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Multiple myeloma is a neoplasm of plasma cells affecting mostly the elderly with incidence peaks between 60 and 70 years. This disease is exceedingly rare in younger people, especially in adults under 30-year-old. Non-secretory multiple myeloma accounts for 1–5% of all cases of multiple myeloma. It is also a rare condition in young adult patients, and only six cases have been reported [1]. We herein describe a rare case of non-secretory myeloma in a 22-year-old male, explaining from chest wall pain, without general manifestation. Plain radiography and CT scans revealed diffuse osteolytic lesion mimicking the Gorham disease. A bone marrow biopsy was conducted, revealing the diagnosis of myeloma.

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Post-mastectomy pain syndrome (PMPS) is a common and often debilitating condition. The syndrome is defined by chest wall pain unresponsive to standard pain medications and the presence of exquisite point tenderness along the inframammary fold at the site of the T4 and T5 cutaneous intercostal nerve branches as they exit from the chest wall. Pressure at the site triggers and reproduces the patient’s spontaneous or motion-evoked pain. The likely pathogenesis is neuroma formation after injury to the T4 and T5 intercostal nerves during breast surgery. We assessed the rate of long-term resolution of post-mastectomy pain after trigger point injections (2 mL of 1:1 mixture of 0.5% bupivacaine and 4 mg/mL dexamethasone) to relieve neuropathic pain in a prospective single-arm cohort study. Fifty-two women (aged 31–92) who underwent partial mastectomy with reduction mammoplasty or mastectomy with or without reconstruction, and who presented with PMPS were enrolled at the University of California San Francisco Breast Care Center from August 2010 through April 2018. The primary outcome was a long-term resolution of pain, defined as significant or complete relief of pain for greater than 3 months. A total of 91 trigger points were treated with mean follow-up 43.9 months with a 91.2% (83/91) success rate. Among those with a long-term resolution of pain, 60 trigger points (72.3%) required a single injection to achieve long-lasting relief. Perineural infiltration with bupivacaine and dexamethasone is a safe, simple, and effective treatment for PMPS presenting as trigger point pain along the inframammary fold.

Celiac artery compression is a rare condition in which the celiac artery is compressed by the median arcuate ligament. Case reports of compression after trauma are hard to find. Blunt traumatic pericardium rupture is also a rare condition. We report a single patient who experienced both rare conditions from a single blunt injury. An 18-year-old woman was brought to the trauma center after a fatal motorcycle accident, in which she was a passenger. The driver was found dead. Her vital signs were stable, but she complained of mild abdominal pain, chest wall pain, and severe back pain. There were no definite neurologic deficits. Her initial computed tomography (CT) scan revealed multiple rib fractures, moderate lung contusions with hemothorax, moderate liver injury, and severe lumbar spine fracture and dislocation. She was brought to the angiography room to check for active bleeding in the liver, which was not apparent. However, the guide wire was not able to pass through the celiac trunk. A review of the initial CT revealed kinking of the celiac trunk, which was assumed to be due to altered anatomy of the median arcuate ligament caused by spine fractures. Immediate fixation of the vertebrae was performed. During recovery, her hemothorax remained loculated. Suspecting empyema, thoracotomy was performed at 3 weeks after admission, revealing organized hematoma without pus formation, as well as rupture of the pericardium, which was immediately sutured, and decortication was carried out. Five weeks after admission, she had recovered without complications and was discharged home.

Patients with systemic lupus erythematosus (SLE) presenting with chest pain pose a unique diagnostic challenge, with causes ranging from cardiopulmonary disease to esophageal disorders and musculoskeletal chest wall pain. The most common biomarkers for myocardial injury are cardiac troponin T and I (cTnT and cTnI) due to their high sensitivity for the early detection of myocardial infarction. In the idiopathic inflammatory myopathies, cTnT is commonly elevated, and this reflects skeletal muscle breakdown rather than myocardial damage. Similar observations have not been reported in SLE myositis to date. We present two cases of patients with SLE and associated myositis who presented with chest pain and elevated cTnT. Both patients had a normal cTnI, transthoracic echocardiogram, and cardiac magnetic resonance imaging, likely indicating noncardiac chest pain. Clinicians should be aware that the specificity of cTnT might be lower in SLE myositis and that cTnI elevation may be more specific in detecting myocardial insult.

A 25-year-old man with a venous malformation (VM) along the anterior and posterolateral aspects of the right chest wall presented with progressive enlargement of VM, chest wall pain, and physical disfigurement. Because of the complexity and size of the VM, a staged multidisciplinary team approach, ie percutaneous embolization, followed by surgical resection and tissue-skin grafting was used. The percutaneous embolization was achieved with a combination of liquid embolic agents including n-butyl cyanoacrylate for the superficial cutaneous component and ethylene vinyl alcohol copolymer for the deeper subcutaneous component of the VM. Such a combination can achieve safe occlusion of the VM, facilitate surgical resection without blood loss, and contribute to a cosmetically desirable result.

Background Poststernotomy pain syndrome (PSPS) is defined as chronic pain after thoracic surgery persisting for at least 2 months and without apparent cause. The incidence of PSPS after surgery is reported to be between 7% and 66%. Currently, there is no standard protocol for management of such cases, and treatment modalities are mainly directed towards the use of various analgesics. Numerous other approaches have been tried in order to relieve this pain, including osteopathy, trigger point infiltration and acupuncture. Methods A case series study was conducted; data were collected from 20 patients seeking pain relief for poststernotomy pain, at the Outpatient Pain Clinic, National Research Center, Cairo, Egypt. Treatment consisted of local wound infiltration with lidocaine 1% and acupuncture. Each patient was scheduled for twice weekly sessions over a period of 4 weeks. Pain was measured using visual analogue scales (VAS) pre and post each treatment session. Results Out of the 20 patients, 15 participants completed all 8 sessions. They reported improvement in their chest wall pain, compared to their initial presenting state. There was a significant decrease in pain score from initial VAS to first measurement (p = 0.001), between 3 and 4 (p = 0.014), 4 and 5 (p = 0.013), 5 and 6 (p = 0.014) and between 6 and 7 measurement (p = 0.008). Conclusion The dual approach of acupuncture and trigger point injection for PSPS patients offer a promising means of pain relief. Controlled studies with larger numbers of patients are required.

