Intercostal Nerve Entrapment: Chest Wall

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Intercostal Nerve Entrapment: Chest Wall Copyright Year 2016 Copyright Holder Springer International Publishing Switzerland Corresponding Author Family Name Olamikan Particle Given Name

Sola

Suffix Division Organization/University

Author

City

Dallas

State

TX

Country

USA

Email Family Name

[email protected] Gulati

Particle Given Name

Amitabh

Suffix

Author

Division

Ambulatory Pain, Anesthesiology and Critical Care

Organization/University

Memorial Sloan Kettering Cancer Center

City

New York

State

NY

Country

USA

Email Family Name

[email protected] Trescot

Particle Given Name

Andrea M.

Suffix Division Organization/University

Pain and Headache Center

Q1

Abstract

Keywords (separated by “ - ”)

City

Wasilla

State

AK

Country

USA

Email [email protected] Intercostal nerve entrapment is rarely considered as a cause of chest wall pain, even though the pain is usually dermatomal in nature and therefore should be readily apparent. A history of chest wall injury (trauma, surgery, or infection) should alert the clinician to the possibility of intercostal neuralgia. Intercostal neuralgia - Intercostal nerve entrapment - Intercostal nerve syndrome - Chest wall pain - Abdominal wall pain

AUTHOR QUERIES

Q1 Please provide department and organisation name for Sola Olamikan and provide department name for Andrea M. Trescot.

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Intercostal Nerve Entrapment: Chest Wall

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Sola Olamikan, Amitabh Gulati, and Andrea M. Trescot

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Introduction

Clinical Presentation (Table 29.1)

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5

Intercostal neuralgia (IN), a relatively rare condition, consists of nerve pain secondary to intercostal nerve pathology. The term “intercostal” refers to the location between two ribs. In contrast to more common chest wall pain syndromes such as costochondritis, acute rib fracture, or Tietze’s syndrome, which are musculoskeletal in origin, the pain of intercostal neuralgia is neuropathic in origin. The most common causes of intercostal neuralgia nerve damage-related pain are postherpetic neuralgia, thoracic surgery, and diabetic thoracic neuropathy [1]. Other causes of intercostal neuralgia include direct nerve injury, stretching, entrapment, and inflammation. Direct nerve injury may be due to physical trauma or as an aftereffect of surgery. Stretching injuries include traction on the chest wall from the expanding gravid uterus. Entrapment can be caused by neoplasm, sarcoidosis, and pleural mesothelioma. The pain roughly parallels the rib over the affected nerve. The condition has also been referred to as “intercostal nerve syndrome.” At times, it can be extremely painful, to the point of being debilitating.

Intercostal neuralgia (IN) is easily misdiagnosed due to the ambiguity of its symptoms. Patients may complain of “rib pain” (Fig. 29.1), but they may also describe “chest pain” or upper abdominal pain. The history of onset may be clearly related to a specific event such as blunt trauma or rib fracture or nerve injury such as shingles or thoracotomy and medial sternotomy, but the onset may also be insidious with no identifiable preceding event. The pain is often perceived as stabbing, sharp, spasm-like, tearing, tender, aching, or gnawing. The pain may wrap around the chest in a dermatomal pattern or radiate from the back toward the front of the chest in a bandlike pattern (Fig. 29.2). It may occur in sporadic episodes, or it may be dull and constant. The pain may intensify with exertion such as with heavy lifting, twisting, or turning the torso. Breathing, coughing, laughing, or sneezing may be painful. It may be associated with numbness and tingling. Pain may start in the back and wrap around the front, or it may be felt only in

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Table 29.1 Occupation/exercise/trauma history relevant to intercostal entrapment

t1.1 t1.2

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Surgery Neuropraxia, stretching injury Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-27482-9_29) contains supplementary material, which is available to authorized users. [AU1]

S. Olamikan, MD (*) Dallas, TX, USA e-mail: [email protected] A. Gulati, MD Ambulatory Pain, Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA e-mail: [email protected] A.M. Trescot, MD Pain and Headache Center, Wasilla, AK, USA e-mail: [email protected]

Trauma Neuropathy Entrapment

Intercostobrachial nerve injury Postoperative neuroma

Thoracotomy, median sternotomy Pregnancy, with tension on nerves by gravid uterus; retractor trauma during thoracotomy; frequent, prolonged coughing Rib fracture or rib contusion, breast surgery, prolonged positioning Postherpetic neuralgia, diabetic peripheral neuropathy, pleuritis Scar at chest tube insertion sites; entrapment at lateral rectus border (ACNE syndrome – see Chap. 42); pleural fibrosis [1]; osteoporotic compression, degenerative disk disease, scoliosis, rib articulation arthritis Injured during mastectomies and axillary node dissection Thoracotomy, breast implant [2]

