Topographic anatomy of the chest. Topography of intercostal spaces. Intercostal space What are the main methods of treating intercostal neuralgia

Pulmonary lesions or decay cavities during fluoroscopy or on a radiograph, they are projected anteriorly and posteriorly onto completely different segments of the ribs. For example, if the cavity is located at the level of the II rib in front, then in relation to the posterior segments of the ribs this will correspond to the V or VI rib.

Ribs They don't have the same shape everywhere. In front and partly from the side they are wider and flatter; towards the back they become somewhat narrower and their shape changes, approaching triangular. The scapula is located behind the chest wall, the position of which is not the same in all cases and depends on the shape chest wall. Most authors believe that normally the upper edge of the scapula lies at the level of the II rib, and the lower angle - at the level of the VIII rib.

Apparently this position varies. According to Brezika, the lower angle of the scapula reaches the VII-VIII rib. This is partly confirmed by the fact that after upper thoracoplasty with resection of the 7th ribs, the lower part of the scapula in some cases fits well behind the VIII rib and does not cause the patient any unpleasant sensations. In other cases, the lower angle of the scapula rests on the VIII rib and patients complain of constant pain, which is why it is ultimately necessary to additionally resect the VIII rib or the lower part of the scapula.

The blade is very makes it difficult production of upper thoracoplasty, especially when, according to the operation plan, it is necessary to resect large sections of ribs. Difficulties also lie in the fact that the most severe suppurative processes after thoracoplasty occur precisely under the scapula, and the fight against these suppurations can sometimes be extremely difficult.

Intercostal spaces the back is narrower than the front, and is made of external and internal intercostal muscles. The external ones begin at the junction of the ribs with the transverse processes of the vertebrae and end at the junction of the ribs into the costal cartilages; then they are replaced by interosseous ligaments (lig. intercostalia externi), which are shiny tendon bundles. The external intercostal muscles originate from the lower edge of the overlying rib and are attached to the upper edge of the underlying rib, having a direction from top to bottom and from back to front.

Internal intercostal muscles begin near the angle of the rib and reach the lateral edge of the sternum. They originate from the inner edge of the overlying rib and are attached to the upper edge of the underlying rib, having a direction from top to bottom and from front to back. This arrangement of the internal intercostal muscles is of practical importance: in the posterior sections, starting from the spine to the angle of the ribs, the intercostal vessels and nerves are covered only by the endothoracic fascia and parietal pleura and can easily be damaged when the adhesions are burned directly at the chest wall.

IN between between the external and internal intercostal muscles along the lower edge of each rib there is a groove (sulcus costalis), in which the intercostal vessels and nerve are located. Blood flow in the intercostal arteries comes from three sources: 1) truncus costo-cervicalis, which gives a branch (a. intercostalis suprema) for the two upper intercostal spaces; 2) the thoracic aorta, from which 9 pairs of posterior intercostal arteries emerge (aa. intercostales posteriores); 3) a. mammaria interna, from which the anterior intercostal arteries (aa. intercostales anteriores) depart - two for each intercostal space.

Posterior and anterior intercostal arteries widely anastomose with each other. The posterior intercostal arteries, starting from the spine, are located on the inner surface of the ribs in the sulcus costalis. Anterior to the axillary line, the intercostal arteries enter the intercostal spaces. Thus, dorsal to the axillary line, the intercostal arteries are protected by ribs, but ventral to the axillary line, they are not protected by ribs, since they lie at the lower edge of the rib. The practical significance of this position of the intercostal arteries is that, if necessary, to puncture ventrally from the axillary line, the trocar should be directed obliquely to the upper edge of the underlying rib.

Pairs of intercostal spaces.

The greatest width occurs in the III, then II and I intercostal spaces, but this is not a constant phenomenon. The width and direction of the intercostal spaces vary significantly. The intercostal spaces are made of external and internal intercostal membranes and muscles.

Elderly and sometimes middle-aged people often experience pain in the ribs. It is difficult to immediately accurately determine the cause of their occurrence, since intercostal neuralgia has symptoms similar to heart attacks, radiculitis, pneumonia, hepatic colic and other diseases. Thoracalgia is more often observed in men, which is caused by the characteristics of their work and lifestyle.

Intercostal neuralgia, symptoms

Intercostal neuralgia is manifested by severe pain in the ribs and chest. When you try to take a deep breath and change your body position, the pain intensifies. This happens when coughing, sneezing and even talking loudly. The pain may be:

on right;
left;
encircling.

With palpation, you can feel the direction of the spasm, which runs from the spine between the ribs. This may cause numbness and paleness of the skin in the affected area. When pressed, the pain intensifies.

It is impossible to make an accurate diagnosis right away, since the pain radiates (radiates) often to the shoulder and arm, to the navel area and below, along the edge of the sternum and to the lower back. In addition, burning, numbness and tingling in the chest area may occur.

Causes of pain

By its nature, neuralgia is a pinched nerve, which can occur in two areas:

spinal column, infringement of the spinal nerves of the thoracic region;
in the intercostal space there is inflammation or pinching of nerve endings.

In both cases, the pain is very strong, prolonged and does not go away without taking painkillers. The cause of a pinched nerve is various diseases in the body. Therefore, it is important to eliminate the cause, otherwise the pain syndrome will remain.

Pinched spinal nerves

The roots of the thoracic spinal nerves are pinched at the point where the nerve exits the spinal canal. This is caused by a disease of the musculoskeletal system. With the deposition of salts, inflammation of the joints and deformation as a result of osteoporosis and injuries, the vertebral bones change their shape and size and begin to put pressure on the nerves extending from spinal cord into the intercostal space. The nerve stops receiving nutrition and signals a violation with pain along its entire length.

When a spinal nerve is pinched, girdle pain often occurs because the deformed bones of the spinal column compress both nerves. Unilateral neuralgia in this case is often a consequence of injury. With inflammation in the spine, the temperature may rise.

Pinched nerve endings

More frequent cases of thoracolgia are caused by compression of nerve endings in the intercostal space. The reason for this may be nervous disorders, stress, illness internal organs, viral infections, hypothermia and overload. The muscles increase in size or contract due to spasm and put pressure on the nerve endings. In such cases, the pain spreads on one side.

Pain on the left

Pain on the left side is often mistaken for heart pain, since numerous roots have branches and pass in the area of the heart and under the scapula. There is a difference in symptoms. Angina pectoris is characterized by throbbing pain, which is relieved by taking nitroglycerin. In this case, the pulse is disrupted and the pressure reading changes.

With intercostal neuralgia on the left, the pulse and pressure remain the same, but when you try to take a deep breath and change position, the pain will intensify. The temperature may rise slightly in any case. Taking heart medications will help prevent the development of a heart attack and more accurately determine the diagnosis.

Pain on the right

Often left-sided neuralgia is mistaken for attacks of pain in the liver and renal colic. Pain from the intercostal area can radiate to the lumbar and kidney areas. The main signs of intercostal neuralgia, severe constant pain, aggravated by movement, coughing, sneezing and inhaling, when pressing with fingers at the point where the nerve passes from the spine to the sides and forward between the ribs.

When the internal organs are diseased, the body temperature rises significantly, the pain is aching and spasmodic in nature. In any case, it is necessary to consult a doctor and undergo an examination to correctly determine the diagnosis. Disease of the internal organs can also provoke intercostal neuralgia.

Causes of thoracolgia

The nerve can be pinched by the spinal corpus, enlarged muscles, or muscle spasm. This is provoked by diseases of the supporting system, osteochondrosis and microtrauma. When lifting weights, muscle spasms occur. This reaction can also be caused by working in a room where low temperature, or on the street.

Pain occurs when there is a disruption in the supply of oxygen to nerve cells, which can be caused by diabetes mellitus, anemia, toxicity of the body due to alcohol consumption, smoking, chemical poisoning and biological substances, spoiled and low-quality products.

