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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.63 no.3b São Paulo Sept. 2005

https://doi.org/10.1590/S0004-282X2005000500011 

Intercostal nerve mononeuropathy: study of 14 cases

 

Mononeuropatia de nervo intercostal: estudo de 14 casos

 

 

Paulo Sergio S. dos SantosI; Luiz Antonio Lima ResendeII; Ronaldo G. FonsecaII; L. LemônicaI; Raul Lopes Ruiz JrIII; Antonio José M. CatâneoIII

IService of Anesthesiology, Botucatu School of Medicine, Unesp, Botucatu SP, Brazil
IIService of Neurology, Botucatu School of Medicine, Unesp, Botucatu SP, Brazil
IIIService of Thoracic Surgery, Botucatu School of Medicine, Unesp, Botucatu SP, Brazil

 

 


ABSTRACT

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.

Key words: intercostal mononeuropathy, EMG, etiology.


RESUMO

Este trabalho apresenta estudo retrospectivo de 14 pacientes com mononeuropatia de nervo intercostal (MNI), obtidos dentre 5.560 exames eletromiográficos, realizados de janeiro de 1991 até junho de 2004, em nosso Hospital Universitário. MNI foi encontrada em 14 pacientes, tendo como causas prováveis intervenções cirúrgicas torácicas em 6 (43%), neuropatia por herpes-zoster em 4 (28%), provável neurite de nervo intercostal em 2 (14%), neoplasia pulmonar em 1 (7%) e radiculopatia em 1 (7%). As principais causas de MNI de nosso Serviço são similares às da literatura. Os antidepressivos tricíclicos e anticonvulsivantes foram os fármacos mais utilizados no controle da dor.

Palavras-chave: mononeuropatia intercostal, EMG, etiologia.


 

 

The first descriptions of intercostal nerve mononeuropathy (INM) were reported by USA army surgeons treating patients with chronic pain after thoracotomy as a result of thoracic trauma during the Second World War1. There is an estimated 11 to 80% incidence of chronic pain after thoracotomy2, but chronic pain tends to reduce over time3. High doses of analgesics consumed during the first week after surgery may be a risk factor for pain after thoracotomy3. However, low-dose treatment of post-surgical pain induces the liberation of stress related chemical mediators, which may cause pulmonary, cardiovascular, metabolic and neuroendochrine disturbances4. Despite these clinical problems, intercostal nerves have been transferred to the brachial plexus to treat traumatic brachial plexopathy with minimal effects on pulmonary function5.

The first clinical descriptions related to Varicella zoster were in the XIX century6. Infection by Varicella zoster is also a common cause of INM7, usually presented as unilateral vesicular eruption in a belt-like distribution mainly on the thoracic sensory dermatomes, most cases preceded by pain and paresthesias. The prognosis is usually good, most cases presents complete recovery or significant improvement7. Atypical clinical presentations are described in imunosupressed patients7.

The objective of our study is to describe INM found in our Service, diagnosed by electromyography (EMG).

 

METHOD

A retrospective study was made of all patients diagnosed with INM by EMG between January 1991 and June 2004. Patients with insufficient clinical history and physical examination data were excluded.

EMG examinations were performed a) in the paravertebral muscles corresponding to the dermatome or myotome where clinical alterations had been reported or found by examination. Concentric needle electodes were inserted 1cm lateral to the corresponding vertebra’s posterior spinous process; or b) in the intercostal muscles, distal to the surgical scar or other visible skin lesion. Electrode insertion was slow, the examiner listening to respiratory muscle contraction sounds, and electrode progression was stopped when the first clear motor units were seen and heard on recruitment to avoid the pneumothorax. Analysis time was set to 10 ms/cm, filter band-pass to 10-10,000 Hz, sensitivity to 20 mV/cm (at rest), 200 mV/cm (slight effort) and 1 mV/cm (maximum effort). The exams were obtained using a 2-channel Nihon-Kohden Neuropack 2.

The EMG criteria for neurogenic process into the intercostal muscles were a) at rest: presence of fibrillations, positive sharp waves, and/or fasiculations; b) slight effort: elongated duration of motor unit potential; and c) maximum effort: increased amplitude of the motor unit potentials (above 5 mV) and different degrees of rarefaction of the interferential pattern.

 

RESULTS

There were 14 cases of INM diagnosed from 5,560 EMG exams (0.25%). Probable etiological diagnoses were a) thoracotomy (6 patients), post-herpetic infection (4), intercostals nerve neuritis (2), lung neoplasia (1), and radiculopathy (1). For the patient with lung neoplasia, impairment of bone, muscles, and intercostal nerve was by contiguity. In some patients with INM after thoracotomy, intercostal nerve impairment was at more than one level, resulting in multiple mononeuropathy (Fig 1). Two patients were diabetic, but no etiological relationship between their INM and diabetes could be found.

 

 

The most common drugs employed for pain treatment were tricyclic antidepressants (amitriptilin) and anti-epileptics (carbamazepine). Other drugs were used; they included non-steroid anti-inflamatories, dipirone, and tramadol. In one case, patient controlled analgesy was necessary; fentanil was employed.

