Intercostal Neuralgia

What the intercostal nerves do

There are 12 pairs of thoracic nerves. Eleven run between the ribs as intercostal nerves, with the twelfth below the last rib. Each carries sensation from a band of skin (a dermatome) wrapping from the spine around to the front of the chest or abdomen, and controls the muscles between the ribs used in breathing. Irritation anywhere along a nerve causes pain in its band.

Symptoms

• Burning, sharp, stabbing or shooting pain along the ribs
• Pain wrapping around the chest or upper abdomen in a band, usually on one side
• Pain worse with deep breaths, coughing, sneezing, laughing, twisting or reaching
• Tenderness between the ribs
• Numbness, tingling or extreme sensitivity of the skin, where even clothing hurts (allodynia)
• Pain may be felt in the upper abdomen with lower intercostal nerves, mimicking digestive problems

Causes

Shingles and postherpetic neuralgia

Shingles commonly affects thoracic nerves. Pain often starts days before the rash. In some people, especially those over 60, pain continues for months after the rash heals, called postherpetic neuralgia.

Surgery

• Thoracotomy (open chest surgery) and keyhole chest surgery
• Mastectomy and breast surgery
• Heart surgery through the breastbone
• Chest drain insertion

Persistent post-surgical nerve pain is common after chest surgery.

Injury

• Rib fractures and bruising
• Blunt chest trauma
• Repetitive strain or severe coughing

Spine problems

Herniated thoracic discs, arthritis, vertebral compression fractures and, rarely, tumors can compress nerve roots as they leave the spine.

Other causes

• Pregnancy, from the expanding rib cage and abdomen
• Diabetes and other neuropathies
• Slipping rib syndrome
• Inflammation or tumors along the nerve

Conditions with similar symptoms

Diagnosis

1. Rule out serious causes: ECG, blood tests and chest X-ray for heart and lung problems where appropriate.
2. Examination: tenderness along the rib, sensory changes in a band, reproduction of pain with pressure or movement.
3. Imaging: X-ray, CT or MRI of the chest or thoracic spine to look for fractures, disc problems or tumors.
4. Diagnostic intercostal nerve block: if a local anesthetic injection relieves the pain, the diagnosis is supported.

Treatment

Medicines

• Simple pain relief: acetaminophen (paracetamol) or NSAIDs at label doses, which help inflammation-related pain more than nerve pain
• Nerve pain medicines: amitriptyline, duloxetine, gabapentin or pregabalin, as recommended in NICE neuropathic pain guidance
• Topical treatments: lidocaine patches or capsaicin cream over the painful area
• Antivirals for acute shingles, ideally within 72 hours of the rash

Procedures

• Intercostal nerve blocks: local anesthetic, often with steroid, injected near the nerve under ultrasound guidance. Relief can last weeks to months
• Pulsed radiofrequency or cryoablation for persistent pain
• Thoracic epidural or paravertebral injections for nerve root causes

Other approaches

• Physical therapy, posture correction and gentle breathing and stretching exercises
• Heat or cold packs
• TENS (transcutaneous electrical nerve stimulation)
• Psychological pain management for chronic pain

Outlook

Pain from injuries and acute shingles often settles within weeks to months. Post-surgical pain and postherpetic neuralgia can persist longer but usually improve with a combination of treatments. Getting the shingles vaccine reduces the risk of shingles and postherpetic neuralgia in adults 50 and older.

Frequently asked questions

What does intercostal neuralgia feel like?

It usually feels like burning, stabbing or shooting pain along the ribs, often wrapping around one side of the chest or upper abdomen. It is often worse with deep breathing, coughing or twisting, and the skin may be numb or very sensitive.

What causes intercostal neuralgia?

Common causes are shingles, chest or breast surgery, rib fractures or chest injury, and pinched nerves in the thoracic spine. Pregnancy, diabetes and, rarely, tumors can also cause it.

How is intercostal neuralgia treated?

Treatment includes nerve pain medicines such as amitriptyline, duloxetine, gabapentin or pregabalin, lidocaine patches, and intercostal nerve blocks. Physical therapy, heat and TENS may help. Shingles is treated with antivirals early.

How long does intercostal neuralgia last?

It depends on the cause. Pain after an injury or acute shingles often improves within weeks to a few months. Postherpetic neuralgia and post-surgical nerve pain can last months or longer but usually respond to treatment.

How can I tell intercostal neuralgia from heart pain?

You cannot always tell from symptoms alone. Intercostal neuralgia tends to be burning or stabbing along a rib and worse with movement or breathing, while heart pain is often pressure-like and linked to exertion. New chest pain should be checked urgently to rule out heart problems.