Disrupts metabolism and oxygen supply to body cells and increased cholecystitis, obesity and long stay in one position without movement. Increased cholecystitis and obesity interfere with normal blood flow, as do diseases gastrointestinal organs, especially ulcers, colitis, gastritis, hemorrhoids. Metabolism is disrupted due to a lack of B vitamins in the body and diabetes mellitus.

In men, an attack of intercostal neuralgia most often begins when lifting weights, especially in the cold, since muscle contraction from low temperature is added to the stress from excessive physical activity. This is especially possible if the body is constantly exposed to nicotine and alcohol poisoning and there are toxins in the blood that reduce the oxygen content and increase the number of oxidants.

Treatment of intercostal neuralgia

You need to start by seeing a doctor and getting examined. Then, after determining the cause of neuralgia, a course of treatment follows in three stages.

Relieving acute pain and bed rest. A blockade is made and applied dry heat, bypassing the heart zone.
Treatment of muscle and nerve inflammation with a course of anti-inflammatory drugs and B vitamins.
Treatment of the disease that caused intercostal neuralgia.

It is necessary to determine and eliminate the cause of a pinched nerve in the intercostal area and spine in order to avoid recurrence of attacks of pain. In addition, it is necessary to treat the disease in itself, and not just because of its ability to provoke neuralgia.

Prevention

Since pain is caused by a lack of oxygen supply to the body’s cells, including nerve cells, measures to prevent the disease are standard. This is a healthy lifestyle, proper nutrition and exercise, especially if you have to spend a lot of time in one position, standing or sitting.

An annual medical examination is also of great importance in order to identify abnormalities in the functioning of organs. initial stage development of the disease. This is especially important for men old age and those who have harmful working conditions at work, including cold, fumes, dampness and gas pollution.

For the purpose of prevention, it is necessary to periodically take a course of vitamins and minerals. Once a year, cleanse the blood with antioxidants, especially for residents of large cities. Watch your weight and do not wear tight clothing that interferes with natural blood circulation. Dress for the weather and don't freeze.

No need to treat joints with pills!

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inability to move easily and comfortably;
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unpleasant crunching, clicking not of your own accord;
pain during or after exercise;
inflammation in the joints and swelling;
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Intercostal neuralgia: symptoms and causes. Treatment of intercostal neuralgia: new drugs

Intercostal neuralgia is one of the most common reasons chest pain. In most cases, intercostal neuralgia is observed in elderly and middle-aged people. This disease practically does not occur in children.

Symptoms of intercostal neuralgia

By its nature, intercostal neuralgia is:

Basically, the pain with intercostal neuralgia is localized in the intercostal space, but pain can radiate along the path of the pinched nerve - in the lower back, in the back, under the scapula. Spastic muscle contractions, redness or paleness of the skin, and loss of skin sensitivity in the area of the affected nerve may occur. The pain with intercostal neuralgia is very strong, burning, constant, without attacks

Intercostal neuralgia - clarifying the diagnosis

Intercostal neuralgia is sometimes confused with heart pain. Although it is not so difficult to distinguish them.

With intercostal neuralgia, the pain intensifies with deep breath or exhalation, or any other movement of the body, including coughing or sneezing, during physical activity. Sometimes it’s painful and you can’t even take a deep breath - attacks of burning pain appear along the intercostal spaces (pain can only be felt on one side of the chest).

Heart pain during angina pectoris does not change with deep inhalation or exhalation, from a change in position or movement in the chest; usually relieved with nitroglycerin; may be accompanied by irregular pulse rhythm, a drop or increase in blood pressure.

With intercostal neuralgia, the pain may intensify with palpation - you can feel the direction of the pain along the nerve. Aching or paroxysmal pain, spreading along the trunk of the nerve or its branches, may be accompanied by other unpleasant sensations - burning, tingling, numbness. By the way, this is why intercostal neuralgia can cause pain not only in the heart area, but also under the shoulder blade, in the back, and lower back (they can sometimes be confused with kidney pain).

It is important to differentiate an attack of intercostal neuralgia and myocardial infarction, which can also cause severe pain that is not relieved by nitroglycerin. Therefore, in case of a sudden attack of pain in the heart area, it is imperative to call ambulance and do an electrocardiogram, since a heart attack requires urgent medical attention.

Causes of intercostal neuralgia

There are many causes that can cause intercostal neuralgia, but essentially the pain is caused by either a pinched spinal nerve root in the thoracic spine or pinched or irritated intercostal nerves in the intercostal space.

Pinched roots are most often caused by various manifestations of osteochondrosis, but other causes are also possible (spondylitis, ankylosing spondylitis, and others).

However, more often, attacks occur as a result of irritation of the nerve due to its pinching by the intercostal muscles due to inflammation or muscle spasm.

The cause of the spasm and, accordingly, an attack of neuralgia may be mental stress, traumatic effects, excessive physical activity without the necessary preparation. Spasm and inflammation of the intercostal muscles can be caused by hypothermia or infection. Sometimes intercostal neuralgia occurs due to lung diseases.

An attack of intercostal neuralgia can occur due to poisoning, with changes in the spine caused by hormonal disorders in menopausal women. The cause of neuralgia may be allergic diseases, diseases of the nervous system (multiple sclerosis, polyradiculoneuritis). It is possible to develop intercostal neuralgia with an aortic aneurysm, diseases of the internal organs, after undergoing herpetic infection.

Neuralgia can also be caused by microtrauma due to constant physical stress (for example, when lifting something heavy), especially in combination with hypothermia.

The development of the disease can be caused by alcohol abuse (due to the toxic effects of alcohol on the nervous system), as well as diabetes mellitus and a lack of B vitamins in the body (observed with stomach and duodenal ulcers, gastritis, hepatitis, colitis) - due to a violation metabolism in nervous tissue.

It should be noted that symptoms resembling intercostal neuralgia are possible due to excessive tone (spasm) of one or more back muscles. In this case, an increase in pain is typical when the affected muscle is stretched (bending forward, moving the shoulder or shoulder blade).

What is intercostal neuralgia? What are its reasons? How to treat intercostal neuralgia?

Candidate of Medical Sciences talks about the causes and symptoms of intercostal neuralgia and new treatment methods. E.L. Shakhramanova, doctor of the consultative and outpatient department of the Research Institute of Rheumatology.

Treatment of intercostal neuralgia

Treatment of intercostal neuralgia usually consists of two stages. First, it is necessary to relieve the pain that accompanies intercostal neuralgia, then it is necessary to treat the disease that caused the nerve injury.

In the first week of the disease, it is better to observe bed rest for 1-3 days, preferably lying on a hard surface; it is best to place a shield under the mattress. To relieve pain, painkillers are prescribed, usually from the NSAID group, which not only relieve pain, but also have an anti-inflammatory effect. In addition, muscle relaxants are prescribed to relieve muscle spasms and sedatives. B vitamins (B1, B6, B12) are recommended - they help restore damaged nerve structures. During attacks, light, dry heat helps.

After the acute symptoms have been relieved, it is necessary to carry out a diagnosis and determine the cause that caused the attack of intercostal neuralgia. If this is any general disease(infectious, cold, allergic, diabetes, nervous system disease, depression) - it is necessary to treat it.

If intercostal neuralgia is caused by a disease of the spine, that is, it is of a vertebrogenic nature, comprehensive treatment of the spine is recommended. To restore the correct physiological position of the thoracic and cervical spine in cases of intercostal neuralgia, courses of therapeutic massage, manual therapy, and physical therapy are conducted.

Physiotherapy, acupuncture, and laser therapy provide good results for vertebrogenic intercostal neuralgia. To prevent the disease from developing into chronic form with frequent attacks, you need to reduce physical activity, do not abuse alcohol, and avoid stressful situations if possible.