© Springer International Publishing Switzerland 2016 A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_29

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

t1.3 t1.4 t1.5 t1.6 t1.7 t1.8 t1.9 t1.10 t1.11 t1.12 t1.13 t1.14 t1.15 t1.16 t1.17 t1.18 t1.19 t1.20 t1.21

S. Olamikan et al.

Fig. 29.1 Patient description of intercostal nerve pain (Image courtesy of Andrea Trescot, MD)

Fig. 29.2 Pain patterns of intercostal neuralgia; A dermatomal pattern, B “band-like” pattern (Image courtesy of Andrea Trescot, MD)

Fig. 29.3 Anatomy of the abdominal wall (Image by Springer)

T7 T8 T9

Thoracoabdominal nerves

T10 Anterior cutaneous nerves

T11 Subcostal nerve (T12) Iliohypogastric nerve (L1) Ilioinguinal nerve (L1) Femoral branch of the genitofemoral nerve Genital branch of the genitofemoral nerve

43 44 45 46 47 48 49 50 51 52 53

the front or back. If the subcostal nerve is involved, patients may believe they are suffering from gallbladder disease. The lower intercostal nerves actually travel around to the upper abdomen and can get trapped at the edge of the rectus abdominis (Fig. 29.3), the muscle that runs vertically from the bottom of the breastbone to the top of the pubic bones causing an anterior cutaneous nerve entrapment syndrome (ACNE syndrome) discussed in Chap. 42. Allodynia may be present. Trejjo-Gabriel-Galan et al. [1] described intercostal neuralgia caused by compression of the nerves from a fibrotic mass from a prior tuberculosis infection with chronic pleuritis.

Anatomy (Table 29.2)

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Intercostal nerves are the anterior rami of the first 11 thoracic spinal nerves. The anterior ramus of the 12th thoracic nerve travels to the abdomen as the subcostal nerve. The intercostal nerve travels from the foramen, under the inferior edge of the rib with the intercostal artery and vein, to the anterior chest or abdominal wall. Each intercostal nerve enters the corresponding intercostal space between the posterior intercostal membrane and the parietal pleura. The inner layer (the innermost intercostal muscle) does not exist at this point,

55 56 57 58 59 60 61 62 63

29 Intercostal Nerve Entrapment: Chest Wall t2.1

Table 29.2 Intercostal nerve anatomy

t2.2 t2.3

Origin

t2.4

General route

t2.5 t2.6 t2.7 t2.8 t2.9 t2.10 t2.11 t2.12 t2.13 t2.14 t2.15

Sensory distribution Motor innervation Anatomic variability Other relevant structures Fig. 29.4 Branches of the intercostal nerve (Image by Springer)

Anterior rami of the first 11 thoracic nerve roots; T12 anterior ramus is called the subcostal nerve (not technically an “intercostal” nerve because there is no 13th rib) Main intercostal runs in subcostal groove to the anterior chest or abdominal wall – four branches Gray ramus communicans connects to the sympathetic chain Posterior cutaneous innervates the muscles and skin of the paraspinal area Lateral cutaneous separates from the main nerve in the anterior axillary line and provides the skin sensation to the chest and abdominal wall T2 (sometimes also T3) lateral cutaneous nerve is called intercostobrachial, crosses axilla to medial arm Anterior cutaneous provides innervation of the abdominal wall, piercing the fascia of the abdominal wall at the lateral border of the rectus abdominis muscle Skin of the chest wall and abdominal wall Intercostal muscles and abdominal wall Collateral nerves connect with a variable number of nerves Subcostal groove, lateral rectus border

Posterior cutaneous

Spinal sensory (dorsal root ganglion)

Main intercostal Intercostal muscle

Dorsal root Ventral root

Gray ramus

Lateral cutaneous branch

Pleura

Anterior cutaneous branch

64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80

and only the parietal pleura is present on the inner side. The intercostal nerve then travels forward with the intercostal vessels in the subcostal groove of the corresponding rib between the innermost intercostal and internal intercostal muscles (Fig. 29.4). The first six intercostal nerves terminate within their respective intercostal spaces in the anterior chest. The seventh, eighth, and ninth leave their intercostal spaces anteriorly (after innervating the structures within) and pass to the anterior abdominal wall (Fig. 29.3). The main intercostal nerve runs in the subcostal groove contained in a fibrous sheath with the intercostal vessels. A typical intercostal nerve has four major branches [3] (Fig. 29.4). The gray ramus communicans consists of unmyelinated postganglionic fibers that interface with the sympathetic chain. The posterior cutaneous intercostal branch innervates the muscles and skin of the paraspinal area. The lateral cutaneous nerve courses with the main intercostal

