12th rib syndrome....again?

[epidural man]

So in Sluijter's Radiofrequency book, he talks about a thing called 12th rib syndrome. I had never heard of it before this.

He says you should rule this out, or at least check for it since it is so easily treatable.

Anyway, I started paying attention.

Since then, I have seen 5 people with what I think was this diagnosis. They all presented with lower quadrant abdominal pain and some complained of some associated mid back pain. All had completely negative workups. On exam, they were all exquisitely tender along the 12th rib. Each one of them have responded very well with diagnostic block and pulsed RF - despite the fact that I have no idea what RF dose they recieved.

Anyway, today my fellow approaches with his presentation - another lower quadrant abdominal pain. I have to ask - "is she tender along the rib?" He doesn't know - he didn't check. So I examine her - and wow....very tender along the twelth rib - and this was surprising to her because her only complaint was abdominal pain. (I have found that in almost every case, the patient had no idea the rib was painful.)

Anyway, has anyone else found this?

Interesting, today was the first girl. It is described to occure 3:1, men:women. Cool that my experience matches that.

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[Ligament]

Yes I have seen 12 rib syndrome pretty often. More often in women actually. It occurs in old folks who have lost spinal column height and this causes the 12th rib to rub against the iliac crest. I usually just need to do 1 or 2 intercostal nerve blocks and good to go. Recently did a thermal RF on the 12th intercostal nerve/subcostal nerve on an older guy who could not finish a round of golf due to the pain. He is doing great now.

 

[clubdeac]

I have seen this several times. Also known as "slipped rib syndrome" or "rib tip syndrome" I believe. Tried pulsing the T11/12 DRG without success. Where along the ICN are you ablating? I would like to try that. What does Sluijter say to do for it? It's primarily a somatic pain and not neuropathic so I wasn't surprised when pRFA didn't work.

 

[Ligament]

I have seen this several times. Also known as "slipped rib syndrome" or "rib tip syndrome" I believe. Tried pulsing the T11/12 DRG without success. Where along the ICN are you ablating? I would like to try that. What does Sluijter say to do for it? It's primarily a somatic pain and not neuropathic so I wasn't surprised when pRFA didn't work.

I put two 18 ga 10mm active tip needles parallel to the ICN at roughly the level of the rib angle. Did this after getting an intercostal neurogram to outline the nerve. Made sure I got good sensory and motor stim first. Then made lots of burns. It hurt a lot, pain went right into belly. Nurse was scared. Pain is now gone and he is golfing. BTW, I did the 11th and 12th ICNs...not just the 12th as I said above.

I don't know if this was the best way to do it or not.

I'll see if I can pull up the images.

 

[clubdeac]

Cool thanks ligamemt, and if u can find images that would be awesome, gracias

I put two 18 ga 10mm active tip needles parallel to the ICN at roughly the level of the rib angle. Did this after getting an intercostal neurogram to outline the nerve. Made sure I got good sensory and motor stim first. Then made lots of burns. It hurt a lot, pain went right into belly. Nurse was scared. Pain is now gone and he is golfing. BTW, I did the 11th and 12th ICNs...not just the 12th as I said above.

I don't know if this was the best way to do it or not.

I'll see if I can pull up the images.

 

[painstop]

It would make sense that if TAP blocks (anterior rami of T7-L1) work for lower abdominal surgeries then neurolytic (whether thermal RF or chemical neurolysis) intercostal nerve blocks would also help with pain radiating to the abdomen since they're both targeting the lower thoracic peripheral nerves...interesting

 

[drf]

It would make sense that if TAP blocks (anterior rami of T7-L1) work for lower abdominal surgeries then neurolytic (whether thermal RF or chemical neurolysis) intercostal nerve blocks would also help with pain radiating to the abdomen since they're both targeting the lower thoracic peripheral nerves...interesting

There was a thread about phenol TAP blocks recently. Still haven't found a Cancer pt to try it on.

 

[knoxdoc]

Is this the same as costoiliac impingement syndrome? If so, I've seen it several times in old, osteoporotic, kyphotic folks. I usually try a soft corset - I didn't know there were any procedures that could be done other than rib resection.

 

[Ligament]

Is this the same as costoiliac impingement syndrome? If so, I've seen it several times in old, osteoporotic, kyphotic folks. I usually try a soft corset - I didn't know there were any procedures that could be done other than rib resection.

Yes it is basically the same thing. You can RF the 11th and 12 intercostal nerves or just block them sometimes will do the trick. I've rarely needed to go to RF.

 

[ParaVert]

Agreed. I find that infiltrating around the periosteum of the iliac crest (a glorified TPI) does pretty well. I've never tried any denervation procedures, either neurolytic injectate or RF, haven't needed to.

