a 74-year - old female patient visited a pain clinic , complaining of pain in her back , and left chest wall .
six years earlier , the patient had a lateral fixation at t12 , l1 , and l2 , due to a compression fracture at l1 .
two years after this operation , the patient had osteoporotic compression fractures at t6 and t9 . for the past three months
, the patient had complained about pain at an nrs 7 on the left chest wall , which started without any serious trauma .
after the patient was diagnosed in the neurosurgery department , with compression fractures at t8 and t9 , she was scheduled to undergo vertebroplasty . on the physical examination
, the patient stated that the left paraspinal muscles at the height of t8-t10 were tender when compressed , but did not have any percussion pain or facet joint tenderness .
when the spine was bent forward , the patient complained about a sharp pain in the left mid - axillary line and radiating pain toward the abdomen .
however , the patient did not have any tenderness in her ribs , and the pain was not elicited when she took a deep breath or coughed .
on palpation , the 10 rib was not felt , and the rib - cage image confirmed that the left 10 rib was severed ( fig .
we had determined that perhaps the 10 rib was severed during the last operation 6 years previous . when applying pressure to the 10 rib from the legs to the lower margin of the 9 rib of the patient ( the hooking maneuver ) , the pain was reproduced .
therefore , we assumed that the patient had 9 rib syndrome , similar to 12 rib syndrome , and ultrasound - guided 9 and 10 intercostal nerve blocks using 2 ml of 0.25% ropivacaine and 10 mg of triamcinolone were performed around the tips of the severed 10 rib . in addition , 2 ml of 0.25% ropivacaine and 10 ml of triamcinolone were administered into the muscles beneath the 9 rib at the point of the greatest tenderness .
no additional procedures were performed , but the patient was instructed to avoid postures that could cause pain .
the pain has not occured again up to date , and the patient is only receiving only the treatment for osteoporosis .
cyriax reported in 1919 that pain could be caused by impingement on the intercostal nerves , and in 1922 it was named the slipping rib syndrome by davies - colley . depending on the locations of the impinged intercostal nerves and the authors writing about the syndrome
, various names were used to refer to the syndrome , including 12 rib syndrome , slipping rib syndrome , rib tip syndrome , clicking rib syndrome , cyriax 's rib syndrome , and painful rib syndrome .
the mechanism that causes pain in the intercostal nerves is a hypermobile rib impinging on the intercostal nerve of the rib one level above due to the loosening of the costochondral cartilages of the lower rib .
therefore , pain can be triggered or made more severe when patients perform lateral flexion and rotation of the trunk .
slipping rib syndrome is a common disorder , and shows a higher prevalence among women than men by a ratio of 3:1 . while the 12 rib syndrome occurs more frequently among women than men by a ratio of 4:1 .
scott et al .   conducted a study targeting 76 patients with painful rib syndrome .
the mean age of the patients at presentation was 48 years , and the mean duration of pain at presentation was 32 months .
forty - three percent of the subjects had pain in the left side , 45% had pain in the right side , 4% had pain in both sides , and 7% had pain in the xiphoid area .
among the entire study population , 43% said that they already underwent various tests , including barium meal , barium enema , endoscopy , ultrasound scanning , intravenous urography , and spinal radiology ; some patients had laparotomy and non - curative cholecystectomy in combination with them . if a patient tests positive using the hooking maneuver , the syndrome is suspected .
if tender spots causing pain are felt upon palpation , and the pain can be relieved when intercostal nerve blocks are performed , this confirms the diagnosis of the syndrome .
imaging tests such as ct , mri , or bone scan do not offer much help , and if a differential diagnosis is deemed necessary , tests for biliary tract pathology , peptic ulceration , and urological pathology can be performed .
scott et al .   stated , " with firm reassurance and explanation , the pain either disappears usually within three months , or the patient learns to live with it as a minor nuisance .
if the pain does not settle within three months it will become chronic in the vast majority " .
if a physician approaches patients without suspecting 12 rib syndromes , diagnosis will be delayed .
so the patients ' activities will be limited by pain , the patient may lead to depression and anxiety , due to prolonged pain without knowing the cause , and the patient may suffer financial burdens due to unnecessary medical tests .
the most important aspect of medical treatment is that physicians provide accurate information on diseases , give reassurance , and advise patients to refrain from physical activities , which may cause pain .
if pain is not controlled by medication , an intercostal nerve block with local anesthetics and long - acting steroid infiltration to the tip of the affected rib can be performed .
if the pain relief effect is not sustained , an intercostal nerve cryotherapy , costo - vertebral blocks , and a percutaneous dorsal root ganglion radiofrequency thermos - coagulation can be performed .
if the pain is not controlled by the above procedures , a rib resection can be performed . in this case - study , it is suspected that the patient had a partial resection of the left 10 rib in the past , and subsequent compression fractures at t8 and t9 led to the deformation of the rib cage ( fig .
3 ) , causing the tip of the remaining 10 rib to impinge on the 9 intercostal nerves , causing pain .
 the 12th rib syndrome is a disease that causes pain between the upper abdomen and the lower chest . 
 it is assumed that the impinging on the nerves between the ribs causes pain in the lower chest , upper abdomen , and flank . 
 a 74-year - old female patient visited a pain clinic complaining of pain in her back , and left chest wall at a 7 on the 0 - 10 numeric rating scale ( nrs ) . 
 she had a lateral fixation at t12-l2 , 6 years earlier . 
 after the operation , she had multiple osteoporotic compression fractures . 
 when the spine was bent , the patient complained about a sharp pain in the left mid - axillary line and radiating pain toward the abdomen . on physical examination , the 10th rib was not felt , and an image of the rib - cage confirmed that the left 10th rib was severed . when applying pressure from the legs to the 9th rib of the patient , pain was reproduced . 
 therefore , the patient was diagnosed with 9th rib syndrome , and ultrasound - guided 9th and 10th intercostal nerve blocks were performed around the tips of the severed 10th rib . 
 in addition , local anesthetics with triamcinolone were administered into the muscles beneath the 9th rib at the point of the greatest tenderness . 
 the patient 's pain was reduced to nrs 2 point . in this case , it is suspected that the patient had a partial resection of the left 10th rib in the past , and subsequent compression fractures at t8 and t9 led to the deformation of the rib cage , causing the tip of the remaining 10th rib to impinge on the 9th intercostal nerves , causing pain . 
CASE REPORT
DISCUSSION