nerve until it penetrates the intercostal muscles to arrive at the skin along the midaxillary line, and the anterior cutaneous nerve, providing innervation of the abdominal wall, pierces the fascia of the abdominal wall at the lateral border of the rectus abdominis muscle. At this point, the nerve, accompanied by an epigastric artery and vein, makes a sharp turn anteriorly to supply sensation to the anterior abdominal wall; the nerve passes through a firm fibrous ring as it transits the fascia, which results in a site of entrapment. Although traditionally considered unilateral structures, occasionally a given intercostal nerve will cross the midline to provide sensation to the contralateral side. There is also a collateral branch with a less predictable path, though it usually travels near the superior border of the rib below for at least part of its route. Usually, neighboring intercostal nerves communicate with each other via variable additional nerve branches.

81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

S. Olamikan et al. t3.1 t3.2 t3.3 t3.4

Table 29.3 Branches of intercostal nerves (see Fig. 29.4) Nerve Rami communicans

t3.5 t3.6

Collateral branch

t3.7 t3.8

Posterior cutaneous

t3.9 t3.10 t3.11

Lateral cutaneous branch

t3.12 t3.13 t3.14

Anterior cutaneous branch

t3.15 t3.16

Muscular branches

t3.17

Pleural branches Peritoneal sensory branches

t3.18 t3.19 t3.20

Anatomic course and function Connects the intercostal nerves to the sympathetic trunk Runs parallel to main nerve on upper border of the rib below Innervates the muscles and skin of the paraspinal area Innervates the skin on the side of the thoracic wall by dividing into anterior and posterior branches Terminal portion of the intercostal nerves, which innervate the skin near the midline of the chest Supply all the muscles of the intercostal spaces Sensory branches to the parietal pleura Similar to the pleural sensory branches but arise from the lower intercostal nerves and supply the abdominal peritoneum

100

The 12th intercostal nerve, also called the subcostal nerve, is unique in that it joins with the first lumbar nerve root, thus becoming part of the lumbar plexus (Table 29.3).

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Causes of Intercostal Neuralgia

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A variety of mild to severe diseases, disorders, and conditions may lead to the development of intercostal neuralgia. A chest or rib injury, such as a fractured rib or bruised chest sustained in a motor vehicle accident or participation in sports that involve high speeds or contact with other athletes (e.g., skiing, snowboarding, football, wrestling, and rugby), can be precipitating events. Thoracic shingles, along the path of the intercostal nerve, is the most common site of herpes zoster eruptions (55 % of the cases) [4]. In pregnancy, the increasing size of a growing baby alters the structure of the torso and rib cage such that pressure on the nerves between the ribs can occur. Intercostal neuralgia in pregnancy has been associated with pain and numbness in the ribs, abdomen, and back. Oesch et al. [5] documented 14 cases of intercostal neuralgia resulting from an impingement of the intercostal nerve at the level of the anterior rectus sheath, presenting as acute or chronic abdominal pain, also known as anterior cutaneous nerve entrapment (ACNE) syndrome, as described in Chap. 42. The authors were able to identify the correct diagnosis upon noting a positive Carnett test (pain intensification during palpation while contracting the abdominal muscles by raising the head while lying supine) and relief of pain after injecting local anesthesia at the point of maximal tenderness. The first intercostal nerve joins the brachial plexus through a small branch and is very small compared to the other intercostal nerves. The intercostobrachial nerve (ICBN) is the lateral cutaneous branch of the second intercostal nerve. It

98 99

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Fig. 29.5 Costochondral and chondrochondral junctions (Image courtesy of Andrea Trescot, MD)

crosses the axilla to the medial side of the arm and joins with a filament from the medial brachial cutaneous nerve. It then pierces the fascia and supplies the skin of the upper half of the medial and posterior part of the arm and axilla. A second intercostobrachial nerve is frequently given off from the lateral cutaneous branch of the third intercostal nerve, as well as sometimes from the fourth intercostal nerve. It supplies filaments to the axilla and medial side of the arm. Women who undergo a partial or radical mastectomy including an axillary lymph node dissection are at extreme risk for transection of this nerve. Subsequent pain and sensory deficit are localized to the axilla and/or arm in the distribution of innervation of this nerve [6]. In addition, the ICBN contributes to the innervation of the posterior forearm via connections with the posterior antebrachial cutaneous nerve and contributions to the upper anterior chest wall secondary to connections with the long thoracic nerve (see Chap. 30). The intercostal nerve also innervates the costochondral junction (where the rib attaches to the cartilage) and the chondrochondral junction (where the cartilage attaches to the cartilage above) (Fig. 29.5). These junctions are traumatized by