Proton beam therapy (PBT) is one of the advances in radiotherapy techniques, which enables dose escalation with lower probability of radiation-induced liver or gastrointestinal injuries. However, the chest wall proximal to the tumor can be affected by high dose irradiation. Here, we report on a 58-year-old male patient who presented with huge hepatocellular carcinoma, received treatment with transarterial chemoembolization and PBT, and developed severe chest wall pain due to radiation-induced myositis. The patient’s symptoms were controlled by oral steroids. (J Liver Cancer 2019;19:136-142)

A 75-year-old man presented to our Interventional Cancer Pain service for consideration of a percutaneous cervical cordotomy (PCC) to control severe chest wall pain secondary to malignant mesothelioma. His medical history included a neuroinflammatory disorder, neuromyelitis optica, for which he had previously had a prolonged hospital admission, with ongoing neurological deficit. Little information is available regarding the safety of PCC in a patient with this condition, specifically the risk of neurological relapse, and we were initially wary about going ahead. After discussion with the patient’s neurology team and other UK experts and with the patient’s informed consent, we proceeded to PCC with additional steroid cover. No adverse neurological symptoms were encountered perioperatively or postoperatively and the patient had an excellent analgesic result. As this combination of circumstances has not to our knowledge been documented, we wished to present this case and discuss the factors affecting our decision and management.

Atypical chest wall pain may present as an isolated musculoskeletal pain syndrome or as a manifestation of a systemic process, including rheumatic or malignant disease. Potentially life-threatening cardiac and pulmonary causes must be ruled out in the initial diagnostic evaluation for chest pain. Noncardiopulmonary chest wall pain is more commonly due to costosternal syndrome and lower rib syndrome; however, more rare causes should be considered, such as sternalis syndrome, Tietze's syndrome, and xiphoidalgia. These syndromes are typically managed conservatively and are self-limited while treatment is considered for refractory cases.

Radiation-induced chest wall pain (cwp) and rib fracture (rf) are late adverse effects after stereotactic body radiation therapy (sbrt) for stage i non-small-cell lung cancer (nsclc), however, the literature about their incidence and risk factors shows variability. We performed a systematic review to determine the pooled incidence of cwp and rf in the relevant population. A literature search using the prisma (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines considered English publications in medline and embase from January 1996 to August 2017. Abstracts were screened, followed by full-text review and data extraction. The database searches identified 547 records. Twenty-eight publications comprising 3892 patients met the inclusion criteria. Median reported ages and follow-up durations fell into the ranges 67&ndash, 82 years and 12&ndash, 84 months. Prescriptions fell into the range of 40&ndash, 70 Gy in 3&ndash, 10 fractions. Despite study heterogeneity, the pooled incidences of cwp and rf were estimated to be 8.94% and 5.27% respectively. Nineteen studies reported cwp grade: 58 of 308 patients (18.8%) experienced grades 3&ndash, 4 cwp (no grade 5 events reported). Thirteen studies reported rf grade: grades 3&ndash, 4 rf were observed in 9 of 113 patients (7.96%). A high chest wall V30 was an important predictor of cwp and rf. In patients with stage i nsclc, rates of cwp and rf after sbrt are low, however, tumour location, accurate toxicity reporting, and dose&ndash, fractionation schemes might alter those rates. Prospective correlation with dosimetry and quality of life assessment will further improve the understanding of cwp and rf after sbrt.

Highlights • The role of SBRT for T3N0 lung cancer invading the chest wall is unknown. • We treated 12 patients with T3N0 chest wall-invading lung cancer with SBRT. • Local control was excellent and no grade 3+ toxicity was observed. • Pre-treatment chest wall pain was relieved after SBRT in most patients., Objectives Chest wall invasion (CWI) is observed in 5% of localized non-small cell lung cancer (NSCLC). The role of stereotactic body radiotherapy (SBRT) in these patients is unknown. We investigate the safety and efficacy of SBRT in patients with T3N0 NSCLC due to CWI. Methods Patients with T3N0 NSCLC due to CWI were identified using a prospective registry. CWI was defined as radiographic evidence of soft tissue invasion or bony destruction. We excluded patients with recurrent or metastatic disease. All patients were treated with definitive SBRT. Prescribed dose was 50 Gy in 5 fractions for most patients. Kaplan-Meier analysis was used to estimate survival outcomes. Results We identified 12 patients treated between 2006 and 2017. Median age was 70 (range, 58–85). Median tumor diameter was 3.0 cm (range, 0.9–7.2). Median survival was 12.0 months (range, 2.4–63). At a median follow-up of 8.9 months (range, 2.1–63), 1-year primary tumor control was 89%, involved lobar control was 89%, local–regional control was 82%, distant control was 91%, and survival was 63%. Of the 4 patients with pre-treatment chest wall pain, 3 reported improvement after SBRT. Two patients reported new grade 1–2 chest wall pain. No grade 3+ toxicity was reported, with 1 patient experiencing grade 1 skin toxicity and 3 patients experiencing grade 1–2 radiation pneumonitis. Conclusions SBRT for CWI NSCLC is safe, with high early tumor control and low treatment-related toxicity. Most patients with pre-treatment chest wall pain experienced relief after SBRT, with no grade 3+ toxicity observed.