 

[epidural man]

Agreed. I find that infiltrating around the periosteum of the iliac crest (a glorified TPI) does pretty well. I've never tried any denervation procedures, either neurolytic injectate or RF, haven't needed to.

You may be describing a cluneal nerve block. I have seen that nerve entraped a handful of times - and fixes the back pain. Cyro works well on that nerve.

 

[MFMRN]

I sincerely apologize to forum members for misrepresenting myself in joining or violating site rules, but here goes. I'm writing about my own case because this is the page I finally landed on while trying to find someone in Philadelphia (very small medical backwater) who knows what this condition is and how to treat it. I actually am a medical professional- a nurse with over 20 years of experience in Perinatal Medicine. However that fact has helped me not a bit. Short version is I have a single curve thoracolumbar scoliosis of approx 30 degrees and also injured myself 10 yrs ago while jumping feet first into the water from cliffs. I had whiplash and very unstable-feeling sternum for months, but the main thing has been the recurring slipping 12th rib (posterior) which sometimes "freezes" while out of place, other times just pops in and out multiple times daily. While it's out I have muscle spasms from hip through scapulae and up to the neck. I also have pretty bad GERD (related??) resulting in Barrett's, since about 2 yrs post injury. I have described the feeling of this rib popping in and out to a back surgeon, 2 chiropractors, and a PT at a very highly regarded rehab institute. All basically responded with some version of, "haha, ribs don't pop in and out (stupid OB nurse)". Any suggestions about who I should go to and what to say to be taken seriously and perhaps even treated in some way described above? This is getting old. Thanks. Hopefully the moderator doesn't delete this because I'm here seeking advice, but it's worth a shot.

 

[willabeast]

I sincerely apologize to forum members for misrepresenting myself in joining or violating site rules, but here goes. I'm writing about my own case because this is the page I finally landed on while trying to find someone in Philadelphia (very small medical backwater) who knows what this condition is and how to treat it. I actually am a medical professional- a nurse with over 20 years of experience in Perinatal Medicine. However that fact has helped me not a bit. Short version is I have a single curve thoracolumbar scoliosis of approx 30 degrees and also injured myself 10 yrs ago while jumping feet first into the water from cliffs. I had whiplash and very unstable-feeling sternum for months, but the main thing has been the recurring slipping 12th rib (posterior) which sometimes "freezes" while out of place, other times just pops in and out multiple times daily. While it's out I have muscle spasms from hip through scapulae and up to the neck. I also have pretty bad GERD (related??) resulting in Barrett's, since about 2 yrs post injury. I have described the feeling of this rib popping in and out to a back surgeon, 2 chiropractors, and a PT at a very highly regarded rehab institute. All basically responded with some version of, "haha, ribs don't pop in and out (stupid OB nurse)". Any suggestions about who I should go to and what to say to be taken seriously and perhaps even treated in some way described above? This is getting old. Thanks. Hopefully the moderator doesn't delete this because I'm here seeking advice, but it's worth a shot.

12 rib does exist, it is usually described as inflammation of the end of the rib. usually responds to NSAIDS. i would beware of having rib removed. i had an excellent surgeon do this on a fairly young woman years ago. developed a hernia. had mesh placed. chronic pain after mesh placed. i have never tried an IC ablative procedure because i read somewhere that IC nerves have the highest incidence of neuropathic pain after an ablation. that was before pulsed RF.

 

[bedrock]

I sincerely apologize to forum members for misrepresenting myself in joining or violating site rules, but here goes. I'm writing about my own case because this is the page I finally landed on while trying to find someone in Philadelphia (very small medical backwater) who knows what this condition is and how to treat it. I actually am a medical professional- a nurse with over 20 years of experience in Perinatal Medicine. However that fact has helped me not a bit. Short version is I have a single curve thoracolumbar scoliosis of approx 30 degrees and also injured myself 10 yrs ago while jumping feet first into the water from cliffs. I had whiplash and very unstable-feeling sternum for months, but the main thing has been the recurring slipping 12th rib (posterior) which sometimes "freezes" while out of place, other times just pops in and out multiple times daily. While it's out I have muscle spasms from hip through scapulae and up to the neck. I also have pretty bad GERD (related??) resulting in Barrett's, since about 2 yrs post injury. I have described the feeling of this rib popping in and out to a back surgeon, 2 chiropractors, and a PT at a very highly regarded rehab institute. All basically responded with some version of, "haha, ribs don't pop in and out (stupid OB nurse)". Any suggestions about who I should go to and what to say to be taken seriously and perhaps even treated in some way described above? This is getting old. Thanks. Hopefully the moderator doesn't delete this because I'm here seeking advice, but it's worth a shot.