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29 Intercostal Nerve Entrapment: Chest Wall 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204

forces less than those necessary to fracture the rib itself (visualize how easy it is to pop the cartilage off the end of a barbequed spare rib), but will not show up on X-ray. The patient may describe a sharp, painful, slipping, or popping sensation in the anterior chest with movement; smokers, perhaps because they have poor blood flow to the tissues or because of chronic cough, seem to be most susceptible. Intercostal nerve injury has long been suspected as a complication of thoracotomy procedures. Rogers et al. [7] recorded motor evoked potentials from intercostals muscles in 13 patients undergoing thoracotomy. Intercostal nerves functioned normally before and after entering the pleural space. After the rib retractor was removed, there was a total conduction block in the nerve immediately above the incision in every patient. In the nerves above this, six had a total block, one had a partial block, and three had normal conduction. There was a total conduction block in the nerve immediately below the incision in all but one patient. Of the nerves below this, four had a total block, two had a partial block, and three had normal conduction. In a single patient where rib retraction was not employed, there was no impairment of the intercostal nerves throughout the operation. This study demonstrates that intercostal nerve injury occurs routinely due to rib retraction during thoracotomy. Wildgaard et al. [8] reviewed literature published from 2000 to 2008 on post-thoracotomy pain syndrome. Although the authors noted the limit of their ability to compare data from the various studies, they concluded that intercostal nerve injury does appear to be the most important pathogenic factor in chronic post-thoracotomy pain. Intercostal neuromas have also been identified as a source of pain after aesthetic and reconstructive breast implant surgery [2]. Shingles (also termed herpes zoster or zoster) is a disease caused by reactivation of a previous infection with the herpes zoster virus (the same virus that causes chicken pox, termed varicella zoster virus). After a chicken pox outbreak, the virus remains dormant for many years, usually in the roots of sensory nerves. Upon reactivation, it typically causes unilateral pain, burning, or tingling and a blistering rash in the sensory distribution of the nerve. Shingles can involve an intercostal nerve and results in a painful rash along the chest or abdominal wall. The risk of the disease increases with age, with about half of all cases occurring among men and women 60 years of age or older. Conditions that may trigger reactivation include stress, fatigue, weakened immune system, cancer, and HIV. As many as 25 % of people over 50 years old with shingles develop postherpetic neuralgia [9], where significant pain remains even after the rash has resolved. It can be very difficult to treat. Atypical chest pain is a common complaint among patients with complex regional pain syndrome (CRPS), formerly reflex sympathetic dystrophy (RSD) or causalgia. It is a chronic systemic disease characterized by severe pain, swelling, and changes in the skin. CRPS is an uncommon

form of chronic pain that usually affects an arm or leg. It normally develops after an injury, surgery, stroke, or heart attack, but the pain is out of proportion to the severity of the initial injury, if any. In CRPS affecting the arm, the intercostobrachial nerve (ICBN) has been implicated. It is connected to the brachial plexus and innervates the axilla, medial arm, and anterior chest wall. By connecting to the brachial plexus, the intercostobrachial nerve can become sensitized and produce atypical chest pain [6]. Rasmussen et al. [6] described evidence of ICBN sensitization in CRPS; they evaluated 40 patients and controls, finding that 94 % of CRPS patients reported a history of chest pain versus only 19 % of the controls.

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Physical Exam

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The physical examination will generally reveal minimal physical findings, unless there is a history of previous thoracic or subcostal surgery, or cutaneous findings of herpes zoster involving the thoracic dermatomes. In contrast to musculoskeletal chest wall pain syndromes, the patient does not attempt to splint or protect the affected area. Careful sensory examination of the affected dermatomes may reveal decreased sensation or allodynia. With significant motor involvement of the subcostal nerve, the patient may complain that his or her abdomen bulges out (Fig. 29.6). Pressure or stretching over the site of the nerve injury will typically reproduce symptoms (Video 29.1) (Fig. 29.7). Finally, the single most diagnostic test for intercostal neuralgia is an intercostal nerve block.

