Location
Philadelphia, PA
Start Date
1-5-2024 1:00 PM
End Date
1-5-2024 4:00 PM
Description
Background: Thoracic pain can be challenging to diagnose due to a wide variety of etiologies in the area. Intercostal neuromas are a potential source of pain in the thoracic region. In the setting of blunt intercostal trauma, neuromas should be higher on the differential following rib fracture, anterior cutaneous nerve entrapment syndrome (ACNES), slipping rib syndrome, costochondritis, and visceral etiologies. ACNES and intercostal neuromas can present similarly and lead to misdiagnosis and delay in treatment.
Case Description: 69-year-old male with a complex medical history who was evaluated in the OMM Clinic at PCOM for left sided rib pain for 10 years. In 2013, the patient was hit with a scaffolding pipe in a “battering-ram” fashion at the level of the seventh rib. He had immediate, severe pain and was evaluated in the emergency department. Since this incident he has had focal, sharp, pain that is non-radiating. The pain is aggravated by all movement, including walking and moving his arm. The pain comes on suddenly, lasting for seconds to minutes as long as the inciting factor is still present. A CT scan in March of 2022 which showed lung nodules, but no evidence of rib fracture. He had an extensive workup and treatment including physical therapy, lidocaine patches, fentanyl patches, medical marijuana, 2 intercostal nerve blocks, 2 radiofrequency ablations, and chiropractic work, without any relief. The patient was also treated with steroids for polymyalgia rheumatica for 1-2 years without any relief of his rib pain. His only relief comes from oxycodone 7.5mg. Examination was significant for a focal area of tenderness about the width of a thumb pad along the lateral aspect of rib 7 including the serratus anterior musculature. He was referred for musculoskeletal ultrasound, which confirmed an intercostal neuroma at the area of complaint. The patient had the neuroma excised and approximately one month after surgery, the patient had 80% resolution of pain, and at two months post-op he had complete resolution of his pain without further need for opioid pain management.
Discussion: In cases of thoracic wall trauma, intercostal neuroma should be considered as a differential diagnosis, especially as the pain persists and is not ameliorated with common musculoskeletal treatment modalities such as physical therapy and pharmacologic measures. Understanding the causes and treatment options of intercostal neuromas can help prevent significant delay in successful treatment, which can improve patient quality of life and limit unnecessary testing and treatments for patients. Musculoskeletal ultrasound is an imaging modality that can be helpful in diagnosing intercostal neuroma and allow for timely surgical excision. Ultrasound is a cost effective, fast, non-invasive, safe modality to examine for the presence of intercostal neuromas.
Embargo Period
7-1-2024
Included in
Differentiating Chronic Neuropathic Rib Pain: A Case Report
Philadelphia, PA
Background: Thoracic pain can be challenging to diagnose due to a wide variety of etiologies in the area. Intercostal neuromas are a potential source of pain in the thoracic region. In the setting of blunt intercostal trauma, neuromas should be higher on the differential following rib fracture, anterior cutaneous nerve entrapment syndrome (ACNES), slipping rib syndrome, costochondritis, and visceral etiologies. ACNES and intercostal neuromas can present similarly and lead to misdiagnosis and delay in treatment.
Case Description: 69-year-old male with a complex medical history who was evaluated in the OMM Clinic at PCOM for left sided rib pain for 10 years. In 2013, the patient was hit with a scaffolding pipe in a “battering-ram” fashion at the level of the seventh rib. He had immediate, severe pain and was evaluated in the emergency department. Since this incident he has had focal, sharp, pain that is non-radiating. The pain is aggravated by all movement, including walking and moving his arm. The pain comes on suddenly, lasting for seconds to minutes as long as the inciting factor is still present. A CT scan in March of 2022 which showed lung nodules, but no evidence of rib fracture. He had an extensive workup and treatment including physical therapy, lidocaine patches, fentanyl patches, medical marijuana, 2 intercostal nerve blocks, 2 radiofrequency ablations, and chiropractic work, without any relief. The patient was also treated with steroids for polymyalgia rheumatica for 1-2 years without any relief of his rib pain. His only relief comes from oxycodone 7.5mg. Examination was significant for a focal area of tenderness about the width of a thumb pad along the lateral aspect of rib 7 including the serratus anterior musculature. He was referred for musculoskeletal ultrasound, which confirmed an intercostal neuroma at the area of complaint. The patient had the neuroma excised and approximately one month after surgery, the patient had 80% resolution of pain, and at two months post-op he had complete resolution of his pain without further need for opioid pain management.
Discussion: In cases of thoracic wall trauma, intercostal neuroma should be considered as a differential diagnosis, especially as the pain persists and is not ameliorated with common musculoskeletal treatment modalities such as physical therapy and pharmacologic measures. Understanding the causes and treatment options of intercostal neuromas can help prevent significant delay in successful treatment, which can improve patient quality of life and limit unnecessary testing and treatments for patients. Musculoskeletal ultrasound is an imaging modality that can be helpful in diagnosing intercostal neuroma and allow for timely surgical excision. Ultrasound is a cost effective, fast, non-invasive, safe modality to examine for the presence of intercostal neuromas.