Intercostal Neuralgia Causes, Symptoms, Treatment, Ayurveda Concept

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Intercostal space is the space between any 2 ribs. There are many structures in this space which are attached to and passing through this space and ribs therein. The muscles adhering and connecting two ribs in this space are called intercostal muscles. These muscles are supplied with intercostal nerves. These nerves arise from the spinal cord and pass through these spaces.
Intercostal – in between the ribs
Neuralgia – nerve related pain / neuropathic pain

Intercostal neuralgia is the neuralgic pain involving these intercostal nerves. It can also be defined as ‘nerve pain’ that affects the area below the ribs. It is caused by many conditions. It causes severe pain in ribs, chest (thorax / chest wall or cavity), or upper region of the abdomen / trunk.
Read – Trigeminal Neuralgia: Ayurvedic Treatment, Medicines

Symptoms

Pain in the chest wall is the main symptom of intercostal neuralgia. The pain may be shooting, sharp, aching, radiating, stabbing or burning in nature. It usually occurs in a band that wraps around chest or abdomen. The pain can either be constant or intermittent. Numbness and tingling may be associated with pain. The pain may last long even after the causes have been removed or subsided.
Read – Brachial Neuritis: Ayurvedic Treatment, Medicines, Remedies

Location of pain –
Around the ribs
In the upper part of the chest and back
Other symptoms –
Squeeze – a squeezing kind of pain or pressure or discomfort can be experienced as if it is wrapping your chest from the front to the back
Tingling sensation
Numbness
Pain while breathing in and out

Pain aggravating factors –
Doing gentle physical activities like deep breathing, stretching etc- 
When you jump, laugh, cough and sneeze

Referred Pain – The pain may be referred to the shoulder blade, back, groin or lower part of the pelvis.
Pain of postherpetic neuralgia – Itching in the skin and extreme sensitivity in the skin (even to clothing) may be experienced in intercostals neuralgia of postherpetic neuralgia (caused by shingles virus).
Read – Visarpa: Causes, Types, Treatment, Medicines

Symptoms of severe form of intercostals neuralgia –
Involuntary twitching of muscles
Muscle atrophy
Pain as if struck by a lightning bolt
Paralysis
Loss of appetite

Causes

Inflammation of intercostal nerves
Irritation of intercostal nerves
Compression of intercostal nerves
Chest trauma
Nerve entrapment / compression of nerves
Nerve pressure
Viral infections (shingles)
Injury caused by a surgical procedure involving opening your chest (thoracotomy)
Pregnancy
Abnormal growths

Many times exact causes for this condition cannot be found. Such cases are called as idiopathic intercostal neuralgia.
Read – Clinical Case Study: Herpes Zoster – By Dr Rangaprasad Bhat

Conditions and injuries which tend to damage the intercostal nerves are as given below –PTPS / Post Thoracotomy Pain Syndrome – Thoracotomy is a surgical incision made between your ribs for surgical procedures to access the heart or lungs. This can cause injury / trauma to the intercostal nerve which will cause pain. It is found that about 50% of people who have undergone this develop PTPS. Also about 30% of people have pain 4-5 years after surgery. The pain in most cases is complained to be of mild degree and doesn’t interfere with daily activities.

Postherpetic Neuralgia – This condition occurs as a complication of shingles (occurs in those who have suffered from chickenpox in the past). Postherpetic neuralgia is a chronic condition. It may last long even after the shingles go away. About 30-60% people aged 60 and over who suffer from shingles will develop postherpetic neuralgia. If antiviral medications are started within 72 hours of developing shingles rashes one would not develop postherpetic neuralgia. Therefore one should see the doctor immediately if he or she suspects the appearance of shingles.
Read – Charaka Chikitsa Sthana: Visarpa Chikitsa 21st Chapter

Trauma – the intercostal nerves are damaged by traumatic injury. This leads to intercostal neuralgia.

Medical procedures – medical procedures such as mastectomy, chest tube placement etc might cause intercostal neuralgia.

When to see the doctor?

Chronic disease may impact one’s life to a great extent. It can cause extreme discomfort. Chronic pain may lead to reduced movements and poor quality of sleep and also might cause difficulty in breathing.

Intercostal neuralgia has similar symptoms with other serious health conditions including –Fractured ribs
Pleurisy
Heart or lung damage
Compression of vertebrae
Pulmonary embolism
Malignant cancer / tumors

Therefore it is important to see a doctor immediately and seek medical help. One should also see the doctor if symptoms of shingles are seen.
Read – Cancer- Ayurvedic Understanding And Hopeful Treatment Modalities

Diagnosis

Diagnose of intercostal neuralgia is conducted through thorough examination. Doctor would rule out other causes of pain before coming to the conclusive diagnosis of intercostal neuralgia. If pressing the space between your ribs or taking a deep breath causes pain it is likely that you have intercostal neuralgia.

The below mentioned tests may be recommended depending on symptoms –
Complete neurological examination
X-ray
Ultrasound
CT Scan
MRI
Read – Relationship Between Doshas And Nervous System

Prevention

Prevention of intercostal neuralgia is difficult since it is associated with many potential causes. Preventing the infection of wounds is the most effective preventive measure when thoracotomy is the cause of intercostal neuralgia. Appropriate anesthetics shall be used for this purpose.

Minimizing the risk of contracting infection is the effective preventive strategy when shingles is the cause of intercostal neuralgia. Shingles vaccine should be taken as it reduces the likelihood of shingles by about 51%. This vaccine also reduces the risk of pain from shingles to a great extent.
Read – Doshas And Ayurvedic Immunology

Treatment

Combinations of different kinds of treatments work best for many people. Treatment also depends on severity of symptoms and other associated medical issues.