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Differential Diagnosis (Table 29.4)

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The diagnosis of intercostal neuralgia is typically one of exclusion. Cardiac disease and abdominal pathology should be ruled out. Although uncommon, thoracic disk herniation should be excluded. Intercostal nerve conduction study has proved to be an accurate technique in diagnosis of thoracic radiculopathy. Johnson et al. [11] performed intercostal nerve conduction studies in 161 patients, 80 of whom had subsequent posterior rhizotomy (81 % of those noted relief of pain with surgery). The only significant complication of the intercostal nerve conduction study is an 8.8 % incidence of pneumothorax. Pradhan and Taly [12] then developed a surface nerve conduction study for the intercostal nerves. Chen et al. described two patients with pain after shingles, presumed because of postherpetic neuralgia; both patients complained of burning, shooting, aching pain, and allodynia (consistent with neuropathic pain), localized to the site of the previous lesions. However, they were able to identify trigger points in the intercostal muscles just below the hyperesthetic region; injections of local anesthetic in

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220 221 222 223 224 225 226 227 228 229 230 231 232

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S. Olamikan et al. Table 29.4 Differential diagnosis of chest wall pain Cardiac pathology Myofascial pain

Rib fracture Costochondritis Pleurisy Hepatic disease Thoracic radiculopathy

Potential distinguishing features Positive EKG Palpable trigger points in the intercostal space (can be seen after shingles and mimic postherpetic neuralgia) [10] X-rays or bone scan will show fracture Tenderness to palpation at costochondral border Auscultation revels “rubbing” sound; chest X-ray shows pleural fluid Elevated liver function tests; enlarged liver by palpation and US Thoracic herniated disk by MRI

Table 29.5 Diagnostic tests for intercostal neuralgia Physical exam Diagnostic injection Ultrasound MRI/CT Arteriography X-ray Electrodiagnostic studies

Fig. 29.6 Bulging abdominal wall caused by intercostal nerve injury – arrow shows the abdominal wall bulge (Image courtesy of Andrea Trescot, MD)

Fig. 29.7 Palpation of the intercostal nerve (Image courtesy of Andrea Trescot, MD) 253 254 255 256 257 258 259

this region replicated the pain and then abolished the pain. Although the patients required several sessions of injections, both were virtually pain-free 6 months later. The authors felt that the relief was unlikely to be due to an intercostal nerve block, since they injected only 1 cc of local anesthetic at the superior (not inferior) edge of the rib. However, it is conceivable that, by relaxing the intercostal

Potential distinguishing features Tenderness over the rib or rib cartilage junction Intercostal nerve block is diagnostic Useful for nerve localization May show rib fracture Nondiagnostic May show rib fracture or calcification of cartilage May show conduction slowing

t4.1 t4.2 t4.3 t4.4 t4.5 t4.6 t4.7 t4.8 t4.9 t4.10 t4.11 t4.12 t4.13 t4.14

t5.1 t5.2 t5.3 t5.4 t5.5 t5.6 t5.7 t5.8 t5.9 t5.10 t5.11

muscle, they released an entrapment of the intercostal nerve (Table 29.5).

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I dentification and Treatment of Contributing Factors

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Chronic cough or increased abdominal girth (obesity, pregnancy, ascites) will put tension on the intercostal nerve. As noted above, smokers appear to be more likely to have rib nonunion or nonhealing cartilage issues. For thoracic disk herniations, percutaneous discectomy can offer relief. For chronic cough leading to costochondral pathology, the use of cough suppressants may help. Topical medications can give relief from postherpetic neuralgia.

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Intercostal Nerve Block Techniques

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The technique may be performed with landmark guidance, with fluoroscopic guidance, or with the use of ultrasound guidance. Radiological guidance is advised for neurolytic blocks. An intercostal nerve block with local anesthetic and corticosteroid serves as a diagnostic test for intercostal neuralgia and offers short-term (and potentially long-term) therapeutic relief. The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The deposteroid starts working in about 3–5 days, and its effect can last for several days to a few months. The injections can be done

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29 Intercostal Nerve Entrapment: Chest Wall

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a

b

c

d

Fig. 29.8 Landmark-guided intercostal nerve block. (a) The needle is placed perpendicular to the skin; (b) the needle is walked inferiorly; (c) stimulator is used to identify the nerve location at a higher voltage; (d)

stimulator is used at a lower voltage to identify the nerve (Image courtesy of Thialgo Nouer Frederico, MD)

about 1 week apart and only if needed. If the first injection does not relieve symptoms in about a week or 2, a second injection may be recommended.

The skin is first drawn cephalad about 1 cm with the palpating hand, and a 1.5–2 inch (5 cm) 22- to 27-gauge (for single-shot injection) short-bevel needle is introduced through the chosen site of entry at a 20° cephalad angle, with the bevel facing cephalad. The needle is advanced until it contacts the rib at a depth of less than 1 cm (for most nonobese patients). At this moment, a small amount of local anesthetic may be injected to anesthetize the periosteum. With the palpating hand holding the needle firmly and resting securely on the patient’s back, the injecting hand gently walks the needle caudally while the skin is allowed to move back over the rib. The needle is now advanced 3 mm, still maintaining the 20° tilt angle cephalad. A subtle “give” or “pop” of the fascia of the internal intercostal muscle may be felt, especially if a short-bevel needle is used. As the distance from the posterior aspect of the rib to the pleura averages 8 mm, advancement of the needle much beyond 3 mm increases the risk of pneumothorax. Paresthesia, while not actively sought, confirms needle placement. A peripheral nerve stimulator may aid in confirmation (Fig. 29.8). After