Background: Interventional pain management is essential for patients with cancer who experience medically uncontrollable chest wall pain to help control their symptoms and improve their quality of life. However, there is a lack of data on this topic, so there is an urgent need for further research. Objectives: To identify the effects of radiofrequency ablation (RFA) of the thoracic nerve roots on pain outcomes in patients with cancer and intractable chest wall pain. Study Design: Retrospective, observational cohort study. Setting: National Cancer Center in Korea. Methods: The medical records of patients with cancer who were referred to the pain clinic at our National Cancer Center for intractable chest wall pain and who underwent thoracic nerve root RFA between Jan. 1, 2011 and Dec. 31, 2015 were analyzed. The primary outcome was the change in Numeric Rating Scale (NRS) scores between pre-procedure and one week, one month, and 6 months post-procedure. The secondary outcomes were the change in morphine equivalent daily dose (MEDD) between pre-procedure and one week, one month, and 6 months post-procedure, and whether the primary cancer type (lung vs. non-lung) or radiotherapy to the chest within one month affected the outcomes of RFA. The Wilcoxon signed-rank test was used to compare RFA data between pre and post-procedure and P values less than 0.05 were considered statistically significant. Results: One hundred patients were included in the final analysis. The median NRS score in patients who underwent RFA decreased from 7 (range 3–10) pre-procedure to 4 (0–9) at one week and one-month post-procedure (both P < 0.001) and 4 (1–8) at 6 months post-procedure (P < 0.001). The median MEDD value decreased from 200 (range 30–1800) mg pre-procedure to 180 (10–1600) mg at one week post-procedure (P < 0.001), but there was no statistically significant change at one month (P = 0.699) or 6 months (P = 0.151) post-procedure. There was no difference in RFA outcome according to type of primary cancer or radiotherapy to the chest within one month. Limitations: Retrospective design. Conclusion: Radiofrequency thermocoagulation of the thoracic nerve roots achieved effective short-term pain control in patients with cancer and intractable chest wall pain. Key words: Radiofrequency ablation, thermocoagulation, thoracic nerve root, cancer, chest wall pain, radiotherapy, pain relief

BACKGROUND Regaining and maintaining sternal stability is key to recovering from cardiac surgery and resuming normal life. MontageTM (ABYRX, Irvington, NY, USA) is a settable, resorbable putty that adheres to bleeding bone and achieves rigid sternal fixation following application (Image). We evaluated feasibility, safety, and efficacy of enhanced sternal closure (ESC) with a novel bone putty to accelerate post-operative functional recovery in patients receiving median sternotomy. METHODS AND RESULTS A single-center, single-blinded (participant only), randomized controlled trial was performed (NCT03365843). Consenting patients for elective cardiac surgery via sternotomy received sternal closure using either 8-10 cc of bone putty with wire cerclage (ESC) or wire cerclage alone (control). To date, 32 patients with ESC and 25 control patients reached 6 weeks with 100% follow-up. Student t-test and Fischer's exact test analyzed continuous (mean ± SEM) and categorical variables (Table). Both groups had similar BMI. There were no device-related safety concerns. The ESC group had a shorter time to discharge. Bedside spirometry was used when COVID-19 restrictions allowed. At 5 days or discharge, more patients with ESC recovered to 60% of their baseline FVC (22/28 patients vs 11/23 patients; p=0.04; ESC vs Control). A Likert-type 11-point scale quantified incisional, chest wall, and back pain/discomfort. The ESC group had less incisional pain while resting and at post-operative day 5 or discharge; while breathing at day 5 or discharge; while sleeping at day 5 or discharge and 2 weeks; and while walking at day 5 or discharge. The ESC group had less chest wall pain at day 3 and day 5 or discharge; and less back pain at day 3 and day 5 or discharge. Standardized patient-reported outcomes measures assessed health-related quality of life (EQ-5D index) and physical disability (Health Assessment Questionnaire). ESC improved physical functional recovery with a lower HAQ Index at day 5 or discharge, 2 weeks, and 4 weeks. More patients with ESC recovered to baseline HAQ at 2 weeks and 4 weeks. ESC increased EQ-5D Index scores for quality of life at day 5 or discharge, 2 weeks, and 4 weeks. More patients with ESC recovered to baseline EQ-5D Index by 5 days or discharge. CONCLUSION Enhanced sternal closure with a novel hardening bone putty for rigid fixation accelerates patient recovery. ESC improved ventilatory recovery, reduced pain, and accelerated recovery to baseline function and quality of life. Earlier hospital discharge with ESC may provide substantial cost benefits for the healthcare system.

Author(s): Chandwani, Deepak; Arnold, Jeff; Terrusa, John | Abstract: Case Presentation: A 30-year-old healthy male presented with a complaint of chest pain after mild thoracic trauma sustained while rescuing stranded flood victims during Hurricane Harvey. Careful physical examination revealed a tender palpable cord along the lateral aspect of his chest consistent with a superficial thrombophlebitis.Discussion: Mondor’s disease is a superficial thrombophlebitis with myriad underlying causes that can involve the thoracic wall. Although Mondor’s disease has been well described in the literature, this case describes a unique presentation in an austere environment with blunt trauma as the underlying cause.

Chronic chest wall pain syndrome is a rare phenomenon in which a patient may experience recurrent sharp, shooting, or dull, achy pain along part of or the entire chest wall. Due to a number of diseases, some of them life threatening, associated with chest pain, patients often undergo a series of tests to rule out a variety of different etiologies, including pain secondary to cardiac, pulmonary, and oncologic pathologies. Often times, as a last resort effort to determine the cause of the pain, patients will undergo an MRI of the thoracic spine, showing a mildly herniated intervertebral disc impinging on one or more intercostal nerves. While rare in the thoracic vertebrae, disc herniation can lead to this chronic chest wall pain syndrome and should be dealt with in a stepwise manner. Treatment options include conservative management in the beginning, including physical therapy, stretching, ice and hot packs, and anti-inflammatory medications to relieve the pain. With further intractable pain, more invasive treatment options are available, and include thoracic epidural steroid injections, intercostal nerve blocks, intervertebral discectomy, radiofrequency ablation of the intercostal nerves, and implantation of spinal cord stimulators. Early interventions have been shown to decrease both the time to alleviation and risk of recurrence of chronic chest wall pain syndrome, while longer episodes have been associated with an intractable form of the condition.