In the first week of the disease, it is better to observe bed rest for 1-3 days, preferably lying on a hard surface; it is best to place a shield under the mattress. During attacks, light, dry heat helps.

To relieve pain, take painkillers and sedatives. Physiotherapy, acupuncture, and laser therapy provide good results for intercostal neuralgia. It is advisable to take B vitamins (B1, B6, B12). To prevent the disease from becoming chronic with frequent attacks, you need to reduce physical activity, not abuse alcohol, and avoid stressful situations if possible.

To restore the correct physiological position of the thoracic and cervical spine in cases of intercostal neuralgia, courses of therapeutic massage, manual therapy, and physical therapy are conducted.

If conservative treatment does not help, then surgical treatment is performed (for example, osteochondrosis or disc herniation, which causes attacks of intercostal neuralgia).

Treatment of intercostal neuralgia with a new drug - NANOPLAST forte therapeutic patch

In the therapeutic treatment of intercostal neuralgia, various means, such as NSAIDs, analgesics, etc. All these drugs are effective, but with prolonged use they can cause harm to the body. Therefore, it is very important to minimize side effects and increase the effectiveness of treatment for intercostal neuralgia. A new generation drug can help with this - the pain-relieving anti-inflammatory medical patch NANOPLAST forte.

In the treatment of intercostal neuralgia, the therapeutic plaster NANOPLAST forte is highly effective, it relieves pain and inflammation, improves blood circulation in the affected area, and allows you to reduce the dose of painkillers and anti-inflammatory drugs.

For intercostal neuralgia, the therapeutic plaster NANOPLAST forte is applied to the intercostal area (avoiding the heart area) or to the exit projection spinal nerves, usually strangulated against the background of osteochondrosis to the right or left of the spine in the thoracic region - depending on the location of the pain. It is possible to simultaneously use the patch in the intercostal area (where the pain is localized) and at the site of the projection of the corresponding nerve in the thoracic spine. It is usually recommended to use the patch in the morning for 12 hours, but it can also be used at night. The duration of the course of treatment of intercostal neuralgia with a therapeutic patch is from 9 days.

High efficiency, unique composition, long-lasting (up to 12 hours!) therapeutic effect, ease of use and affordable price make NANOPLAST forte the drug of choice in the treatment of intercostal neuralgia.

Intercostal space

In the spaces between the ribs there are external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

The external intercostal muscles run from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which retains the direction of the connective tissue bundles corresponding to the course of the muscles.

Figure 7.4. Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest (diagram). I - between the middle axillary and paravertebral lines; II - between the middle axillary and midclavicular lines. 1 - fascia m. latissimus dorsi; 2 - m. latissimus dorsi; 3 - fascia thoracica; 4 - v. intercostalis; 5 - a. intercostalis; 6 - n. intercostalis; 7 - m. intercostalis externus; 8 - m. intercostalis internus; 9 - fascia endothoracica; 10 - prepleural tissue; 11 - pleura parietalis; 12 - fascia pectoralis; 13 - m. pectoralis major.

Deeper are the internal intercostal muscles, the bundles of which go in the opposite direction: from bottom to top and back. Posterior to the costal angles, the internal intercostal muscles are no longer there; they are replaced by thin bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, limited externally and internally by the corresponding intercostal muscles, called intercostal space, spatium intercostale. It contains intercostal vessels and a nerve: a vein, below it is an artery, and even lower is a nerve (for ease of remembering: Vein, Artery, Nerve - VANYA). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Anterior to the mid-axillary line, the intercostal vessels and nerves are located in the intermuscular tissue and are not protected by the ribs, therefore, any punctures of the chest are preferable to be made posterior to the mid-axillary line along the upper edge of the underlying rib.

Topographic anatomy of the chest. Topography of intercostal spaces.

The rib cage is the bony base of the chest walls. Consists of XII thoracic vertebrae, XII pairs of ribs and sternum.

Chest walls:

Back wall formed by the thoracic part of the spinal column, as well as the posterior sections of the ribs from the head to their corners.

The anterior wall is formed by the sternum and the cartilaginous ends of the ribs.

The lateral walls are formed by the bony part of the ribs.

The upper aperture of the chest is limited by the posterior surface of the manubrium of the sternum, the inner edges of the first ribs and the anterior surface of the first thoracic vertebra.

The lower aperture of the chest is limited by the posterior surface of the xiphoid process of the sternum, the lower edge of the costal arch, and the anterior surface of the X thoracic vertebra. The lower aperture is closed by a diaphragm.

Skeleton of the chest, a - front view. 1 - upper thoracic aperture; 2 - jugular

tenderloin; 3 - manubrium of the sternum; 4 - body of the sternum; 5 - xiphoid process of the sternum; 6 - oscillating ribs (XI-XII); 7 - substernal angle; 8 - lower thoracic aperture; 9 - false ribs (VIII-X); 10 - costal cartilages; true ribs (I-VII); 12 - collarbone.

Topography of intercostal spaces.

Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest:

I – between the middle axillary and paravertebral lines;

II - between the middle axillary and midclavicular lines.

1 – fascia m. latissimusdorsi; 2 – m. latissimusdorsi; 3 – fascia thoracica; 4 – v. intercostalis;

5 – a. intercostalis; 6 – n. intercostalis; 7 – m. Intercostalisexternus; 8 – m. intercostalisinternus;

9 – fasciaendothoracica; 10 – prepleural tissue; 11 – pleura parietalis;

12 – fasciapectoralis; 13 - m. pectoralis major.

In the spaces between the ribs there are external and internal intercostal muscles, fiber and neurovascular bundles.

External intercostal muscles (mm. intercostalis externi) run from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, muscles are absent and replaced by the outer intercostal membrane.

The internal intercostal muscles (mm. intercostales interni) run obliquely from bottom to top and back. Posterior to the costal angles, muscle bundles are absent and replaced by an internal intercostal membrane.

The space between adjacent ribs, limited externally and internally by the corresponding intercostal muscles, is called the intercostal space. It contains a vein, below ee- artery, even lower is the nerve.

The posterior intercostal arteries (IX-X pairs) arise from the aorta and are located in the intervals from the III to the XI ribs; the twelfth artery, lying under the XII rib, is called the subcostal artery (a. subcostalis). Branches:

· Dorsal branch (r. dorsalis) goes to the muscles and skin of the back

· Lateral and medial cutaneous branches (r. cutaneus lateraliset medialis) go to the skin of the chest and abdomen

· Lateral and medial branches of the mammary gland (rr. mammariilateraliset medialis)

The anterior intercostal arteries arise from the internal mammary artery.

Venous outflow occurs through the veins of the same name.

The intercostal nerves (n. intercostalis) first run directly adjacent to the parietal pleura, and then lie in the intercostal groove. Branches:

· Anterior and lateral cutaneous branches (r. cutaneianterioresetlaterales)

Muscular branches innervating the intercostal muscles

Intercostal space;

complex area of the human body containing vital important organs: heart and lungs.

The upper border of the chest is determined by a line drawn along the upper edge of the jugular notch, the clavicles, the humeral processes of the scapulae and the spinous process of the VII cervical vertebra.

The lower border is represented by a line running from the xiphoid process of the sternum, along the costal arches, along the free edges of the X-XII ribs and the spinous process of the XII thoracic vertebra. The chest is separated from the upper limbs by the deltoid grooves in front, and by the medial edge of the deltoid muscle behind.

The boundaries of the chest cavity do not correspond to the boundaries of the chest, since the dome of the pleura of the right and left lungs protrudes above the collarbones by 2-3 cm, and the 2 domes of the diaphragm are located at the level of the IV and V thoracic vertebrae.

The jugular notch is projected onto the lower edge of the II thoracic vertebra. The lower angle of the scapula is projected onto the upper edge of the VIII rib.