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Landmark-Guided Injection

287

The patient is placed in the prone position with the patient’s arm hanging loosely off the side of the table. Alternatively, this block can be done with the patient in the sitting or lateral position. Because of the overlapping innervation of the chest and upper abdominal wall, the intercostal nerves above and below the nerve suspected of subserving the painful condition will likely need to be injected as well. There are several sites for injecting an intercostal nerve, based on the location of pathology. Perhaps the most common site is at the angle of the rib about 7 cm lateral to the midline in adults. The landmark-guided (“blind”) injection should be reserved for those patients in whom the ribs and rib interspace can be reliably palpated.

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S. Olamikan et al.

Fig. 29.10 Fluoroscopic standard intercostal nerve injection; the needle is perpendicular to the nerve (Image courtesy of Miles Day, MD)

Fig. 29.9 Landmark-guided intercostal nerve block (alternative technique) – the needle is parallel to the inferior rib (Image courtesy of Andrea Trescot, MD)

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negative aspiration to ensure the needle is not in a blood vessel or intrapleural, local anesthetic and steroid are injected. It is desirable to block at least one intercostal nerve cephalad and one caudad due to overlapping innervation. Because the perpendicular approach has a significant risk of pneumothorax, an alternative approach places the needle more parallel to the bottom of the rib, sliding the needle up underneath the inferior edge of the rib (Video 29.2) (Fig. 29.9).

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Fluoroscopic-Guided Technique

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Use of fluoroscopy allows precise localization of the rib, potentially decreasing the risk of pneumothorax. The patient is positioned prone, supine, or lateral, depending on the site of pain. Instead of placing the needle perpendicular to the rib (Fig. 29.10), the needle can be placed obliquely at the inferior edge of the rib, sliding up underneath the edge of the rib (Fig. 29.11). A peripheral nerve stimulator will help to identify the nerve (Fig. 29.12), and contrast will confirm the perivascular spread of medication (Fig. 29.13).

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Ultrasound-Guided Technique

340

Use of ultrasound has dramatically decreased the risk of pneumothorax by allowing clear identification of the rib at the bedside. The patient can be positioned prone, lateral, or sitting. With the US probe placed vertically (Fig. 29.14a),

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Fig. 29.11 Fluoroscopic intercostal nerve injection; the needle is parallel to the inferior edge of the rib and then is slid up under the rib (Image courtesy of Andrea Trescot, MD)

Fig. 29.12 Fluoroscopic intercostal nerve injection; the needle is parallel to the inferior edge of the rib and then is slid up under the rib using a peripheral nerve stimulator (Image courtesy of Andrea Trescot, MD)


a

Fig. 29.13 Fluoroscopic intercostal nerve injection; the needle is parallel to the inferior edge of the rib and then is slid up under the rib using a peripheral nerve stimulator, with position confirmed by contrast (Image courtesy of Andrea Trescot, MD)

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the US images demonstrate three layers of the intercostal muscles (external, internal, and innermost) covering the pleural line (Fig. 29.14b) [13]. The neurovascular bundle lies between the internal and innermost intercostal muscles. The US probe is then placed horizontally (Fig. 29.15) or kept vertically (Fig. 29.16), and the needle is introduced in-plane.

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Neurolytic/Surgical Technique

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Intercostal nerve blocks can predict how a patient will respond to neurolytic techniques. A good response usually means the patient will benefit from neurolytic procedures as well. Fluoroscopic or ultrasound guidance improves the accuracy of these blocks and minimizes complications.

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Cryoneuroablation

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One of the most commonly described uses of cryoneuroablation has been for intercostal neuralgia. A 14-gauge Angiocath is introduced at the inferior border of the rib and advanced laterally; the stylet is then removed and the probe introduced underneath the inferior edge of the rib (Figs. 29.17 and 29.18). Byas-Smith and Gulati [14] reported on the use of cryoneuroablation of the intercostal nerves under US to treat post-thoracotomy pain. They were able to see the tip of the probe and the pleura, as well as the ice ball itself (Fig. 29.19). Green and colleagues [15] retrospectively looked at 43 patients with chronic chest pain treated with cryoneuroablation. The mean duration of pain prior to cryoneurolysis was 31 months (range 0.5 months to 24 years). Sixty percent of the patients reported a decrease in their pain immediately after the procedure. Three months after the

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b

Fig. 29.14 Ultrasound identification of the intercostal space, with the US probe placed vertically. (a) Location of probe; (b) US image showing the rib, intercostal space, and pleura (Images courtesy of Thialgo Nouer Frederico, MD)

cryoneurolysis, 50 % of the patients still reported significant pain relief.