Thoracic facet joint injection is performed for chronic facet-related back pain. This chapter provides a step-by-step guide on how to perform this intervention safely and shows all the relevant C-arm and needle positions that need to be demonstrated during the Fellow of Interventional Pain Practice (FIPP) exam administered by the World Institute of Pain (WIP). Both native and edited high-quality images are included, so the fluoroscopy anatomy is more easily understood.

Intercostal nerve block is performed for intercostal neuralgia and chest wall pain. This chapter provides a step-by-step guide on how to perform this intervention safely and shows all the relevant C-arm and needle positions that need to be demonstrated during the Fellow of Interventional Pain Practice (FIPP) exam administered by the World Institute of Pain (WIP). Both native and edited high-quality images are included, so the fluoroscopy anatomy is more easily understood.

Background: Lymphedema of the breast/chest wall after breast cancer treatment is often associated with pain and reduced quality of life. We conducted a pilot study to evaluate whether the use of a compression vest reduced symptoms of breast/chest wall edema in breast cancer patients. Methods and Results: This single-center study included patients (n = 25) with symptomatic breast/chest wall edema with a pain score of ≥3 on the Numerical Rating Scales (range 1-10). The patients were instructed to wear a compression vest (Lymphatrex, Class II) for 6 months. Wilcoxon signed-rank tests were used to compare differences in patient-reported pain intensity/severity. Analyses included all patients with available data. In total, 17 (68%) continued to wear their vests for 6 months, whereas the other 8 withdrew prematurely. At baseline, median pain severity (4.9, interquartile range [IQR] 3.6-6.0) and pain interference (4.3, IQR 2.1-5.9) scores were significantly higher compared with pain scores after wearing the compression vest for 6 months (1.8 IQR 1.0-4.8 and 1.4 IQR 0.9-4.4, resp.). Patient-reported breast/chest wall swelling decreased from 92% (n = 22) at baseline to 71% (n = 12) at 6 months. The prevalence of moderate/severe patient-reported breast/chest wall pain declined from 63% (n = 15) at baseline to 18% (n = 3) at 6 months. Physical, emotional, and social functioning improved over time and was comparable to scores of the Dutch reference population. Conclusion: The results of this pilot study suggest that a compression vest could be an acceptable and effective treatment option for patients with painful breast/chest wall edema. In compliant patients, swelling and pain was significantly reduced.

Introduction: Diabetic polyneuropathy involves peripheral, cranial or autonomic nerves causing well known clinical presentations, easily identifiable by clinicians. Rarely, diabetic neuropathy affects the intercostal neural roots causing severe and difficult to treat thoracic and abdominal pain. We present an interesting case where diagnosis of thoracic radiculopathy was made 8 years later. Case Presentation: A 62-year-old man with type 1 diabetes mellitus presented with a history of severe right lower thoracic and flank pain. He was diagnosed with diabetes at age 20 and developed complications such as peripheral polyneuropathy. His pain was sharp and burning in nature in a “band like” distribution in the right lateral subcostal margin. The intensity ranged from 3-10/10. Exam showed tenderness to touch in the right lateral subcostal margin with no sensory deficits. He visited different specialists within a year in attempts to obtain pain relief. Therapeutic attempts done included opiates, duloxetine, gabapentin and NSAIDs with minimal improvement. Initial workup included a normal bone scan and thoracic spine MRI which showed degenerative disk disease at the level of T7-T8. Corticosteroid injection at T7-T9 resulted in no pain relief. Then a pain specialist made the diagnosis of DTR. A T10 nerve block was given with significant relief. Since then, he has received intermittent nerve blocks with complete resolution of his symptoms. Discussion: Diabetic neuropathy is the most common complication of diabetes mellitus. Truncal roots originating from the spinal cord can be affected causing a distinct disorder termed Diabetic Truncal Radiculopathy (DTR). DTR is a rare form of diabetic neuropathy that is significantly underdiagnosed. DTR is of three types - Cervical, thoracic and lumbosacral. It is commonly unilateral following the distribution of an intercostal nerve in a band like pattern. The pain is described as burning or aching in nature, frequently intensified at night associated with sensitivity to touch. The patients are usually middle aged or older adults with long standing history of diabetes. There is certain preference for men with DM type 2. It is a diagnosis of exclusion. EMG typically demonstrates denervation potentials in the intercostal, anterior abdominal wall and paraspinal muscles. The differential diagnosis is primarily based on the localization of neural injury. Involvement of upper thoracic nerves causes chest pain whereas lower thoracic nerves causes upper abdominal pain. The management is similar to other diabetic related neuropathies but challenging. Intensive glycemic control is ineffective in pain relief. DTR should be considered as a possible cause of atypical flank or chest wall pain not explained by other causes. Simple interventions such as intercostal nerve blocks are successful in improving the pain, quality of life and functionality of patients. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Introduction: The relationship between chronic empyema and malignant tumors, most of which are lymphoma, has been recognized for many decades. Sarcomatoid carcinoma associated with chronic empyema is extremely rare, may metastasize to other organs in the early stage, and rapidly progresses to death. As far as we know, this was the first case report on sarcomatoid carcinoma associated chronic empyema. The patient's main concerns and important clinical findings: A 59-year-old man presented to our hospital with a 9-year history of chronic empyema and a chief complaint of left chest wall pain for 5 months. The diagnostic contrast-enhanced computed tomography (CT) showed a large irregular soft tissue mass located on the left lower hemithorax at the margin of the empyema cavity extending to the adjacent chest wall and lung parenchyma. In addition, CT revealed pleural and pulmonary metastases surrounded by ground glass opacity. The main diagnosis, therapeutics interventions, and outcomes: The patient underwent CT guided percutaneous core needle biopsy (PCNB). The histopathological evaluation showed carcinomatous proliferation of pleomorphic spindle cells with extensive necrosis. Immunohistochemically, tumor cells were positive for cytokeratin and vimentin. The final histopathological diagnosis was sarcomatoid carcinoma underlying chronic empyema. The tumors showed rapid progression on serial simple radiography. Palliative treatments were performed, but the patient still developed severe dyspnea and died shortly after on day 16. Conclusion: Sarcomatoid carcinoma can occur very rarely as a complication of chronic empyema, and is more aggressive than usual. Early detection of developing malignancy during the follow-up of chronic empyema is an important factor for patient prognosis.