To determine the projection of the thoracic cavity organs onto the chest wall, the following lines are used:

Anterior midline

Anterior axillary line

Mid axillary line

Posterior axillary line

Posterior midline

Skin, subcutaneous fat,

The superficial fascia, which forms the fascial sheath for the mammary gland, also gives off septa from the posterior layer to the anterior one, forming lobules.

The proper fascia of the chest, which forms fascial sheaths for the pectoralis major and minor muscles on the anterior surface of the chest. On the posterior surface of the chest, the own fascia is divided into two sheets and forms fascial sheaths for the latissimus and dorsi muscles and the lower part of the trapezius muscle. And the deep layer of its own fascia limits the osteofibrous bed of the scapula with the muscles, vessels and nerves lying in them, and also forms cases for the rhomboid major and minor muscles of the back and the levator scapulae muscle.

Pectoralis major muscle

Superficial subpectoral cellular space,

pectoralis minor muscle,

Deep subpectoral cellular space,

Serratus anterior muscle.

Ribs with external and internal intercostal muscles,

Prepleural fatty tissue,

ribs above and below,

external intercostal muscle outside

internal intercostal muscle inside

Moreover, the relative position of the muscles is not the same throughout the entire interval from the vertebral lines to the sternal lines. Along the posterior surface, the internal pectoral muscles do not reach the vertebral line, and thus a gap remains between the muscles. And in front, at the level of the costal cartilages, the muscles are represented by an aponeurotic plate, tightly fixed to the sternum.

In the intercostal spaces there are intercostal neurovascular bundles, represented by intercostal arteries, intercostal veins and intercostal nerves.

There are anterior and posterior intercostal arteries. The anterior intercostal arteries begin from the internal thoracic arteries, which in turn are branches subclavian arteries. The posterior intercostal arteries are branches of thoracic aorta.

Thus, an arterial ring is formed, the presence of which carries both benefit and danger.

The “+” of this anatomy is the presence of anastomoses between two main sources of blood circulation, which ensures adequate blood supply to the intercostal muscles responsible for our breathing even in the event of occlusion of one of the main sources.

“-” is that when the intercostal arteries are injured, the volume of blood loss doubles.

Intercostal veins, corresponding to arteries, are superior, inferior, anterior and posterior. Again, the main ones will be the front and rear. From the anterior intercostal arteries, blood flows into the anterior thoracic veins. And from the posterior intercostal veins, blood flows on the left into the hemizygos vein, and on the right into the azygos vein.

The intercostal nerves are branches of the sympathetic trunk.

The intercostal neurovascular bundle is located in the rib groove, and if viewed from top to bottom, the vein lies above all, the artery below it, and the nerve below the artery.

However, the SNP is located in the groove not along the entire length of the intercostal space, but only up to the midaxillary line, medial to which the neurovascular bundle exits the groove.

Thus, the indicated topographical and anatomical features of the location of the SNP determined certain rules for performing the puncture pleural cavity.

Massage for intercostal neuralgia: techniques for performing acupressure and classical methods

Intercostal neuralgia causes acute, severe pain in the rib area.

It can be burning or dull in nature.

Although this pathology and does not pose any particular danger, treatment still cannot be postponed until later.

When treating this disease, special attention is paid to massage.

After all, the main cause of pain is muscle spasm.

A well-executed massage can reduce muscle tightness. As a result, the intensity of pain decreases.

What is intercostal neuralgia?

Intercostal neuralgia is a syndrome characterized by the appearance severe pain in the space between the ribs. The pain occurs due to compression of the nerve endings that pass between the ribs.

The nerves passing between the ribs cause intercostal neuralgia when they are compressed and inflamed

radicular, in which the nerve fibers passing in the spine are pinched;
reflexive, it is caused by muscle spasm in the space between the ribs.

The disease is not life-threatening, but significantly worsens its quality. After all, because of pain syndrome the patient sleeps poorly, his irritability increases, and hypertensive crises may occur.

What are the main methods of treating intercostal neuralgia?

If pain occurs in the intercostal space, you should contact a neurologist as soon as possible. The doctor will assess the condition and select the most appropriate treatment tactics. Most often, drug treatment is prescribed.

Doctors prescribe injections, tablets, ointments that help relieve inflammation and relieve pain. At the same time, B vitamins are prescribed, which have a positive effect on the condition of nerve endings.

In addition, neurologists prescribe:

physiotherapy;
wearing belts, corsets that limit mobility;
massage;
manual therapy;
reflexology.

The use of massage for intercostal neuralgia

Massage is an independent therapeutic tool that can be used to reduce the severity of pain. But it is often used as one of the components of complex treatment. It is combined with medication, physiotherapy, manual therapy, and exercise therapy.

Before prescribing a massage, the patient must be examined. If the cause of pain is a tumor, then massage procedures are contraindicated. Due to increased blood flow, the tumor may begin to grow faster.

What are the benefits and how massage can help with intercostal neuralgia

strengthen the muscle corset;
eliminate muscle tightness;
improve blood flow in tissues;
stimulate local metabolic processes.

The main benefit of massage is the elimination of muscle spasms, which contribute to pinched nerves.

The main cause of severe pain is muscle spasm, because of which the pain goes from acute form into chronic. Massage allows you to remove spasms, thereby reducing the severity of pain.

When can you have a massage?

Massage procedures are prescribed only after the acute stage of the disease has passed. The patient should not complain of severe pain that interferes with speaking, inhaling deeply, or emptying the bowels.

If you consult a doctor in a timely manner and prescribe adequate treatment, 4-5 days pass from the moment severe pain appears until the acute stage subsides. After this, the doctor can give a referral to a massage therapist to consolidate the effect obtained from drug therapy. Often, drug treatment continues and can be combined with medication.

Contraindications to the use of massage for intercostal neuralgia

Before prescribing treatment and massage, the patient is sent to comprehensive diagnostics. The doctor needs to find out the reason why they were pinched nerve roots. In some pathologies, massage is prohibited.

Massage is not prescribed in the following cases:

acute infectious and inflammatory processes, due to increased blood flow, the infection spreads throughout the body;
purulent skin lesions, dermatological diseases;
severe exhaustion of the body;
high blood pressure, hypertension;
oncological diseases;
mental illness;
epilepsy;
hereditary blood diseases in which there is an increased tendency to thrombosis and bleeding (thrombophlebitis, severe atherosclerosis, hemophilia, hemorrhagic vasculitis);
disruption of intestinal function (dysbacteriosis, diarrhea).

In such situations, massage can worsen the patient's condition.

Video: “How to treat intercostal neuralgia at home?”

Types of massage used for intercostal neuralgia

After severe pain subsides, the patient can go to the massage therapist. To alleviate the condition and reduce pain, the specialist will knead the back and chest. Patients are prescribed therapeutic or acupressure massage.

Classic therapeutic massage procedures allow you to:

stimulate blood flow in small arteries, capillaries;
warm up the skin and tissues that are under it;
strengthen metabolic processes;
improve the functioning of the nervous system, the conduction of nerve impulses;
speed up the process of removing toxins and other substances that are involved in the inflammatory process.

By doing acupressure the specialist influences biologically active points. Finger piercing, pressure, kneading, and nail pricking are used. To reduce the severity of pain, use strong and medium-duration exposure from 2 to 5 minutes.

Points affected during thoracalgia

Technique and features of implementation for intercostal neuralgia

A selection of interesting facts:

The massage is done in the back and chest area. Before starting it, the massage therapist must clarify on which side and at what level the painful sensations are concentrated.

Begin the massage on the opposite side from the place where the pain is concentrated. The specialist gradually moves from healthy areas to problematic areas. The massage therapist begins to work on the affected area after the 3rd session.

If intercostal neuralgia provokes the appearance of pain on both sides, then the effect begins from those places where discomfort less pronounced. The massage is done as carefully as possible the first time. Over time, the intensity and strength of the impact can be increased.

