300 mg/day, which resulted in a good analgesic effect.
The patient had doubts about the need for neurosurgical intervention. In order to resolve the issue of the need to decompress the trigeminal nerve root, Finlepsin was discontinued, after which the pain syndrome resumed. There was no doubt that the patient was indicated for surgical intervention - microvascular decompression of the trigeminal nerve root on the right in order to resolve the vasoneural conflict and achieve stable remission of trigeminal neuralgia.
Neurosurgical intervention was performed (see Fig. 2-3), as a result of which the pain syndrome was completely relieved.
Drug therapy
Drug therapy involves the use of the following groups of drugs:
- Anticonvulsants (Lyrica, Neurontin, others). These drugs have shown good effectiveness against neuropathic pain. However, they have a number of side effects, the most common of which are decreased concentration, drowsiness and swelling of the legs;
- Antidepressants. Some antidepressants (Amitriptyline, Duloxetine) affect the production of special brain substances that are responsible for both depressive states and the perception of pain. Doctors often prescribe minimal doses of antidepressants in the complex treatment of postherpetic neuralgia. Their main side effects include: drowsiness, dry mouth, dizziness;
- In cases of severe pain and insufficient effectiveness of other drugs, patients may be prescribed narcotic analgesics.