Case Report
Flank pain caused by slipping rib syndrome Marcello Migliore, Maria Signorelli, Rosario Caltabiano, Eugenio Aguglia Lancet 2014; 383: 844 Department of Surgery, Section of Thoracic Surgery (M Migliore PhD), Department of Clinical and Molecular Biomedicine, Section of Psychiatry (M Signorelli PhD, E Aguglia MD), and Department Ingrassia, Section of Human Pathology,University of Catania, Catania, Italy (R Caltabiano, MD) Correspondence to: Dr Marcello Migliore, Policlinico University Hospital, Department of Surgery, Section of Thoracic SurgeryVia S. Sofia 78, 95124, Catania, Italy [email protected]
A
In November, 2011, a 21-year-old woman, while jogging, felt a sudden intolerable left lower chest pain that forced her to stop. The pain did not radiate, but was exacerbated by movement. She was assessed in the emergency room. The patient stated that she took no medications; medical history included rhinitis, appendectomy, and a motor vehicle accident 5 years earlier which caused contusion of the right knee. Palpation of the flank exacerbated the pain, but the Giordano manoeuvre (percussion with the medial aspect of the hand in the lumbar region) was negative. Urinary analysis, abdominal radiograph, and kidney ultrasound were normal. Non-steroidal inflammatory drugs (NSAIDs) were given, the pain settled down, and the patient was discharged. After 1 week the pain returned and the patient’s general practitioner suggested a chest radiograph (which was negative), and represcribed NSAIDs. After 2 weeks, the patient still had pain. This pain was not alleviated by chiropracty. A gastroenterologist suspected the presence of irritable bowel syndrome, and recommended anticholinergic medications. Medical therapy failed to alleviate the pain, which caused a gradual reduction in the patient’s academic and social activities. For this reason, her general practitioner suggested she consult a psychiatrist, but the patient declined the offer. The patient was then admitted to our surgical department and a multidisciplinary team discussed the case. Other differential diagnoses including pleuritis, pneumonia, radiculitis, herpes zoster, and aortic aneurysm were considered. The psychiatrist excluded mood and somatoform disorders, but found the patient to be preoccupied with her pain. During examination of B
Figure: Slipping rib syndrome (A) Intraoperative photo of the resected rib. (B) Enchondroma: normal bone is indicated by red arrow, bone marrow by green arrow (haematoxylin and eosin stain, ×100 magnification).
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the patient, the surgeon reproduced the pain by lifting up the left costal margin (hooking manoeuvre), and found that the area was tender. An injection of a local anaesthetic into the trigger point was done, which relieved pain for 48 h. 3D CT scan of the chest did not show malformations of the rib or costal cartilages. The multidisciplinary team confirmed the diagnosis of slipping rib syndrome, and the final decision was made to remove the affected 11th rib. At surgery, 10 distal cm of the 11th rib were removed (figure). The day after the intervention the patient had pronounced improvement of flank pain. Pathological examination of the excised material revealed the presence of an unexpected enchondroma (figure). At final followup in November, 2013, the patient was well and continued to enjoy jogging. Flank pain is a sense of discomfort below the rib, and is the classic presenting symptom of urinary disease. Flank pain caused by a lower rib problem is frequently underdiagnosed in favour of renal or pleuritic pain. This case serves as a reminder of the importance of an accurate examination. Together with the left flank pain a tender spot on the left costal margin and reproduction of pain on pressure was noted. Furthermore, the hooking manoeuvre was positive1 and psychiatric assessment was negative. Finally, the persistence of pain after oral and local treatments suggested the possibility of slipping rib syndrome,2 which is thought to be caused by intercostal nerve irritation by a mobile 11th or 12th rib. A multidisciplinary approach is the key to manage complex cases. Surgeons, pain clinic specialists, radiologists, and psychiatrists should provide an integrated approach to care for patients with unexplained pain syndromes.3,4 Contributors MM and MS looked after the patient. All authors wrote the manuscript. Written consent to publish was obtained. References 1 Heinz GJ, Zavala DC. Slipping rib syndrome. Diagnosis using the hooking maneuver. JAMA 1977; 237: 794–95. 2 Wright JT. Slipping-rib syndrome. Lancet 1980; 2: 632–34. 3 Elwahab SMA, Doherty E, Elsheikh H. Somatoform abdominal pain in surgery: is SD worthy of surgical attention? Case reports and literature review. BMJ Case Reports 2012; doi:10.1136/bcr-2012006306 . 4 Migliore M, Signorelli M. Episodic abdominal and chest pain in a young adult. JAMA 2012; 25: 1746–47.