To perform a massage, the patient is first placed on the massage table on his stomach. A special pillow is placed under the chest. After complete treatment of the back, the patient turns over, the specialist continues to massage, working on the muscles of the chest.

For intercostal neuralgia, massage sessions are usually prescribed. Most people experiencing intercostal neuralgia are prescribed massage sessions. The duration of the first of them should not be more than 15 minutes. Over time it increases.

In the absence of contraindications, warming ointments are used. Pain-relieving ointments and gels can be applied to problem areas after the massage is completed.

To carry out the massage, the patient is placed on his stomach, and his arms are asked to be extended along the body. First, the back is stroked with both hands on both sides. The movement is repeated 7–9 times.

Then they begin squeezing on the healthy part of the back. Make it with the edge of the palm. The movement occurs in the direction from the long dorsi muscle down towards the couch.

Having completed this combined stroking, the massage therapist can proceed to kneading. The procedure begins with the long muscles of the back.

kneading with 4 fingertips (repeat 3-4 times);
stroking with 2 hands (2–3 times);
impact with the finger phalanges, while the palms are clenched into a fist (3–4 times).

The kneading ends with stroking to soothe the sore muscles.

After treating the long back muscle, they move on to the latissimus.

To warm it up and warm up, use the following techniques:

ordinary kneading (3-4 times);
shaking, carried out in the direction from the iliac crests to the armpits (2-3 repetitions);
double ring kneading (3-4 times);
shaking (2-3 times);
stroking (3 times).

The complex on the healthy side is repeated 2-3 times, then the massage therapist can move to the sore side. The impact on it should be less intense. You should focus on the patient’s well-being.

The techniques described are the preparatory stage of massage. After it is carried out, they proceed to rubbing the spaces between the ribs where pain is felt. It should be carried out in the direction from the spinous vertebral processes along the spaces between the ribs, through the long back muscle. The massage therapist should use his fingertips to get into the grooves between the ribs to the maximum depth. Treatment begins from below the waist.

After completion, the patient is asked to turn over on his back. The development of the pectoral muscles begins with stroking and squeezing movements (3-4 repetitions).

Then the following complex is performed:

shaking (2-3 repetitions);
kneading (4–6 times);
alternating stroking and shaking (3 times).

After completing the warm-up of the pectoral muscles, proceed to the intercostal muscles. The masseur carries out circular, zigzag, straight rubbing in the direction from the sternum to the pectoralis major muscle (up to mammary gland in women), then it moves down to the back. Each technique is repeated 3-4 times.

Familiarize yourself with the technique and sequence of massage procedures for thoracalgia. Afterwards, the massage therapist should rub the subcostal angle. When performing a massage, the fingers are positioned so that 4 of them go deep under the hypochondrium, and the thumb remains on top. Rub them from the center of the sternum down to the couch. After 3-4 repetitions, stroking, squeezing, rubbing, kneading movements are performed on the treated area. Repeat them 2-3 times.

The anterior and lateral parts of the chest are massaged separately. The specialist should work by stroking and squeezing the pectoralis major muscles, the movements are repeated 3-4 times. Then he rubs the intercostal spaces in the direction from the sternum to the back. You need to move your hands as far as possible.

Repeat straight, spiral, circular, zigzag rubbing 3-4 times, which is done with the pads of 4 fingers. After rubbing, begin squeezing with the heel of your palm along the ribs. Then alternate stroking and squeezing movements.

After completion, carry out ordinary kneading (4 times), kneading with the finger phalanges, while the palms are clenched into a fist (3 times). These movements alternate with stroking and shaking (2 times each).

After completing this complex, they begin to rub the spaces between the ribs. To do this, the hand on the treated side is placed behind the head, and the massage therapist performs the following movements:

zigzag stroking along the ribs towards the iliac fossa, along the torso (3-4 repetitions);
squeezing with the bases of the palms (5 repetitions), movements are directed along the ribs;
straight, zigzag rubbing (each 3-4 repetitions);
squeezing (3 times).

After this, the patient should take a deep breath several times, leaning to the healthy side, clasp his hands, raise his arms up and lower them to his hips. To complete the procedure, the patient turns on his stomach, and the massage therapist strokes, squeezes, shakes, and kneads the latissimus dorsi muscle.

During the massage or after its completion, you can use warming ointments and creams.

Video: “Massage for intercostal neuralgia: technique”

45 Topography of intercostal spaces

The bony basis of the segment is represented by the ribs, and the muscular basis is represented by the external and internal intercostal muscles, the neurovascular part consists of the intercostal nerve and intercostal vessels: from top to bottom - vein, artery. nerve. The chest segments are covered with soft tissue both inside and outside.

Topography: skin, subcutaneous fat, superficial fascia, pectoral fascia, muscles (pectoralis major or serratus anterior or latissimus dorsi), pectoral fascia, chest segment, intrathoracic fascia, tissue (prepleural, parapleural, pleural), costal pleura.

Treatment of purulent pleurisy:

Puncture of the pleural cavity.

Passive drainage according to Bulau.

Puncture of the pleural cavity: in the 7-8 intercostal space. along the scapular or posterior axillary line along the upper edge of the rib, a puncture is made in the chest wall with a thick needle connected to a short rubber tube, which is clamped after removing each portion of pus.

Passive drainage, according to Bulau: a drainage tube connected to a jar from the Bobrov apparatus is inserted into the pleural cavity or a puncture in the 6-7 intercostal space (in adults with resection of the rib, but with preservation of the periosteum) along the midaxillary line using a thoracary, pus flows into the jar according to the law of communicating vessels.

Active aspiration: i.e., but a water jet pump is connected to a short tube, the pus flows out under the influence of negative pressure in the system, equal to 10-40 cm of water column.

46 Topography of the diaphragm

Along the right middle line, the dome of the diaphragm is located at the level of the 4th rib, and along the left middle line - at the 5th rib. The diaphragm is covered with serous membranes. On the side of the cavity, it is covered with the diaphragmatic pleura and partially with the pericardium. On the abdominal side, the diaphragm is covered by the parietal peritoneum. central part The diaphragm is represented by the tendon center. The muscular section of the diaphragm consists of 3 parts: sternal, costal, lumbar. The sternal part begins from the posterior part of the xiphoid process. To the left of the xiphoid process between the sternum and costal parts there is a gap (described by Larrey) - the left sternocostal triangulation. To the right of the xiphoid process, between the sternum and costal parts of the diaphragm, there is a similar gap (described by Morgagni) - the right costosternal triangulation. The internal mammary artery passes through each of the slits. The lumbar part of the diaphragm is represented by powerful muscle bundles, forming 3 pairs of legs: internal, intermediate, lateral. Inner legs starting from the anterolateral surface of the bodies of 1-4 lumbar vertebrae. Going up, the inner legs converge, forming 2 holes. The first is at the level of the 7th-1st vertebrae and is called the aortic. The second is at the level of 11 degrees pos. and is called esophageal. Intermediate legs shorter and starting from the lateral part of the body of the 2nd vertebral belt. Lateral crura even shorter, they can start from the lateral surface of the body of the first or second vertebral belt. The descending aorta passes through the aortic opening, and the thoracic duct passes posteriorly and to the right. Through hiatus gr cavity leaves the esophagus with vagus nerves. On the left, between the internal and intermediate legs, the hemizygos vein and splanchnic nerves pass. On the right, between similar legs, there is the azygos vein and celiac nerves. The sympathetic trunk passes between the intermediate and lateral crura on the left and right. Between the costal and waist sections of the diaphragm there are 2 triangles (described by Bokhdalik) - lumbocostal triangles. To the right of the midline in the tendon center of the diaphragm there is a hole through which the lower vena cava. To the right of this opening, the branches of the right phrenic nerve pass through the tendinous center.