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Radio-frequency Lesioning

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A case series by Engel [16] reports efficacy of conventional radio-frequency neurolysis in refractory intercostal neuralgia due to blunt chest wall trauma. Garcia Cosamalòn et al. [17] describe the use of CT-guided dorsal percutaneous radiofrequency rhizotomy for intercostal neuralgia. Akkaya and Ozkan [18] described good relief treating three intercostal neuralgia patients using pulsed radio frequency under US guidance.

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Fig. 29.15 Ultrasound injection of the intercostal space, from vertical orientation. PL pleural space, TP transverse process, PVS paravertebral space, IIM internal intercostal membrane (Images courtesy of Thialgo Nouer Frederico, MD)

Chemical Neurolysis Alcohol and phenol are the preferred agents for neurolytic procedures because they cause axonal degeneration within minutes and effectively interrupt the central transmission of pain impulses. Chemical neurolysis can result in significant pain relief in selected patients but should only be considered for refractory neuralgic pain due to intercostal nerve injury from rib fracture or post-thoracotomy and for refractory postherpetic neuralgia or c ancer invasion, since complications can include unintended spread of alcohol or phenol to the root cuff, epidural space, or cerebrospinal fluid (which could cause paralysis).

Fig. 29.16 Ultrasound injection of the intercostal space, from horizontal orientation. 1 needle, 2 rib (Images courtesy of Róbert Rapčan, MD)

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eripheral Nerve Stimulation P Peyravi et al. [20] report the use of subcutaneous peripheral neurostimulation for the treatment of severe chronic poststernotomy neuralgia.

388 401 389 402 390 403 391 404 392

eripheral Nerve Field Stimulation P McJunkin et al. [21] described a case of field stimulation used successfully to treat pain after a thoracotomy, with 80 % relief and dramatic improvement in mobility.

Neuromodulation

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Long-Term Epidural Nerve Catheter pinal Cord Stimulation S Graybill et al. [19] describe successful pain relief from post- Samlaska and Dews [22] report successful pain relief of thoracotomy pain with spinal cord stimulation in a single pregnancy-induced intercostal neuralgia using long-term case report, with a single lead placed midline up to T3. indwelling epidural analgesia.

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Fig. 29.17 Intercostal cryoneuroablation (Image courtesy of Andrea Trescot, MD)

Fig. 29.18 Location of the cryoprobe for intercostal neuralgia (Image courtesy of Andrea Trescot, MD)

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Surgical Decompression/Neurectomy

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Oesch et al. [5] reported results of a retrospective study of 14 patients with intercostal nerve impingement at the level of the anterior rectus sheath, called anterior cutaneous nerve entrapment (ACNE) (see Chap. 42). All patients were treated with neurectomy (surgical resection) at the point of exit of the nerve from the anterior rectus sheath. Minimal side effects were noted, but follow-up was limited. In a double- blind, randomized, controlled trial, Boelens et al. [23] studied 44 patients with anterior cutaneous nerve entrapment from 2008 to 2010. Half of the patients underwent neurectomy at the level of the abdominal wall. The other half underwent a sham surgical procedure. Of the 22 neurectomy patients, 16 reported a successful pain response at 6 weeks postoperatively. The authors concluded that neurectomy is an effective surgical procedure for pain reduction in anterior cutaneous nerve entrapment syndrome. Williams et al. [24] studied five consecutive patients who underwent neurectomy of one or more intercostal nerves and implantation of the cut nerve(s) into the latissimus dorsi or

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Fig. 29.19 Cryoneuroablation probe placed under ultrasound direction (Image courtesy of Christ Declerck, MD)

into the rib. Average follow-up after surgery was 8.8 months. Preoperatively, mean average pain level was 8 (range 7–9). Mean average pain level postoperatively was 2.2 (range 0–7). The authors concluded that neurectomy and implantation of the cut intercostal nerve into the latissimus dorsi or into the rib was an efficacious treatment for this small group of patients. Concerns still exist regarding the overall efficacy of neurectomy as a treatment for intercostal nerve impingement. Neurectomy complications include neuroma formation, which may result in worsened pain. According to Shapiro et al. [25], nerve transections of rat sciatic nerves performed by use of a scalpel or a CO2 laser resulted in neuroma formation in all cases.

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Complications

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Pneumothorax or penetration of peritoneum and abdominal viscera are potential complications. Absorption of local anesthetic from the intercostal space is rapid; toxicity is

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always a concern with multiple or continuous intercostal injections. Because the dural sheath can extend up to 8 cm laterally, there is a chance of spinal anesthesia and unexpected spread of chemical neurolytics into the spinal canal.