BackgroundThere is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.MethodsA systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.ResultsTwenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.ConclusionsGiven the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.Level of evidenceLevel IV systematic reviews and meta-analyses.

Management of intractable cancer-associated chest wall pain is difficult once patients have reached dose-limiting side effects of opioids and coanalgesic medications. This case series describes 11 patients with intractable cancer-associated chest wall pain who were treated with a diagnostic intercostal nerve block. Six patients subsequently received chemical neurolysis with phenol using the same approach. No serious adverse events were observed. Radiopaque contrast dye spread into the paravertebral space in all 11 patients, and in 1 patient contrast dye spread into the epidural space. Seven of 11 patients experienced pain relief from the diagnostic blockade. Four of six patients experienced pain relief from the neurolytic blockade. The principal reportable finding from this case series is the observation that contrast dye spread liberally from the intercostal space into other anatomic spaces, even though very small volumes of injectate (less than 5 mL) were used. Definitive evidence of safety and efficacy of intercostal nerve block and neurolysis for cancer pain will require a prospective randomized clinical trial.

In this case report, we described the use of the continuous erector spinae plane (ESP) block in a patient presenting with severe chest wall pain due to terminal metastatic breast cancer. Her pain was refractory to most treatment modalities despite being on huge doses of parenteral opioids for 6 months. A single shot ESP block was initially trialed, which provided her complete pain relief. This was followed by an ESP catheter insertion and continuous infusion of local anesthetic, which helped her wean off the parenteral opioids over the next 4 days. She was discharged home with the catheter in situ, attached to a delivery pump.

A 71-year-old female presented to the emergency room eight weeks status post open heart surgery for aortic valve replacement with right-sided chest wall pain and swelling. Computed tomographic (CT) angiography demonstrated a hyperattenuating structure arising from the right internal mammary artery surrounded by a heterogeneously-attenuating fluid collection in the anterior right chest wall, compatible with a right internal mammary artery pseudoaneurysm with surrounding chest wall hematoma. Follow up color Doppler ultrasound confirmed the diagnosis. Under direct ultrasound visualization, we injected four hundred units of thrombin into the neck of the pseudoaneurysm using a 25-gauge spinal needle. Post-injection imaging demonstrated a successful cessation of flow within the pseudoaneurysm sac.

Background Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. Case Report A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. Why Should an Emergency Physician Be Aware of This? In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.

Background. The aim of the study was to determine the diagnostic agreement between the discharge diagnosis and the suspected diagnosis by the prehospital emergency physician and to run a sensitivity analysis of the most common diagnoses by the prehospital emergency physician. Methods. The diagnostic agreement was determined by a systematic comparison of the discharge diagnosis with suspected diagnosis by the prehospital emergency physician in a period of 24 months at the emergency medical services in Bad Belzig. The diagnostic agreement of the 13 most common discharge diagnoses was compared to the remaining diagnostic agreement. The results were tested for statistical significance using the chi-squared test. Results. In 64.1% of cases included, a diagnostic agreement occurred. There was a high proportion of diagnostic agreement for hypoglycemia (97%), atrial fibrillation (87%), cramping seizure (86%), hypertensive crisis (85.5%), and syncope (81%). There was a low proportion of diagnostic agreement for chest wall pain (27%), pneumonia (32%), and cardiac decompensation (53%). Conclusions. Our attention in practice and emergency medical courses should be directed to chest pain patients and the main symptom of dyspnea, because of the high proportion of incorrect diagnoses by the prehospital emergency physician. It should be noted that 92% of incorrectly diagnosed chest wall pain cases were overestimated with an acute coronary syndrome.

Conditions affecting the musculoskeletal structures of the chest wall are among the most common causes of chest pain. It is vital to rule out coronary syndromes in patients presenting with chest wall pain, who have risk factors for coronary artery disease. Presented are some of the more common causes of chest wall pain and their clinical findings, diagnostics and treatment.

Radiation-induced pain syndromes are an unfortunate consequence of radiation therapy administered during the treatment of various malignancies. It often manifests several months to years after completion of radiotherapy, with the diagnosis complicated by concern for local cancer recurrence. Pain syndromes due to radiation can be characterized based on anatomic location and specific tissues affected. Several radiation-induced pain syndromes have been described along with proposed pathophysiological mechanisms of injury. Common risk factors include total radiation dose, fractionation schedule, and radiation field size.

Studies have confirmed that, for severe flail chest or sternal fractures and even multiple rib fractures, surgical treatment can effectively reduce hospital stay and relieve chest wall pain. However, fixation of multiple costal cartilage fractures in such a small area is a challenge if an internal fixator is simply placed directly on the sternum. This case report shares a method of simultaneous fixation of multiple costal cartilage and sternal fractures through a small incision, and it is also appropriate for multiple costal cartilage fractures without sternal fracture.