Finding out the symptoms of intercostal neuralgia on the right

With the development of intercostal neuralgia, the localization of the site of pain may differ significantly. This is due to the peculiarity of the anatomical location of the intercostal nerves, which make up 12 pairs in the body. Depending on the affected nerve, pain may be felt in the lower back, back, chest, or under the shoulder blade. In addition, the appearance of characteristic pain for intercostal neuralgia may indicate other diseases.

Symptoms on the right

This disease is characterized by the development of an acute pain syndrome that occurs unexpectedly. The location of the source of pain can be easily palpated: as a rule, painful sensations spread along the affected area of the nerve and intensify when pressed. At rest, the pain is of minor concern, has an aching character, abruptly giving way to paroxysmal contractions when changing position, turning the body, inhaling and exhaling. In our section you will find all necessary information about intercostal neuralgia.

In addition to pain, there may be a burning sensation, tingling, or numbness in certain areas of the body, thereby making it difficult to make a correct diagnosis. Pain due to intercostal neuralgia can manifest itself both in the area of the heart and under the shoulder blade, in the back, and lower back.

In addition, the symptoms directly depend on which part of the nerve is affected and the degree of damage, since they consist of sensory, motor and autonomic fibers.

Important! When a sensory nerve is compressed, it results in acute pain. In addition to pain, sweating in the chest area increases, and during physical exercises, an additional symptom is increased shortness of breath.

Causes

In the vast majority of cases, the manifestation of intercostal neuralgia is a consequence of any pathological changes in the body, or a negative impact on health.

The occurrence of pain itself is associated mainly with pinching of the spinal nerves in the thoracic spine. In the intercostal space, the appearance of pain occurs due to infringement of the intercostal nerves. The reasons for this may be developing osteochondrosis, inflammatory processes that provoke muscle spasms and attacks. Such processes can be the result of stress, injury, excessive physical stress on an unprepared body and muscle fatigue.

Important! Also, factors contributing to the onset of the disease may be hypothermia of the body or previous infectious diseases.

Intercostal neuralgia can also be caused by other destructive processes in the chest and back area: scoliosis, osteochondrosis of the thoracic region, intervertebral hernia, joint dysfunction, tumors, protrusion. Only a full examination by a specialist will help identify the source and begin adequate treatment.

Important! Intercostal neuralgia is not so much independent disease, but a consequence of the presence of certain health problems. Therefore, it is important to identify and solve these problems in order to exclude future relapses, as well as to determine the correct diagnosis so as not to miss diseases that threaten life and health, for example, myocardial infarction.

Neuralgia right front

The symptoms that appear with intercostal neuralgia, depending on the location of the pain, may indicate the development of other diseases. As a rule, in such cases, if the diagnosis is not clear, then additional studies are prescribed.

In case of pain in the front chest area, fluorography, examination of the thyroid gland and consultation with a mammologist in women, examination by a cardiologist and appointment of an ECG may be additionally prescribed.

Regardless of the center of pain, a course of treatment is carried out aimed at reducing and removing it, identifying the causes and eliminating them.

The course of treatment consists of anti-inflammatory and analgesic drugs, muscle relaxants. When passing through the acute stage, a course of massage, physiotherapy and acupuncture is possible.

Neuralgia right back

The development of intercostal neuralgia, which radiates pain mainly from the back to the right, indicates infringement lower sections intercostal nerves.

This may also indicate the presence of kidney problems, therefore, in order to exclude the possibility of developing renal pathology, an additional examination is carried out by a urologist or nephrologist.

Otherwise, treatment and examinations are carried out as part of therapy for ordinary intercostal neuralgia.

Neuralgia on the right under the scapula

If pain appears under the shoulder blade, it is necessary to exclude diseases associated with the lungs. For this, fluorography may additionally be prescribed.

A diagnosis of the spine is also carried out, and if the vertebrogenic nature of intercostal neuralgia is established, comprehensive treatment of the spine is prescribed. It includes not only drug treatment, but also the use of massage, physiotherapy courses, and classes with a kinesitherapy specialist are recommended.

Neuralgia on the right under the ribs

One of the most common forms of manifestation of intercostal neuralgia is its development in the intercostal space to the right and below.

Symptoms of intercostal neuralgia in the case of pain concentrated mainly under the ribs may indicate problems with internal organs. These may be diseases of the stomach, liver, pancreas and other digestive organs. Therefore, additional consultations with a gastroenterologist are often prescribed and ultrasound examinations are performed.

Treatment of the disease

A full course of treatment can be prescribed by a doctor after examining and examining the patient. Self-treatment, including taking medications, in this case may not only be useless, but also cause harm to health if another disease is hidden under the symptoms of intercostal neuralgia.

Examinations may include:

Ultrasound diagnostics;
magnetic resonance imaging or MRI;
radiography;
CT scan or CT;
additional studies - electrospondylography, myelography, contrast discography.

Treatment includes complex measures depending on the causes and source of intercostal neuralgia. Primary measures are aimed at relieving acute pain syndrome with medications.

First of all, the main task is to relieve acute pain syndrome, which is extremely inconvenient, causes physical distress and can even lead to immobility of the patient due to acute attacks when trying to move. Read also about methods for relieving pain in the tailbone.

At home

Treatment at home is possible only if there is a slight manifestation of the disease and it is impossible for some reason to see a doctor.

During the acute stage of the disease, it is strongly recommended to maintain bed rest for several days. The mattress should be quite rigid; it is better to place some hard surface under it during this period.
Dry warm compresses can be used to relieve pain.
It is important to exclude or limit physical activity during the acute period.

It is permissible to take medications at home by agreement with your doctor. Self-administration is not recommended, since the presence of other diseases that give similar symptoms, such as angina, must first be excluded.

Important! Once the acute stage has passed, going to the doctor should not be postponed.

Drug treatment

When treating intercostal neuralgia on the right, a course of non-steroidal anti-inflammatory drugs is first prescribed to relieve pain. It is possible to use painkillers to alleviate the patient's condition.

Ointments and creams are used as a local anesthetic:

anti-inflammatory and analgesic ointments based on diclofenac;
pain-relieving ointments and gels with active substance– ketaprofen.

Ointments based on bee and snake venom are used, which not only relieve pain, but also accelerate the elimination of substances that contribute to the development of the inflammatory process and increase blood flow. Has a local irritant effect that reduces pain turpentine ointment, camphor, menthol, which can either be added to finished preparations or purchased creams that contain these substances.

To reduce muscle spasm, muscle relaxants are taken, which reduces pain and increases mobility.
For a general strengthening effect, a course of B vitamins and calcium is additionally prescribed.
As part of a general set of measures, and in case of excessively acute pain, a novocaine blockade can be administered to alleviate the condition.

Treatment with folk remedies

Non-drug remedies can help relieve the condition and reduce pain.

Flax seeds

Steamed flax seeds can be used as a source of dry heat. To do this, they are brewed in boiling water, taken out, dried with a towel and then poured into a cotton bag and applied to the sore spot.

Sage baths

It is also useful to take warm baths with sage and sea salt before bed to relax and reduce muscle spasms. The sage must first be filled with warm water and allowed to brew. Take sage - 4-5 tbsp. l. per glass of water. The infusion is poured into the bathtub, a couple of tablespoons of sea salt are added. Take a bath for no more than 15 minutes.

Herbs

An infusion of rue herb helps with pain. To prepare it, 2 tbsp. l. the herbs are poured with 1 glass of alcohol, closed tightly with a lid, put in a dark place and infused for a week.

Steamed and ground aspen buds are used as an ointment, which are mixed with petroleum jelly at a ratio of 1:4.
Additionally, for a warming effect, you can wear woolen clothes in the form of a vest and make bandages around the sore spot.

Compress

Use a mixture of spices as a warming compress: red chili pepper – 1 tsp, ground ginger – 2 tsp, turmeric – 1 tsp. Add a little water to the mixture or vegetable oil. Apply the mixture to a clean cloth and apply to the sore area and wrap with a clean bandage. The bandage is worn until it begins to burn.

