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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Slipping Rib Syndrome: A Case Report

Using an intercostal nerve block to aid diagnosis.

Slipping rib syndrome has been described for almost a century after first being detailed by Cyriax in 1919.1 Since then, a body of study and evidence has been accumulated regarding the pathophysiology of the syndrome. Mechanistically, it arises from the subluxation of the eighth, ninth, and tenth ribs from sudden hypermobility, usually sustained in some manner of trauma. Since these ribs do not articulate with the sternum, but rather, have loose fibrous connections to one another, they are susceptible to becoming “free floating” once these connections are disrupted and may impinge on the intercostal nerves and surrounding abdominal wall tissues and fascia. Due to this mechanism, a common physical exam finding is a positive “hooking maneuver” (see Figure 1), where pulling the lower ribs at the subcostal margin outward and upward will mimic the patient’s pain.

Despite being well described in the literature, slipping rib syndrome remains an elusive diagnosis with the combination of its relative obscurity, ambiguous presentation, and subtlety on even modern imaging techniques.2 To this effect, there are numerous case reports and a series of patients who have gone undiagnosed with prolonged and meandering clinical courses. Here, the authors present a case of slipping rib syndrome that went undiagnosed for 18 months; after an extensive workup in the pain clinic, using confirmation with diagnostic and therapeutic intercostal T9-T11 nerve block under fluoroscopy, a diagnosis was made.

Source: 123RFSlipping rib syndrome remains an elusive diagnosis with the combination of its relative obscurity, ambiguous presentation, and subtlety on even modern imaging techniques.

The Case

A 23-year-old previously healthy male student presented to the pain clinic after referral from his primary care provider. Eighteen months prior, the patient had been moving a large object when he felt a “crack and pop” resulting in immediate severe pain. Since then, the patient had experienced intermittent pain in his left upper quadrant (LUQ), with a sensation he described as “popping,” especially with certain abdominal movements, such as stretching his left flank. He had already undergone extensive workup in the prior 18 months.

He initially presented to his primary care physician (PCP), who referred him to outpatient physical therapy as well as prescribed several over-the-counter remedies, including hot and cold therapy and NSAIDs. The patient sought chiropractic treatment on his own which did not provide relief. He was then referred to a rheumatologist as well as a general surgeon. Multiple rheumatoid panels provided no evidence and he was referred to a general surgeon. The patient underwent a PO and IV contrast abdominal and pelvis CT, that showed a question of Spigelian hernia. As the symptoms continued with no relief, the patient underwent exploratory laparoscopy, which failed to identify any defect; the abdominal anatomy was normal. The patient was then referred to psychiatry but refused to follow through and was finally referred to the authors’ pain clinic by his PCP.

Image courtesy authorsFigure 1: Illustration of the "hooking maneuver."Image courtesy authorsFigure 2. Fluoroscopic image shows placement of intercostal block needles prior to injection.

At the clinic, the patient presents as a tall, thin, white young male, pleasant and eager to find results, with no obvious defect or deformity on initial inspection. On physical exam, he had a grossly tender LUQ on palpation and positive “hooking maneuver.” Initially, the patient was prescribed low dose gabapentin 300 mg PO QHS and gained some relief, but gabapentin was discontinued due to daytime somnolence and inability to focus on his schooling, even after reduction in dosage. He also had a trial of duloxetine 20 mg PO BID but reported gastrointestinal (GI) upset and intolerance. Failing medical management, the discussion of intervention with diagnostic and therapeutic block was approached with the patient, who agreed to proceed.

The patient underwent diagnostic and therapeutic intercostal T9-T11 nerve block in the clinic. No bony deformity (see Figure 2) was appreciated under fluoroscopy and the block was performed with combination 20 mg of Depomedrol diluted in 1.5 ml of 0.25% bupivacaine injected at each level. While monitored post-procedure, the patient reported immediate relief. On follow-up in the clinic, the patient reported over two weeks of approximately 80% relief before his pain gradually returned.

Given these positive findings, the authors identified slipping rib syndrome as the likely source of his pain and referred him to a thoracic surgeon. Upon review of the case and our findings, the surgeon agreed and the patient underwent surgical rib resection. During surgical exploration, the patient was found to have 9th and 10th costal cartilages that did not fuse with the costal margin and insinuated into the external oblique muscles. Summarily, these cartilages were resected with the anterior portion of the ribs. In the immediate postoperative period the patient reported being “sore,” but stated his pain was “nothing compared to before” and that his previous pain had resolved. On follow-up (3 months post surgery), the patient reported complete resolution of his pain.

Discussion

Patients with slipping rib syndrome often have an ambiguous presentation with an extensive list of differentials, including muscular strains, costochondritis, nerve entrapment, somatic dysfunction, bony fracture, GI disorders, hernias, and hepatosplenic conditions. Review of the literature shows frequent mention of poor awareness, misdiagnosis, and extensive unnecessary workup and clinical courses before proper diagnosis and treatment is made.2,3 For example, the clinical course of the patient presented herein spanned a year and a half of symptoms with evaluations by multiple specialists prior to referral to a pain clinic, and included dozens of clinic visits, a CT scam, and a diagnostic laparoscopy.

The importance of early detection and diagnosis cannot be understated. Proper evaluation should include a thorough history, as many times an initial direct or indirect traumatic event may be identified. The “hooking maneuver” reproducing the patient’s pain can also aid in diagnosis and is helpful to add to the common repertoire of physical exam findings used daily in the pain clinic. Diagnostic and therapeutic nerve blocks may be easily and safely performed in a clinic and have been recommended in the literature,4,5 as they may completely resolve slipping rib syndrome pain, even after only one block. Such blocks may also be crucial in confirming pathophysiology and involved anatomy of a patient’s pain, thereby aiding in clinical decision-making and possible surgical planning.

Risks for intercostal nerve block include local bruising, infection, pneumothorax, nerve damage, intravascular injection, and bleeding. The proper diagnosis and treatment, and if not referral, for patients with slipping rib syndrome provides a unique and important opportunity for pain clinics to aid the modern multidisciplinary approach to pain management.

Last updated on: November 7, 2018
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