Postherpetic neuralgia (PHN) is a debilitating condition that frequently arises after herpes zoster (HZ) caused by the varicella-zoster virus. It is characterized by severe neuropathic pain and sensory disturbances persisting after the resolution of characteristic vesicular skin lesions. Most commonly affected are the thoracic dermatomes. Trigeminal (V1), cervical, and lumbar nerves are other frequently affected sites. Early treatment shortens the duration of acute HZ and may prevent the onset of PHN. A variety of modalities are utilized to treat PHN, including chemical compounds, interventional pain techniques, and neuromodulation. HZ vaccine is recommended for individuals more than 60 years old, and it is currently the best method of averting HZ and consequent progression to PHN.

To determine the incidence and predictive factors of rib fracture and chest wall pain after lung stereotactic ablative radiotherapy (SABR).Patients were treated with lung SABR of 48-60 Gy in four to five fractions. The treatment plan and follow-up computed tomography scans of 289 tumours in 239 patients were reviewed. Dose-volume histogram (DVH) metrics and clinical factors were evaluated as potential predictors of chest wall toxicity.The median follow-up was 21.0 months (range 6.2-52.1). Seventeen per cent (50/289) developed a rib fracture, 44% (22/50) were symptomatic; the median time to fracture was 16.4 months. On univariate analysis, female gender, osteoporosis, tumours adjacent (within 5 mm) to the chest wall and all of the chest wall DVH metrics predicted for rib fracture, but only tumour location adjacent to the chest wall remained significant on the multivariate model (P0.01). The 2 year fracture-free probability for those adjacent to the chest wall was 65.6%. Among those tumours adjacent to the chest wall, only osteoporosis (P = 0.02) predicted for fracture, whereas none of the chest wall DVH metrics were predictive. Eight per cent (24/289) experienced chest wall pain without fracture.None of the chest wall DVH metrics independently predicted for SABR-induced rib fracture when tumour location is taken into account. Patients with tumours adjacent (within 5 mm) to the chest wall are at greater risk of rib fracture after lung SABR, and among these, an additional risk was observed in osteoporotic patients.

Background No consensus on how to best predict for chest wall injury following SABR exists. We report our experience in chest wall dose assessment when treating peri-pleural lung lesions with stereotactic ablative radiotherapy (SABR) delivered with volumetric modulated arc therapy (VMAT). Methods 40 patients with peri-pleural peripheral lung tumors underwent SABR between July, 2012 and February, 2015. Chest wall toxicity, dose distribution, and the influence of chest wall delineation method were investigated. Results After a median follow up of 16 months, no rib fracture or skin toxicity was observed. 4 patients (10%) reported persistent chest wall pain (grade 1–2). High dose rate's association with chest wall pain trended toward statistical significance ( p =0.06). PTV exclusion and reducing chest wall expansion to 1 cm led to significant dose reduction in the chest wall dose volume parameters ( p Conclusions The risk of chest wall pain following SABR delivered with VMAT is low. High dose rate, which is 1400 MU/min with flattening filter free (FFF) beams vs. 500–600 MU/min with non-flattening filter free (non-FFF) beams, may contribute to it. Chest wall dose volume parameters may vary with PTV exclusion; while chest wall expansion of 1 cm may fail to account for some high dose regions in the chest wall.

The aim of this study was to investigate quantitatively the dosimetric factors that increase the risk of clinical complications of rib fractures or chest wall pain after stereotactic body radiation therapy (SBRT) to the lung. The correlations of clinical complications with standard-uptake values (SUV) and FDG-PET activity distributions from post-treatment PET-imaging were studied. Mean and maximum doses from treatment plans, FDG-PET activity values on post-SBRT PET scans and the presence of clinical complications were determined in fifteen patients undergoing 16 SBRT treatments for lung cancer. SBRT treatments were delivered in 3 to 5 fractions using 5 to 7 fields to prescription doses in the range from 39.0 to 60.0 Gy. The dose and FDG-PET activity values were extracted from regions of interest in the chest wall that matched anatomically. Quantitative evaluation of the correlation between dose deposition and FDG-PET activity was performed by calculating the Pearson correlation coefficient using pixel-by-pixel analysis of dose and FDG-PET activity maps in selected regions of interest associated with clinical complications. Overall, three of fifteen patients developed rib fractures with chest wall pain, and two patients developed pain symptoms without fracture. The mean dose to the rib cage in patients with fractures was 37.53 Gy compared to 33.35 Gy in patients without fractures. Increased chest wall activity as determined by FDG-uptake was noted in patients who developed rib fractures. Enhanced activity from PET-images correlated strongly with high doses deposited to the chest wall which could be predicted by a linear relationship. The local enhanced activity was associated with the development of clinical complications such as chest wall inflammation and rib fracture. This study demonstrates that rib fractures and chest wall pain can occur after SBRT treatments to the lung and is associated with increased activity on subsequent PET scans. The FDG-PET activity provides a useful parameter that can be used clinically to predict chest wall complication in lung patients.