To use as a warm dry compress, you can use boiled eggs; they can be applied both in felt form and in the shell, after wrapping them in a clean rag and holding them until they cool down.

Topography of intercostal spaces:

In the spaces between the ribs there are external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

External intercostal muscles go from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which retains the direction of the connective tissue bundles corresponding to the course of the muscles.

Deeper located internal intercostal muscles, the beams of which go in the opposite direction: from bottom to top and back. Posterior to the costal angles, the internal intercostal muscles are no longer there; they are replaced by thin bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, limited externally and internally by the corresponding intercostal muscles, is called intercostal space, spatium intercostale. It contains intercostal vessels and a nerve: a vein, below it an artery, and even lower - a nerve (VANA). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Posterior intercostal arteries originate from the aorta, and front- from the internal mammary artery. Thanks to numerous anastomoses, they form a single arterial ring, the rupture of which can lead to severe bleeding from both ends of the damaged vessel. Difficulties in stopping bleeding are also explained by the fact that the intercostal vessels are closely connected to the periosteum of the ribs and the fascial sheaths of the intercostal muscles, which is why their walls do not collapse when wounded.

Intercostal nerves upon exiting the intervertebral foramina, giving off the dorsal branches, they are directed outward. From the side of the thoracic cavity to the angle of the rib, they are not covered with muscles and are separated from the parietal pleura by bundles of the internal intercostal membrane and a thin layer of intrathoracic fascia and subpleural tissue. This explains the possibility of involvement of intercostal nerves in inflammatory process for diseases of the pleura. The lower 6 intercostal nerves innervate the anterolateral abdominal wall.

The next layer of the chest wall is intrathoracic fascia, fascia endothoracica, lining the inside of the intercostal muscles, ribs and costal cartilages, the sternum, as well as the anterior surface of the thoracic vertebrae and the diaphragm. The fascia above each of these formations has a corresponding name: fascia costalis, fascia diaphragmatica, etc. In front, in close connection with the intrathoracic fascia, there is a. thoracica interna.

Primary surgical treatment of penetrating wounds of the chest wall.

Indications: stab, stab, cut, gunshot wounds with open or tension pneumothorax, intrapleural bleeding.

Anesthesia: the operation is performed under endotracheal anesthesia, if possible with separate bronchial intubation. The skin and muscle wound is excised with a bordering incision within healthy tissue. Damaged intercostal muscles and parietal pleura are excised.

Revision of the pleural cavity. The parietal pleura is opened quite widely and the pleural cavity is examined. Remove foreign bodies, blood clots and liquid blood. In some cases, mainly for puncture and stab wounds, liquid blood is filtered and used for back transfusion into a vein. Sources of bleeding and release of air are determined, after which hemostasis and aerostasis are performed. They inspect adjacent organs, the mediastinum and the diaphragm, taking special measures in cases of damage.

One or two drains are inserted into the pleural cavity above the diaphragm - anterior and posterior. The main one is back drainage, which is inserted into the seventh-eighth intercostal space along the posterior axillary line and placed along the posterior chest wall to the dome of the pleural cavity. Anterior drainage is inserted in the fourth or fifth intercostal space in case of insufficient or questionable aerostasis and is placed between the lung and the mediastinum. The end of the drainage should also reach the dome of the pleural cavity.

Suturing a chest wall wound. The basic principle of suturing a chest wall wound is the application of layer-by-layer sutures in order to create complete tightness. If possible, which usually happens only in cases of small wounds, the first row of interrupted sutures is applied to the pleura, intrathoracic fascia and intercostal muscles. The main interrupted sutures are applied in layers to the more superficial muscles of the chest wall. Further

suturing the own and superficial fascia with subcutaneous tissue and then the skin. The diverged ribs are brought together with one, two or three pulley sutures, and the pleural and muscle defects are closed using muscle flaps, which are cut out from the pectoralis major muscle, the latissimus dorsi muscle, the trapezius muscle, thus achieving complete tightness.

Damage to the intercostal nerves, accompanied by acute pain. It is characterized by paroxysmal shooting or burning pain in one or more intercostal spaces, extending from the spinal column to the sternum. Diagnosis is based on complaints and an objective examination of the patient; to exclude/detect pathology of the spine and internal organs, additional examination is carried out using radiography, CT, and endoscopy of the gastrointestinal tract. The main directions of therapy are etiotropic, anti-inflammatory, neuroprotective and physiotherapeutic treatment.

General information

Intercostal neuralgia is a pain syndrome associated with damage to the intercostal nerves of any etiology (due to pinching, irritation, infection, intoxication, hypothermia, etc.). Intercostal neuralgia can occur in people of different ages, including in children. Most often it is observed in adults. The most common is intercostal neuralgia, caused by osteochondrosis of the spine with radicular syndrome or intervertebral hernia of the thoracic region, and also caused by herpes zoster. In some cases, intercostal neuralgia acts as a “signaling signal” serious illnesses structures that form the chest or organs located within it (for example, pleurisy, tumors of the spinal cord, chest and mediastinum). In addition, left-sided intercostal neuralgia can mimic cardiac pathology. Due to the diversity of etiologies of intercostal neuralgia, patient management is not limited to clinical neurology, but often requires the participation of related specialists - vertebrologists, cardiologists, oncologists, pulmonologists.

Anatomy of intercostal nerves

Intercostal nerves are mixed, containing motor, sensory (sensitive) and sympathetic fibers. They originate from the anterior branches of the spinal roots thoracic segments spinal cord. There are a total of 12 pairs of intercostal nerves. Each nerve passes in the intercostal space below the edge of its corresponding rib. The nerves of the last pair (Th12) pass under the 12th ribs and are called subcostal. In the area from the exit from the spinal canal to the costal angles, the intercostal nerves are covered by the parietal pleura.

The intercostal nerves innervate the muscles and skin of the chest, the anterior wall of the abdomen, the mammary gland, the costophrenic part of the pleura, and the peritoneum lining the anterolateral surface of the abdominal cavity. The sensory branches of adjacent intercostal nerves branch and connect with each other, providing cross-innervation, in which an area of skin is innervated by one main intercostal nerve and partially by the superior and inferior lying nerve.

Causes of intercostal neuralgia

Damage to the intercostal nerves may be inflammatory in nature and be associated with previous hypothermia or infectious disease. The most common neuralgia infectious etiology is intercostal neuralgia due to herpetic infection, the so-called. herpes zoster. In some cases, damage to the nerves is associated with their injury due to bruises and fractures of the ribs, other injuries to the chest, and spinal injuries. Neuralgia can occur due to compression of nerves by intercostal muscles or back muscles with the development of muscular-tonic syndromes associated with excessive physical activity, working in an uncomfortable position, reflex impulses in the presence of pleurisy, chronic vertebrogenic pain syndrome.

Various diseases of the spine (thoracic spondylosis, osteochondrosis, intervertebral hernia) often cause irritation or compression of the intercostal nerves at the point of their exit from the spinal canal. In addition, the pathology of the intercostal nerves is associated with dysfunction of the costovertebral joints due to arthrosis or post-traumatic changes in the latter. Factors predisposing to the development of neuralgia of the intercostal nerves are deformations of the chest and curvature of the spine.

In some cases, intercostal neuralgia occurs as a result of compression of the nerves by a growing benign tumor of the pleura, a neoplasm of the chest wall (chondroma, osteoma, rhabdomyoma, lipoma, chondrosarcoma), aneurysm of the descending thoracic aorta. Like other nerve trunks, intercostal nerves can be affected when the body is exposed to toxic substances, hypovitaminosis with B vitamin deficiency.