 

DISCUSSION

Impairment of the intercostal nerves may occur in common clinical conditions such as diabetes8, less frequent pathologies such as neoplasies originating in the intercostal nerves9, or in rare affections, such as sarcoidosis10. Diabetic thoracoabdominal neuropathy usually presents in the 5th and 6th decade, manifests primarily as pain along single or multiple intercostal nerves and may mimic different conditions as coronary artery disease or apendicitis11. Recently it was published the second brazilian case of INM by benign schwannoma, in a patient with expansive nodular lesion of the 7th coster arch projecting within the left hemitórax12.

The more common INM etiologies found in our patients were thoracotomy (43%) and herpes zoster (28%); this is in agreement with literature2,3,7,13,14. Direct injury of the intercostal nerve during thoracic surgery is not needed for symptoms to appear, the use of ratcheted rib spreaders may induce INM some distance from the surgical site13. The main clinical problem related to INM is chronic pain that may become debilitating requiring multidisciplinary attention15. Recent published papers highlight the efficacy of anaesthetic block of intercostal nerves in acute16,17 or chronic18 pain profilaxy. In our patients pain control was possible using common drugs (amitriptine and carbamazepine). In only 1 case was patient controlled analgesy necessary.

As far as we know, this is the first description of INM in our country which has been confirmed by EMG. This serious clinical problem which frequently incapacitates has been overlooked in Brazil. More attention needs to be given to this problem. A multidisciplinary approach involving neurologists, pain specialists, and thoracic surgeons, could improve quality of life for our INM patients.

 

REFERENCES

1. Blades B, Dugan DJ. War wounds of the chest observed at the Thoracic Surgery Center, Walter Reed General Hospital. J Thorac Surg 1944; 13:294-306.        [ Links ]

2. Rogers ML, Duffy JP. Surgical alspects of chronic post-thoracotomy pain. Eur J Cardio-Thor Surg 2000;18:711-716.        [ Links ]

3. Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: a follow-up study. Acta Anesthesiol Scand 1999;43:563-567.        [ Links ]

4. Barros GAM, Lemonica L. Considerações sobre analgesia controlada pelo paciente em hospital universitário. Rev Bras Anestesiol 2003;53:69-82.        [ Links ]

5. Krakauer JD, Wood MB. Intercostal nerve transfer for brachial plexopathy. J Hand Surg (Am) 1994;19:829-835.        [ Links ]

6. Barensprung FGF. Die Gurtelkrankheit. Ann Char-Krankenh (Berl) 1861;9:40.        [ Links ]

7. Baringer JR, Townsend JJ. Herpesvirus infection of the peripheral nervous system. In Dyck P J, Thomas P K, Griffin J W, Low P A, Poduslo J F (eds) Peripheral neurophaty, 3rd Ed.2. Philadelphia: W B Saunders, 1993:1336-1338.        [ Links ]

8. Waxman SG, Sabin TD. Diabetic truncal polyneuropathy. Arch Neurol 1981;38:46-47.        [ Links ]

9. McClenathan JH, Bloom RJ. Ann Thorac Surg 2004;78:713-714.        [ Links ]

10. Reshad K, Sekine T, Tanaka F, Miura H. A case of intercostal neuropathy (Th 2-9) due to sarcoidosis. Nihon Kyobu Shikkan Gakkai Zasshi 1993;31:462-467 (abstract).        [ Links ]

11. Harati Y, Niaran E. Diabetic thoracoabdominal neuropathy: a cause for chest and abdominal pain. Arch Intern Med 1986;146:1493-1494.        [ Links ]

12. Rodriguez CA, Munhoz AHN, Zampier JA, Silva APG, Fustes OH. Benign intercostal nerve schwannoma simulating pulmonary neoplasm: case report. Arq Neuropsiquiatr 2004;62:1100-1103.        [ Links ]

13. Rogers ML, Henderson L, Mahajan RP, Duffy JP. Preliminary findings in the neurphysiological assessment of intercostal nerve injury during thoracotmy. Eur J Cardio-Thor Surg 2002;21:298-301.        [ Links ]

14. Baron R. Post-herpetic neuralgia case study: optimizing pain control. Eur J Neurol 2004;11S(Suppl. 1)S:3-11.        [ Links ]

15. Karmakar MK, Ho AM. Posthoracotomy pain syndrome. Thorac Surg Clin 2004;14:345-352.        [ Links ]

16. Matsota P, Livanios S, Marinopoulou E. Intercostal nerve block sith Bupivacaine for post-thoracotomy pain relief in children. Eur J Pediatr Surg 2001;11:219-222.        [ Links ]

17. Takamori S, Yoshida S, Hayashi A, Matsuo T, Mitsuoka M, Shirouzu K. Intraoperative intercostal nerve blockade for postthoracotomy pain. Ann Throrac Surg 2002;74:338-341.        [ Links ]

18. Doi K, Nikai T, Sakura S, Saito Y. Intercostal nerve block with 5% tetracaine for chronic pain syndromes. J Clin Anesth 2002;14:39-41.        [ Links ]

 

 

Received 22 December 2004, received in final form 16 March 2005. Accepted 6 May 2005.

 

 

Dr. Luiz Antonio Lima Resende - Department of Neurology and Psychiatry / Botucatu School of Medicine - 18618 Botucatu SP - Brazil. E-mail: luan_resende@uol.com.br

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