This forum is not for medical advice.

I would recommend an outpatient pain consult at an academic university pain clinic in Philadelphia.

 

[Doctodd]

find someone who does prolotherapy to try and tighten up the "dislocating rib". Physical therapy may also help.

 

[Extralong]

Wow, cool, I have to read up on this a bit.

 

[ampaphb]

Prolo is hocus pocus mumbo jumbo. Look at the literature for all their "indications". Find me one that has ever survived RCT scrutiny.

For that matter, find me one that demonstrates the therapy does what it claims to do - sclerose, and as a result tighten up loose joints. No x-ray evidence. No histologic evidence.

Prolo is amongst our generation's best medical scams. There's a reason why patients have to pay cash for the therapy.

 

[willabeast]

Prolo is hocus pocus mumbo jumbo. Look at the literature for all their "indications". Find me one that has ever survived RCT scrutiny.

For that matter, find me one that demonstrates the therapy does what it claims to do - sclerose, and as a result tighten up loose joints. No x-ray evidence. No histologic evidence.

Prolo is amongst our generation's best medical scams. There's a reason why patients have to pay cash for the therapy.

i think prolo acts as a mild neurolytic. but i do not think it is a scam. anymore than anything else. i would post a few but then every one's ox is gored

 

[ampaphb]

That would be reasonable if practitioners targeted nerves. They don't. They inject it into joints, ligaments, and tendons, claiming that it will strengthen these structures.

Sent from my SAMSUNG-SM-G920A using SDN mobile

 

[willabeast]

That would be reasonable if practitioners targeted nerves. They don't. They inject it into joints, ligaments, and tendons, claiming that it will strengthen these structures.

Sent from my SAMSUNG-SM-G920A using SDN mobile

true - however some if not all of those structures are innervated. see this
http://www.ncbi.nlm.nih.gov/pubmed/11398848

Autonomic innervation of tendons, ligaments and joint capsules. A morphologic and quantitative study in the rat.
Ackermann PW1, Li J, Finn A, Ahmed M, Kreicbergs A.
Author information

 

[melancholy]

Prolo is hocus pocus mumbo jumbo. Look at the literature for all their "indications". Find me one that has ever survived RCT scrutiny.

For that matter, find me one that demonstrates the therapy does what it claims to do - sclerose, and as a result tighten up loose joints. No x-ray evidence. No histologic evidence.

Prolo is amongst our generation's best medical scams. There's a reason why patients have to pay cash for the therapy.

U of W now has a local insurance provider covering prolotherapy for knee OA and lateral epicondylitis. small start, but it's an acknowledgement that they feel the research is improving to show some benefits in a more controlled setting.

Ann Fam Med. 2013 May-Jun;11(3):229-37. doi: 10.1370/afm.1504.
Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial.
Rabago D1, Patterson JJ, Mundt M, Kijowski R, Grettie J, Segal NA, Zgierska A.
Author information

• 1Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53715, USA. [email protected]

Erratum in

• Ann Fam Med. 2013 Sep-Oct;11(5):480.

Abstract
PURPOSE:
Knee osteoarthritis is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. We conducted a 3-arm, blinded (injector, assessor, injection group participants), randomized controlled trial to assess the efficacy of prolotherapy forknee osteoarthritis.

METHODS:
Ninety adults with at least 3 months of painful knee osteoarthritis were randomized to blinded injection (dextrose prolotherapy or saline) or at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed additional treatments at weeks 13 and 17. Exercise participants received an exercise manual and in-person instruction. Outcome measures included a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points); knee pain scale (KPS; individual knee), post-procedure opioid medication use, and participant satisfaction. Intention-to-treat analysis using analysis of variance was used.

RESULTS:
No baseline differences existed between groups. All groups reported improved composite WOMAC scores compared with baseline status (P <.01) at 52 weeks. Adjusted for sex, age, and body mass index, WOMAC scores for patients receiving dextrose prolotherapy improved more (P <.05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 ± 3.5 vs 7.6 ± 3.4, and 8.2 ± 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference. Individual knee pain scores also improved more in theprolotherapy group (P = .05). Use of prescribed postprocedure opioid medication resulted in rapid diminution of injection-related pain. Satisfaction with prolotherapy was high. There were no adverse events.

CONCLUSIONS:
Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritiscompared with blinded saline injections and at-home exercises.

https://www.ncbi.nlm.nih.gov/pubmed/23690322

 

[melancholy]

That would be reasonable if practitioners targeted nerves. They don't. They inject it into joints, ligaments, and tendons, claiming that it will strengthen these structures.