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Summary

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Intercostal neuralgia can cause severe, debilitating pain that may be difficult to treat. Causes include chest wall injury, pregnancy, abdominal impingement, and shingles. The syndrome may also occur iatrogenically following thoracotomy procedures, axillary node dissection, and breast implant surgery. The condition is also implicated in complex regional pain syndrome. When conservative treatments fail, the first line of more aggressive management consists of a series of anesthetic and corticosteroid nerve blocks. In patients who do not respond to repeat nerve blocks, cryoneuroablation or radio-frequency neurolysis may provide pain relief. Additional measures described in the literature include spinal cord stimulation, long-term epidural block, and neurectomy.

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References

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9. Gimenez-Mila M, Busquets C, Ojeda A, Fauli A, Moreno LA, Videla S. Neuropathic pain with features of complex regional syndrome in the upper extremity after herpes zoster. Pain Pract. 2014;14(2):158–61. 10. Chen SM, Chen JT, Kuan TS, Hong CZ. Myofascial trigger points in intercostal muscles secondary to herpes zoster infection of the intercostal nerve. Arch Phys Med Rehabil. 1998;79(3):336–8. 11. Johnson ER, Powell J, Caldwell J, Crane C. Intercostal nerve conduction and posterior rhizotomy in the diagnosis and treatment of thoracic radiculopathy. J Neurol Neurosurg Psychiatry. 1974; 37(3):330–2. 12. Pradhan S, Taly A. Intercostal nerve conduction study in man. J Neurol Neurosurg Psychiatry. 1989;52(6):763–6. 13. Sakai F, Sone S, Kiyono K, Imai S, Izuno I, Oguchi M, et al. High resolution ultrasound of the chest wall. RoFo: Fortschr Gebiete Rontgenstrahlen Nuklearmedizin. 1990;153(4):390–4. 14. Byas-Smith MG, Gulati A. Ultrasound-guided intercostal nerve cryoablation. Anesth Analg. 2006;103(4):1033–5. 15. Green CR, de Rosayro AM, Tait AR. The role of cryoanalgesia for chronic thoracic pain: results of a long-term follow up. J Natl Med Assoc. 2002;94(8):716–20. 16. Engel AJ. Utility of intercostal nerve conventional thermal radiofrequency ablations in the injured worker after blunt trauma. Pain Phys. 2012;15(5):E711–8. 17. Garcia Cosamalon PJ, Mostaza A, Fernandez J, Vinuela J, Mazabel M, Costilla S, et al. Dorsal percutaneous radiofrequency rhizotomy guided with CT scan in intercostal neuralgias. Technical note. Acta Neurochir (Wien). 1991;109(3–4):140–1. 18. Akkaya T, Ozkan D. Ultrasound-guided pulsed radiofrequency treatment of the intercostal nerve: three cases. J Anesth. 2013;27(6):968–9. 19. Graybill J, Conermann T, Kabazie AJ, Chandy S. Spinal cord stimulation for treatment of pain in a patient with post thoracotomy pain syndrome. Pain Phys. 2011;14(5):441–5. 20. Peyravi M, Capelle HH, Fischer S, Haverich A, Krauss JK. Subcutaneous peripheral neurostimulation for the treatment of severe chronic poststernotomy neuralgia. Stereotact Funct Neurosurg. 2011;89(4):253–7. 21. McJunkin TL, Berardoni N, Lynch PJ, Amrani J. An innovative case report detailing the successful treatment of post-thoracotomy syndrome with peripheral nerve field stimulation. Neuromodulation. 2010;13(4):311–4. 22. Samlaska S, Dews TE. Long-term epidural analgesia for pregnancy- induced intercostal neuralgia. Pain. 1995;62(2):245–8. 23. Boelens OB, van Assen T, Houterman S, Scheltinga MR, Roumen RM. A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome. Ann Surg. 2013;257(5):845–9. 24. Williams EH, Williams CG, Rosson GD, Heitmiller RF, Dellon AL. Neurectomy for treatment of intercostal neuralgia. Ann Thorac Surg. 2008;85(5):1766–70. 25. Shapiro S, Woodall B, Muller J. Comparative study of neuroma formation in the rat sciatic nerve after CO2 laser and scalpel neurectomy in combination with milliwatt CO2 laser “sealing”. Surg Neurol. 1989;32(4):281–4.

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Author Queries Chapter No.: 29

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AU1

Please provide department and organisation name for Sola Olamikan and provide department name for Andrea M. Trescot.

AU2

Please provide volume number for Ref. [4].

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