Symptoms of intercostal neuralgia

The main symptom is a sudden unilateral piercing sharp pain in the chest (thoracalgia), running along the intercostal space and encircling the patient’s torso. Patients often describe it as a “lumbago” or “passing electric current.” Moreover, they clearly indicate the spread of pain along the intercostal space from the spine to the sternum. At the beginning of the disease, thoracalgia may be less intense in the form of tingling, then the pain usually intensifies and becomes unbearable. Depending on the location of the affected nerve, pain can radiate to the scapula, heart, or epigastric region. The pain syndrome is often accompanied by other symptoms (hyperemia or pallor of the skin, local hyperhidrosis) caused by damage to the sympathetic fibers that make up the intercostal nerve.

Characterized by repeated pain paroxysms, lasting from a few seconds to 2-3 minutes. During an attack, the patient freezes and holds his breath while inhaling, since any movements, including respiratory excursion of the chest, cause increased pain. For fear of provoking a new painful paroxysm, during the interictal period patients try to avoid sharp turns of the body, deep sighs, laughter, coughing, etc. During the period between painful paroxysms along the intercostal space, paresthesia may be noted - subjective sensory sensations in the form of tickling, crawling.

With a herpetic infection, intercostal neuralgia is accompanied by skin rashes that appear on the 2-4th day of thoracalgia. The rash is localized on the skin of the intercostal space. It represents small pink spots, which are then transformed into vesicles that dry out to form crusts. Itching is typical, occurring even before the first elements of the rash appear. After the disease resolves, temporary hyperpigmentation remains at the site of the rash.

Diagnosis of intercostal neuralgia

A neurologist can determine the presence of neuralgia of the intercostal nerves based on characteristic complaints and examination data. The patient's antalgic posture is noteworthy: in an effort to reduce pressure on the affected intercostal nerve, he tilts his torso to the healthy side. Palpation in the affected intercostal space provokes the appearance of a typical painful paroxysm; trigger points are identified at the lower edge of the corresponding rib. If several intercostal nerves are affected, during a neurological examination an area of decreased or loss of sensitivity in the corresponding area of the skin of the body can be determined.

Clinical differentiation of pain syndrome is important. Thus, when pain is localized in the cardiac region, it is necessary to differentiate them from pain syndrome with cardiovascular diseases, primarily from angina pectoris. Unlike the latter, intercostal neuralgia is not relieved by taking nitroglycerin, but is provoked by movements in the chest and palpation of the intercostal spaces. With angina, a painful attack is of a compressive nature, provoked by physical activity and is not associated with turning the body, sneezing, etc. In order to clearly exclude coronary heart disease, the patient is given an ECG, and if necessary, a consultation with a cardiologist is indicated.

When the lower intercostal nerves are damaged, the pain syndrome can mimic diseases of the stomach (gastritis, gastric ulcer) and pancreas (acute pancreatitis). Stomach pathology is characterized by a longer and less intense pain paroxysm, usually associated with food intake. With pancreatitis, girdle pain is also observed, but they are usually bilateral in nature and associated with food. In order to exclude pathologies of the gastrointestinal tract, additional examinations may be prescribed: determination of pancreatic enzymes in the blood, gastroscopy, etc. If intercostal neuralgia occurs as a symptom of thoracic radiculitis, then painful paroxysms occur against the background of constant dull pain in the back, which decreases with unloading of the spine in horizontal position. To analyze the condition of the spine, an X-ray of the thoracic region is performed, and if an intervertebral hernia is suspected, an MRI of the spine is performed.

Intercostal neuralgia can be observed in some lung diseases (atypical pneumonia, pleurisy, lung cancer). To exclude/detect such a pathology, a chest x-ray is performed, and if indicated, a computed tomography is performed.

Treatment of intercostal neuralgia

Implemented complex therapy, aimed at eliminating the causative pathology, relieving thoracalgia, and restoring the affected nerve. One of the main components is anti-inflammatory therapy (piroxicam, ibuprofen, diclofenac, nimesulide). In case of severe pain, drugs are administered intramuscularly, therapy is supplemented by therapeutic intercostal blockades with the administration of local anesthetics and glucocorticosteroids. An auxiliary means in relieving pain is the appointment sedatives, allowing to reduce pain by increasing the threshold of excitability of the nervous system.

Etiotropic therapy depends on the genesis of neuralgia. So, for herpes zoster, antivirals(famciclovir, acyclovir, etc.), antihistamine pharmaceuticals and local use of antiherpetic ointments. In the presence of muscular-tonic syndrome, muscle relaxants (tizanidine, tolperisone hydrochloride) are recommended. If there is compression of the intercostal nerve at the exit of the spinal canal due to osteochondrosis and displacement of the vertebrae, gentle manual therapy or spinal traction can be performed to relieve the compression. If nerve compression is caused by a tumor, surgical treatment is considered.

In parallel with etiotropic and anti-inflammatory therapy, neurotropic treatment is carried out. To improve the functioning of the affected nerve, it is prescribed intramuscular injection B vitamins and ascorbic acid. Drug therapy successfully complemented by physiotherapeutic procedures: ultraphonophoresis, magnetotherapy, UHF, reflexology. For herpes zoster, local UV irradiation on the area of the rash is effective.

Forecast and prevention of intercostal neuralgia

In general, with adequate treatment, intercostal neuralgia has a favorable prognosis. Most patients experience complete recovery. In the case of herpetic etiology of neuralgia, relapses are possible. If intercostal neuralgia is persistent and cannot be treated, you should carefully reconsider its etiology and examine the patient for the presence of a herniated disc or tumor process.

Prevention measures include timely treatment diseases of the spine, prevention of its curvature, adequate treatment of chest injuries. The best protection against herpes infection is high level immunity, which is achieved in a healthy way life, hardening, moderate physical activity, active recreation Outdoors.

Rib cage- the bone base of the chest walls. Consists of XII thoracic vertebrae, XII pairs of ribs and sternum.

Chest walls:

The posterior wall is formed by the thoracic part of the spinal column, as well as the posterior sections of the ribs from the head to their corners.

The anterior wall is formed by the sternum and the cartilaginous ends of the ribs.

The lateral walls are formed by the bony part of the ribs.

The upper aperture of the chest is limited by the posterior surface of the manubrium of the sternum, the inner edges of the first ribs and the anterior surface of the first thoracic vertebra.

Skeleton of the chest, a - front view. 1 - upper thoracic aperture; 2 - jugular

Topography of intercostal spaces.

Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest
:

I – between the middle axillary and paravertebral lines;

II - between the middle axillary and midclavicular lines.

1 – fascia m. latissimusdorsi; 2 – m. latissimusdorsi; 3 – fascia thoracica; 4 – v. intercostalis;

5 – a. intercostalis; 6 – n. intercostalis; 7 – m. Intercostalisexternus; 8 – m. intercostalisinternus;

9 – fasciaendothoracica; 10 – prepleural tissue; 11 – pleura parietalis;

12 – fasciapectoralis; 13 - m. pectoralis major.

In the spaces between the ribs there are external and internal intercostal muscles, fiber and neurovascular bundles.

External intercostal muscles (mm. intercostalisexterni) go from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, muscles are absent and replaced by the outer intercostal membrane.

Internal intercostal muscles (mm. intercostales interni) go obliquely from bottom to top and back. Posterior to the costal angles, muscle bundles are absent and replaced by an internal intercostal membrane.

The space between adjacent ribs, limited externally and internally by the corresponding intercostal muscles, is called the intercostal space. It contains a vein, below it is an artery, and even lower is a nerve.

Posterior intercostal arteries(IX-X pairs) extend from the aorta, located in the intervals from the III to the XI ribs, the twelfth artery, lying under the XII rib, is called the subcostal artery (a. subcostalis). Branches:

· Dorsal branch (r. dorsalis) goes to the muscles and skin of the back

· Lateral and medial cutaneous branches (r. cutaneus lateraliset medialis) go to the skin of the chest and abdomen

· Lateral and medial branches of the mammary gland (rr. mammariilateraliset medialis)