Topical treatments – can provide temporary relief and they include capsaicin creams, skin patches, lidocaine gels or skin patches.

Medications
Medicines including aspirin, NSAIDs or low dose narcotics might relieve pain to a certain extent but might not relieve them totally.
Antidepressants like amitriptyline, desipramine, duloxetine or imipramine are useful sometimes to treat nerve-related pain in intercostal neuralgia.
Anticonvulsant medications like carbamazepine, gabapentin, pregabalin etc shall be prescribed.
Opoid painkillers like tramadol oxycodone or morphine may help in relieving nerve pain.
Opiod-aspirin or Opiod-acetaminophen may be prescribed to relieve pain.

Procedures
Intercostal nerve block – It is an injection which is a combination of local anesthetic with corticosteroids. This will help to reduce inflammation and also to relieve pain. 
Thoracic epidural injection – is an anti-inflammatory medication injected around the spinal cord.
Pulsed radiofrequency – is a procedure to provide short-term pain relief using an electrode needle.

Other treatment
Relaxation therapy
Cognitive and behavioral therapy
Physical / occupational therapy
Yoga and meditation

One should try to be physically active as much and as regularly as possible. This will help in keeping the muscles strong and healthy. In severe pain avoid physical activity. This might cause loss of muscle strength. To avoid this physical and occupational therapy is done. Heat and cold treatments also may be used to provide pain relief. 
Read – Health Benefits Of Yoga: Mind And Body

Outlook
There are many causes for intercostal neuralgia which includes infections, cancer, trauma, inflammatory conditions etc. It may be difficult to treat this condition. Some underlying causes will not respond to routine treatment options. Some treatment and preventive strategies will work but not as a rule. Different combinations might work for different people. If untreated, this condition can cause several complications. They include –
Loss of sleep
Low appetite
Anxiety
Depression

Your doctor may refer you to a pain management specialist if the pain and its intensity are not being managed.

Research

Case Study – One of the common complications related to injury of the intercostal nerve is PTPS – Post-Thoracotomy-Pain Syndrome. During this surgery the thoracodorsal and long thoracic nerves can get injured. A study showed that jerks of latissimus dorsi muscle and intercostal neuralgia were reported after posterolateral thoracotomy.

In patients with herpes zoster intercostal neuralgia is the most common complaint. It might also be an initial symptom of very serious diseases such as atraumatic spinal fracture. This might lead to serious consequences if not diagnosed and treated early. But in ankylosing spondylitis with atraumatic vertebral fractures severe intercostal neuralgia is rarely reported as the first symptom. Severe intercostal neuralgia is an early indicator of spinal fractures. Spinal magnetic resonance imaging is crucial for the diagnosis of this condition. (B)

A study – MRN i.e. Magnetic Resonance Neurography is a useful diagnostic algorithm of intercostal neuralgia. MRN positive cases demonstrate favorable treatment response to perneural injections and subsequent surgical management. This MRN has diagnostic utility and efficacy in intercostal neuralgia. This study demonstrates that MRN offers a superior visualization of pathology in intercostal neuralgia. It also would confirm that the treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency. (C)

Ayurveda Concept

Parsva Shula Chikitsa – The signs and symptoms of a painful condition explained by Master Sushruta by the name ‘Parsva Shula’ can be correlated with intercostal neuralgia due to the resemblance in symptoms of both these diseases. Parsva shula is also compared to pleurisy and pleurodynia which are similar painful conditions and are part of differential diagnosis with intercostal neuralgia.
Read – Shoola Types, Symptoms, Treatment, Medicines, Remedies

Other treatment
Anti-Vata measures – Pain in intercostal neuralgia is caused by vata aggravation. This aggravated vata should be controlled at first. Vata mitigating medicines, diet and therapies and lifestyle changes should be included in the treatment. This will ease out tingling sensation and numbness associated with the disease.
Pain of this condition worsens when you indulge in activities like stretching, jumping, laughing, coughing and sneezing. These activities will increase vata and vata will further increase the pain. Neural pain and neuralgia in Ayurveda is correlated with signs and symptoms of aggravation of vata.
Read – Charaka Vatavyadhi Chikitsa 28th Chapter
Pakshaghata and Mamsagata Vata Chikitsa – The other symptoms like involuntary twitching of muscles, atrophy of muscles, lightning pain, and paralysis are also caused due to vata increase. To be specific, the treatment strategies of pakshaghata and mamsagata vata can be adopted in the treatment of intercostal neuralgia.
Read – Vata Disorders (Vatavyadhi): Definition, Causes, Symptoms
Visarpa Chikitsa – done in case of postherpetic neuralgia associated with intercostal neuralgia.
Bhagna Chikitsa – done if intercostal neuralgia is caused due to trauma to the nerves.
External therapies – like shirodhara and other oil therapies done over the head to control vata and also to relieve pain.
Pitta relieving remedies and herbal purgation – If there is severe burning sensation associated with intercostal neuralgia along with pain association of pitta along with vata should be considered and pitta alleviating and flushing remedies should be adopted. Therapeutic purgation is an ideal pitta relieving measure. Other pitta alleviating medicines, diet and lifestyle changes shall be included in the treatment. Tikta ghrita – ghee prepared with bitter tasting herbs are ideal remedies for oral consumption.
Rakta Prasadana – blood purifying medicines, diet and therapies should be included in the treatment plan.
Click to Consult Dr Raghuram Y.S. MD (Ayu)