Data about persistent pain after breast cancer treatment (PPBCT) after cosmetic or reconstructive breast surgery is limited and focuses on subpectoral implant placement or intercostal nerve injury. We report one patient who presented with bilateral PPBCT and thoracodorsal neuroma after immediate breast reconstruction with the latissimus dorsi myocutaneous flap (LDMF) and subpectoral tissue expander (TEs). This case demonstrates that thoracodorsal neuroma can be a potential cause of post-reconstruction breast pain. A 65-year-old woman with a history of right breast cancer presented for evaluation of bilateral chronic breast pain following bilateral skin-sparing mastectomy, right axillary lymph node dissection, and bilateral immediate breast reconstruction with the LDMF and TEs 2 years prior. During the initial operation, the thoracodorsal nerves were not divided surgically and the tissue expanders were placed in the subpectoral and sub-latissimus dorsi plane. She had no chemotherapy or radiotherapy. Postoperatively, she developed significant chest wall pain. Five months later, the TEs were removed and exchanged for silicone breast implants. The pain persisted postoperatively and was attributed to bilateral Baker grade 4 capsular contracture. Three months after implant exchange, she underwent a third surgery where bilateral thoracodorsal nerve main trunk transection, capsulotomy, implant exchange and breast fat grafting were performed. Unfortunately, pain relief only lasted 1.5 months. She was evaluated in a chronic pain clinic and had tried numerous conservative measures without success including bilateral intercostal nerve blocks, supportive bras, topical ketamine, and medications, including gabapentin, celecoxib, diazepam, acetaminophen, oxycodone, and lidocaine 5% patch. At her initial clinical evaluation with us, the patient described breast pain rated at 8/10 on visual analog scale, and spasms located over the anterior lower pole of her breasts which felt like a constricting belt around her chest. Physical examination revealed active LD muscle contraction and involuntary muscle spasms. This prompted us to offer surgical exploration. Intraoperatively, bilateral thoracodorsal nerve trunks were found intact, with a visible intraneural mass in both nerves (Fig. 1). The LD muscles were found in the lower pole of both breasts, and were attenuated. Because the patient desired to reduce her breast size in hope of alleviating pain, it was decided to excise the LD myocutaneous flaps by performing a proximal myotomy. A 3 cm segment of thoracodorsal nerve was sent to pathology from each side, and the proximal thoracodorsal nerve stumps were ligated with permanent suture. To minimize the risk of postoperative muscle spasms, the mastectomy defect was recreated, the pectoralis major was repositioned in anatomic position on the chest wall, and TEs were circumferentially wrapped with acellular dermal matrix (Fig. 2) and secured to the chest wall in the subcutaneous plane. Fig. 1 Bilateral thoracodorsal neuroma: Bilateral thoracodorsal nerves were dissected and isolated. A visible area of enlargement of the proximal thoracodorsal nerve was noticed on both sides, corresponding to the neuroma. (A) Right side. (B) Left side. Fig. 2 Tissue expander (TEs) wrapped with acellular dermal matrix: to minimize the risk of postoperative muscle spasms, the mastectomy defect was recreated, the pectoralis major was repositioned in anatomic position on the chest wall, and TEs were circumferentially ... In the early postoperative course, pain was improved bilaterally. Three months later, the patient underwent bilateral removal of TEs and exchange for silicone breast implants. Six months postoperatively, she remained pain free. Histology of bilateral thoracodorsal nerves revealed dense fibrosis consistent with neuroma (Fig. 3). Fig. 3 Histology of thoracodorsal nerve biopsies: The thoracodorsal nerve biopsies showing haphazardly arranged tangles of variably sized nerve twigs set in a fibrous stroma, characteristic findings of traumatic neuroma. (A) H&E, ×40. (B) H&E, ... PPBCT is a common but poorly understood problem without a clear definition. PPBCT symptoms include altered skin sensations, burning or electric pains, pressure sensations, numbness, aching, and tightening in the breast and axilla. Development of PPBCT is complex and involves multiple preoperative, intraoperative, and postoperative elements [1]. Cosmetic and reconstructive breast surgery may be associated with persistent breast pain, but relevant research on this topic is rare and focuses on subpectoral implant placement or intercostal nerve injury [2]. Limited data show breast reconstruction with subpectoral implant does not confer increased prevalence of persistent pain [3], but capsule formation, compression of the lateral and medial pectoral nerves and intercostal nerve injury may cause chronic pain [2]. The lateral aspect of the breast is most susceptible to intercostal injury. Nearly 80% of intercostal neuromas were seen in this anatomic location [2]. Our case confirmed the complex and heterogenous presentation of PPBCT. We hypothesize that thoracodorsal neuromas-in-continuity were the initial etiology of pain. This would explain why the pain appeared shortly after the first reconstructive surgery. A neuroma-in-continuity is a neuroma that occurs within an intact nerve resulting from failure of the regenerating nerve growth cone to reach peripheral targets and resulting in a distal portion of the nerve that no longer functions properly [4]. The recurrent pain following the third surgery - where thoracodorsal nerve transection was performed - was most likely caused by the thoracodorsal neuroma and LD muscle reinnervation, which occurred either from incomplete nerve resection or spontaneous neurotization [5]. Mechanical injury during flap dissection or traction could be other possible causes. Meanwhile, capsular contracture, compression of the lateral and medial pectoral nerves under the pectoralis muscle are all additional potential additional causes of pain [2]. Since its first introduction in 1896, use of the LD flap for breast reconstruction has remained popular, but whether and when to cut the thoracodorsal nerve is still controversial. Some authors believe that cutting or saving the nerve does not have an effect on the flap volume or muscle activity in the long run. Thus, both practices seem to be justified [3]. But this case offers new evidence why denervation of thoracodorsal nerve should be performed when harvesting the LD flap: keeping the nerve intact can increase the possibility of voluntary muscle spasm and chronic breast pain. Proximal nerve resection at the axillary apex, with a nerve transection of at least 1 cm, was suggested for a successful denervation [5]. PPBCT has a significant negative effect on quality of life. Non-steroidal anti-inflammatory drugs, benzodiazepines and antidepressants are the most commonly used medications, none of which are very effective. If the pain is caused by the presence of a neuroma, surgical resection can result in complete pain relief. A heightened awareness of the diagnosis and management of neuroma is very important, since this is a treatable cause of pain. When having a consultation about chronic pain after LD breast reconstruction, surgeons should always keep in mind that this is a complex and heterogenous condition for both diagnosis and treatment. Thoracodorsal neuroma should be considered as a possible cause.