www.thelancet.com Vol 383 March 1, 2014
Flank pain caused by slipping rib syndrome Marcello Migliore, Maria Signorelli, Rosario Caltabiano, Eugenio Aguglia Lancet 2014; 383: 844 Department of Surgery, Section of Thoracic Surgery (M Migliore PhD), Department of Clinical and Molecular Biomedicine, Section of Psychiatry (M Signorelli PhD, E Aguglia MD), and Department Ingrassia, Section of Human Pathology,University of Catania, Catania, Italy (R Caltabiano, MD) Correspondence to: Dr Marcello Migliore, Policlinico University Hospital, Department of Surgery, Section of Thoracic SurgeryVia S. Sofia 78, 95124, Catania, Italy [email protected]
A
In November, 2011, a 21-year-old woman, while jogging, felt a sudden intolerable left lower chest pain that forced her to stop. The pain did not radiate, but was exacerbated by movement. She was assessed in the emergency room. The patient stated that she took no medications; medical history included rhinitis, appendectomy, and a motor vehicle accident 5 years earlier which caused contusion of the right knee. Palpation of the flank exacerbated the pain, but the Giordano manoeuvre (percussion with the medial aspect of the hand in the lumbar region) was negative. Urinary analysis, abdominal radiograph, and kidney ultrasound were normal. Non-steroidal inflammatory drugs (NSAIDs) were given, the pain settled down, and the patient was discharged. After 1 week the pain returned and the patient’s general practitioner suggested a chest radiograph (which was negative), and represcribed NSAIDs. After 2 weeks, the patient still had pain. This pain was not alleviated by chiropracty. A gastroenterologist suspected the presence of irritable bowel syndrome, and recommended anticholinergic medications. Medical therapy failed to alleviate the pain, which caused a gradual reduction in the patient’s academic and social activities. For this reason, her general practitioner suggested she consult a psychiatrist, but the patient declined the offer. The patient was then admitted to our surgical department and a multidisciplinary team discussed the case. Other differential diagnoses including pleuritis, pneumonia, radiculitis, herpes zoster, and aortic aneurysm were considered. The psychiatrist excluded mood and somatoform disorders, but found the patient to be preoccupied with her pain. During examination of B
Figure: Slipping rib syndrome (A) Intraoperative photo of the resected rib. (B) Enchondroma: normal bone is indicated by red arrow, bone marrow by green arrow (haematoxylin and eosin stain, ×100 magnification).
844
the patient, the surgeon reproduced the pain by lifting up the left costal margin (hooking manoeuvre), and found that the area was tender. An injection of a local anaesthetic into the trigger point was done, which relieved pain for 48 h. 3D CT scan of the chest did not show malformations of the rib or costal cartilages. The multidisciplinary team confirmed the diagnosis of slipping rib syndrome, and the final decision was made to remove the affected 11th rib. At surgery, 10 distal cm of the 11th rib were removed (figure). The day after the intervention the patient had pronounced improvement of flank pain. Pathological examination of the excised material revealed the presence of an unexpected enchondroma (figure). At final followup in November, 2013, the patient was well and continued to enjoy jogging. Flank pain is a sense of discomfort below the rib, and is the classic presenting symptom of urinary disease. Flank pain caused by a lower rib problem is frequently underdiagnosed in favour of renal or pleuritic pain. This case serves as a reminder of the importance of an accurate examination. Together with the left flank pain a tender spot on the left costal margin and reproduction of pain on pressure was noted. Furthermore, the hooking manoeuvre was positive1 and psychiatric assessment was negative. Finally, the persistence of pain after oral and local treatments suggested the possibility of slipping rib syndrome,2 which is thought to be caused by intercostal nerve irritation by a mobile 11th or 12th rib. A multidisciplinary approach is the key to manage complex cases. Surgeons, pain clinic specialists, radiologists, and psychiatrists should provide an integrated approach to care for patients with unexplained pain syndromes.3,4 Contributors MM and MS looked after the patient. All authors wrote the manuscript. Written consent to publish was obtained. References 1 Heinz GJ, Zavala DC. Slipping rib syndrome. Diagnosis using the hooking maneuver. JAMA 1977; 237: 794–95. 2 Wright JT. Slipping-rib syndrome. Lancet 1980; 2: 632–34. 3 Elwahab SMA, Doherty E, Elsheikh H. Somatoform abdominal pain in surgery: is SD worthy of surgical attention? Case reports and literature review. BMJ Case Reports 2012; doi:10.1136/bcr-2012006306 . 4 Migliore M, Signorelli M. Episodic abdominal and chest pain in a young adult. JAMA 2012; 25: 1746–47.
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