Nineth Rib Syndrome after 10(th) Rib Resection

Area of Science:

• Pain Medicine
• Interventional Pain Management
• Surgical Case Reports

Background:

• 12th rib syndrome and 9th rib syndrome are characterized by neuropathic pain in the lower chest, upper abdomen, and flank.
• These conditions are often attributed to nerve impingement by the lower ribs.
• Previous spinal surgery and subsequent osteoporotic fractures can alter rib cage anatomy, potentially leading to rib-related pain syndromes.

Observation:

• A 74-year-old female presented with severe left-sided chest and abdominal pain (Numeric Rating Scale 7/10) following T12-L2 fixation and multiple osteoporotic compression fractures.
• Physical examination revealed a missing 10th rib and reproduction of pain upon palpation of the 9th rib, suggesting 9th rib syndrome.
• Imaging confirmed a severed left 10th rib, with suspected impingement of the 9th intercostal nerves by the remaining 10th rib tip due to rib cage deformation.

Findings:

• Ultrasound-guided 9th and 10th intercostal nerve blocks were performed, targeting the nerves around the severed 10th rib.
• Local anesthetics with triamcinolone were injected into the muscles beneath the 9th rib at the point of maximal tenderness.
• The patient reported significant pain reduction to Numeric Rating Scale 2/10 post-procedure.

Implications:

• This case demonstrates the successful management of 9th rib syndrome using intercostal nerve blocks in a patient with complex spinal history.
• It highlights the importance of considering rib-related neuropathic pain in patients with prior thoracic or spinal surgery and rib cage abnormalities.
• Intercostal nerve blocks offer a minimally invasive therapeutic option for refractory rib pain syndromes, potentially preventing the need for more invasive surgical interventions.