Sent from my SAMSUNG-SM-G920A using SDN mobile

long way to go, but attempts have been made to try and objectify this purported benefit:

https://www.ncbi.nlm.nih.gov/pubmed/10710805

https://www.ncbi.nlm.nih.gov/pubmed/20308509 (attempted to using U/S imaging to measure changes in Achilles tendon appearance and thickness)

 

[melancholy]

You may be describing a cluneal nerve block. I have seen that nerve entraped a handful of times - and fixes the back pain. Cyro works well on that nerve.

There are apparently multiple cluneal nerves. how do you differentiate or come to the decision of a cluneal nerve block vs other back pain conditions/symptoms? would like to know.

 

[Doctodd]

looks like i opened up pandora's box.....and i dont even really do prolo. Ok....well then find another treatment for "lax ligaments"....if they exist, which may now be disputed.

 

[melancholy]

Sorry about that for getting off topic.

For the record, I have no opinion on the use of prolotherapy for what this condition and forum discussion is about and based upon what I am hearing, I am skeptical it would be helpful given what it is supposed to do. I just wanted to provide some additional information that others may not be aware of. carry on.

PS - EDS type 3 really does exist.. at least that's what the geneticists tell me LOL. evaluation for ligament laxity for patients that seem to have diffuse pain that doesn't quite fit FMS or myofascial pain in itself is helpful and may explain some accelerated areas of degenerative changes after trauma, accidents, falls, etc.

 

[HighPercentile]

FWIW; a self-summarized case study. Veterinarian here with 12th Rib; chronic since 6/16/07. With my lifelong history of nephrolithiasis, the initial workup was primarily urogenital but negative all the way through. Although it began on my left, after about 10 weeks it "jumped" across to my right side and has continued in that pattern ever since. With no rationale, every few days, weeks, or months the dull ache or stabbing pain immediately transfers from one side to another and has never been bilateral. Month turned to years in my case--began with localized corticosteroid injections near trigger points-->other various regional nerve blocks-->pulse radiofrequency-->spinal cord stimulator implant, and of course various PO medications throughout as well as trips to Mayo, Cleveland Clinic, etc. Circa 2009 I did see Dr. Tamer Elbaz in Manhattan, who at the time was considered one of the world's authorities on chronic 12th Rib cases, although he did tell me that was primarily due to his fellowship paper on the topic and little else in the literature. In 2010 I was seeing various neurologists and surgeons who were planning on removing ribs 10-13 on both sides of my thorax with all associated nervous tissue; however I wound up at Cleveland Clinic's (excellent!) Chronic Pain Rehabilitation Program who quickly advised me that in their experience, even with ribectomy the pain would continue from imprinting on my CNS and similar Phantom-limb issues. I've ever since utilized the program's techniques along with neuropathic meds, but in the long run it led to the sale of my practice and near-devastation of my career. As with most others with severe chronic pain, hypertension and severe fatigue are secondary components which can be overwhelming at times.

That's all. Whether acute or chronic, intercostal neuralgias tend to be overlooked by many MD's IMO. If my own situation serves to help others, I'm happy for it.

 

[willabeast]

FWIW; a self-summarized case study. Veterinarian here with 12th Rib; chronic since 6/16/07. With my lifelong history of nephrolithiasis, the initial workup was primarily urogenital but negative all the way through. Although it began on my left, after about 10 weeks it "jumped" across to my right side and has continued in that pattern ever since. With no rationale, every few days, weeks, or months the dull ache or stabbing pain immediately transfers from one side to another and has never been bilateral. Month turned to years in my case--began with localized corticosteroid injections near trigger points-->other various regional nerve blocks-->pulse radiofrequency-->spinal cord stimulator implant, and of course various PO medications throughout as well as trips to Mayo, Cleveland Clinic, etc. Circa 2009 I did see Dr. Tamer Elbaz in Manhattan, who at the time was considered one of the world's authorities on chronic 12th Rib cases, although he did tell me that was primarily due to his fellowship paper on the topic and little else in the literature. In 2010 I was seeing various neurologists and surgeons who were planning on removing ribs 10-13 on both sides of my thorax with all associated nervous tissue; however I wound up at Cleveland Clinic's (excellent!) Chronic Pain Rehabilitation Program who quickly advised me that in their experience, even with ribectomy the pain would continue from imprinting on my CNS and similar Phantom-limb issues. I've ever since utilized the program's techniques along with neuropathic meds, but in the long run it led to the sale of my practice and near-devastation of my career. As with most others with severe chronic pain, hypertension and severe fatigue are secondary components which can be overwhelming at times.

That's all. Whether acute or chronic, intercostal neuralgias tend to be overlooked by many MD's IMO. If my own situation serves to help others, I'm happy for it.

Cleveland clinic - smart people. good advice they gave you. maybe go back there for follow up? that would be my suggestion.