Intercostal Neuralgia from Trauma to Dorsal Lipoma Resection Site: A Case Report

Case Diagnosis: Intercostal neuralgia from a fall on healed lipoma resection incision

Case Description or Program Description: A 59-year-old female with history of a dorsal lipoma resection three years prior presented with right sided burning thoracic back pain after falling backwards into her motorcycle and onto her mid-back. After reporting gradual onset non-concurrent burning pain at the site of her previous lipoma resection and lateral trunk, she noted symptoms worsened with activities requiring her to lean forward. These included washing dishes, putting on make-up, and an increase in perceived pain at nighttime.

Setting: Outpatient interventional pain clinic

Assessment/Results: Patient underwent intercostal nerve block with ultrasound guidance, resulting in significant pain reduction. In addition, she completed physical therapy to improve strength and range of motion.

Discussion (relevance): Intercostal neuralgia is characterized by neuropathic pain in the distribution of the affected intercostal nerve. Classic presentation involves a band-like distribution of sharp, burning or stabbing pain with associated numbness along the rib and abdomen. Patients may present with involuntary muscle contractions or change to skin color and texture when palpating the affected area. Upon physical examination, there may be reproduction of pain with lateral bending toward the side of the intercostal nerve as the intercostal structures compress (Schepelmann’s sign). Intercostal neuralgia, often associated with thoracotomy procedures or post-herpetic neuralgia, rarely presents in case reports originating from trauma to prior incision sites of dorsal lipoma resections. In these cases, deep-seated intramuscular dorsal lipomas can grow into the intercostal muscles, increasing the difficulty of dissection and risk of iatrogenic injury to the nerves. Treatment for intercostal neuralgia consists of multi-modal pain control with oral agents, thoracic epidurals, and intercostal nerve blocks.

Conclusions: Though most associated with thoracic surgeries or herpes virus, this case highlighted the possibility of intercostal neuralgia via trauma or iatrogenic injury from resection of deep-seated masses such as dorsal lipomas.