Intercostal Nerves are nerves arising from the spinal cord, just below the ribs. Some conditions can cause irritation or inflammation of these nerve roots leading to neuropathic pain which is referred to as Intercostal Neuralgia. The pain of Intercostal Neuralgia typically radiates along the chest wall and upper trunk. This can be an extremely troublesome condition to suffer from as the pain can be notoriously resistant to conservative measures at times.

• Viral Infections such as Varicella Zoster Infection which is known to cause Chickenpox and Shingles, can result in post viral intercostal neuralgia.
• Trauma to the chest wall or fracture of one or more ribs can be responsible.
• Entrapment of the Intercostal nerve by a tumor of the chest or abdomen. Has been associated with benign tumors as well.
• Iatrogenic- Surgeries which involve opening of the chest to access throat, lungs, heart or diaphragm, can result in Intercostal nerve injury as a surgical complication.
• Neuritis of the Intercostal Nerves- Neuritis, which refers to inflammation of a nerve or a group of nerves can cause Intercostal Neuralgia. The cause of neuritis may be bacterial, viral or immune modulated.
• Muscle pull or strain in the shoulders, chest wall or back can also be the cause.
• Idiopathic- when no clear cut cause is discernible.

• Primarily patients report of pain in the area of the rib cage.
• Patients may experience pain along the length of the ribs and sometimes patients complain of widespread pain spanning the entire chest wall radiating from the back to the chest.
• The pain of intercostal neuralgia is often described as a sharp, stabbing and aching pain. It is also described as a burning or a spasm like pain.
• The pain usually is sporadic but might get aggravated by activities like lifting, coughing, sneezing, turning and twisting of torso and laughing.
• Associated symptoms- These might include fever, itchiness, abdominal pain, tingling, numbness, restricted mobility and pain in the arms, shoulders and back.

The presentation of Intercostal neuralgia is often confused with a heart attack or some other heart ailment. Clinical examination is necessary as sometimes light pressure in the distribution of the intercostal nerves can bring about pain. The following tests can help us rule out the different causes of Intercostal Neuralgia. These are:-

• Chest x ray- Helps in delineating sources of chest and rib pain and even identify issues with airways, heart and lungs.
• Nerve conduction velocity testing-Assesses nerve damage and dysfunction.
• Electromyography-Helps in neuromuscular assessment
• Musculoskeletal ultrasound- High definition ultrasound can give a lot of detailed information on the state of the associated soft tissues.

Sometimes the symptoms of Intercostal Neuralgia subside on their own but many a times in patients this condition becomes chronic, causing persisting pain, very often tolerance towards pain medication often leading to low mood and poor quality of life.

• These include Non steroidal ant inflammatory medications like Naproxen and Etodolac.
• Anti-depressants have been tried in patients exhibiting signs of mood changes and depression.
• A vast majority of patients are put on Neuropathic medication like Gabapentin and Pregabalin which work by influencing the action of nerves causing pain.
• Topical application of Lignocaine patches and Capsaicin cream is also tried for some patients.

AT ALLEVIATE, for refractory cases not responding to any conservative measures, we first subject them to a Fluoroscopy or Ultrasound guided Intercostal Nerve Block. Following this appropriate medical management is initiated. The block comprises of a mixture of local anesthetic and a corticosteroid. Patients can have relief of pain for even upto several months following an Intercostal Nerve Block.

If a patient has had satisfactory pain relief with the Intercostal Nerve Block, we carry out a Radiofrequency Ablation of the affected nerves. This has seen to give lasting pain relief for even 2-3 years following the procedure.

Inputs from a Clinical Psychologist are added as a part of the Multidisciplinary approach and also keeping in mind the psychological impact of a Chronic condition like Intercostal Neuralgia causing relentless pain.

Some healthy lifestyle habits can help reduce the risk of Intercostal Neuralgia. These are:-

• Always wearing a seatbelt while driving
• Timely Vaccination for chickenpox
• Herpes and Shingles Vaccination for the elderly
• Use of protective sports equipment while playing contact sports.
• Good medical management of any existing Chronic Inflammatory diseases