Background Skeletonization of the internal mammary artery for single left internal mammary artery (LIMA) use remains controversial. We sought to elucidate the effect of different harvesting techniques applied in single LIMA grafting. Method Between January 2006 and January 2012, 982 patients undergoing off-pump coronary artery bypass with pedicled LIMA conduits (P Group) and 928 patients undergoing the same operation with skeletonized LIMA conduits (S Group) were enrolled. The length and blood flow of the conduits, and in-hospital and mid-term outcomes with one-year postoperative graft angiographic results were analyzed and compared between groups. Results Twenty-five (2.7%) patients in the S group died in hospital, compared with 26 (2.6%) in the P group, with similar rates of sternal wound infection, chest wall pain, and low-output syndrome. Although the length and blood flow of conduits were increased in the S Group, postoperative conduit patency was similar between groups (p = 0.470). During a median follow-up of 32.2 months, the groups showed similar total survival (88.3 ± 3.2%, S Group; 85.5 ± 2.0%, P Group; p = 0.118) and cardiac event-free survival (82.7 ± 3.3%, S Group; 80.3 ± 2.0%; P Group; p = 0.129), with similar postoperative complications. Conclusions Skeletonization of single LIMA has no extra benefit in early or mid-term outcomes, suggesting no advantage over the pedicled technique. doi: 10.1111/jocs.12551 (J Card Surg 2015;30:494–499)

Chest pain is one of the most common complaints causing patients to seek medical attention. The vast majority of these patients will have a “benign,” nonlife-threatening cause for their chest pain with many of them being labeled with “chest wall syndrome,” a broad term encompassing all causes of musculoskeletal pain. This chapter reviews some of the bone- and cartilage-related causes of chest wall syndrome focusing on the slipping rib syndrome, as well as briefly reviewing other pathologies the practitioner may encounter.

The prevalence of mid- and upper back chronic pain is significantly lower than low back and neck pain with reports showing pain of thoracic origin in 5–15% of the patients, compared to 24–44% with neck pain and 33–56% with low back pain. Thoracic intervertebral discs, nerve roots, and facet joints are capable of transmitting pain in the thoracic spine with radiation into the chest wall and abdominal wall. Chronic, persistent thoracic and chest wall pain and radicular pain may be secondary to disc herniation, discogenic pain, spinal stenosis, or post-thoracic surgery syndrome.

This report presents a case of malignant pleural mesothelioma (MPM) producing granulocyte colony-stimulating factor (G-CSF) that was treated by tumor resection. A 76-year-old male presented with a huge right-side chest wall tumor, along with a slight fever and chest wall pain. Laboratory findings showed an increased white blood cell count (64600 cells/μL) and C-reactive protein level (20.57 mg/dL). The patient underwent surgical removal of the tumor along with tissue from the chest wall and histopathological analysis led to a diagnosis of sarcomatous type of MPM. Immunohistochemical findings for both anti-human G-CSF and interleukin-6 monoclonal antibodies were positive. Although the general condition of the patient quickly improved after surgery, local recurrence occurred two months later and he died of respiratory failure seven months after the operation, though surgery provided symptom relief. G-CSF-producing MPMs usually show a poor prognosis, though less-invasive surgery may be considered for relief of symptoms.

Simultaneous pneumoperitoneum and pneumomediastinum is a rare clinical occurrence. It has been reported in the literature as a complication of various medical and dental procedures. To our knowledge, we present the first case of a non-iatrogenic and traumatic simultaneous pneumoperitoneum and pneumomediastinum in a previously independent 91-year-old man who presented to hospital with back and chest wall pain following mechanical fall from standing. A new radiological diagnosis of diverticular disease with possible perforation was made following admission. Despite appropriate management and supportive measures, the patient died 12 days after admission from a kidney injury.

Chest wall pain is a common complaint after thoracic and chest wall surgery, radiation, and tumor invasion, with significant impact on patients and the healthcare system. If left unmanaged, chest wall pain can significantly impair quality of life. Detection and diagnosis are paramount to management and recovery. Chronic pain also is highly prevalent after breast surgery and thoracotomy. Although many therapies may reduce chest wall pain, a comprehensive treatment plan incorporating potent and targeted interventions may relieve pain and restore function. Chest wall procedures carry several specific risks unique to thoracic anatomy. In this chapter, we explore these risks and present a case of pneumothorax after paravertebral radiofrequency ablation.

A 9-year-old girl from black ethnic origin presented with a history of fever, cough, loss of weight and right-sided chest wall pain for 2 weeks. Chest X-ray demonstrated an effusion, which was shown to be loculated on chest CT scan. She was not responding to medical treatment and at thoracotomy loculated pus was drained. Mycobacterium tuberculosis (TB) was cultured from the pus. TB is a rare cause of loculated empyema with an overlapping clinical and radiological picture with pyogenic infections.

Case report We herein report a case of local recurrence of breast cancer with squamous metaplasia and obvious intratumoral and intertumoral heterogeneity. A 39-year-old female patient was diagnosed with T3N2M0 stage IIIB right breast cancer and underwent right total mastectomy and axillar lymph node dissection. At four years after surgery, she became aware of chest wall pain and diagnostic imaging revealed recurrence in the lung, right thoracic wall and sternum. The recurrent lesions remained stable for 18 months with endocrine therapy. Thereafter, the lesion in the right thoracic wall suddenly became enlarged. Moreover, liver metastasis was confirmed on FDG-PET/CT. She underwent right thoracic wall tumor resection. A biopsy was simultaneously performed to obtain a specimen from the site of liver metastasis. Postoperatively, the right chest wall mass showed obvious intratumoral heterogeneity; squamous differentiation with aggressive features and a papillotubular component similar to the primary tumor. The metastatic liver tumor showed similar pathological features to the primary tumor. Conclusion Intratumoral and intertumoral heterogeneity within primary tumors and associated metastatic sites may contribute to treatment failure and drug resistance.

Background Despite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken. Case Report A primigravida woman with unbearable abdominal pain was referred repeatedly seeking a solution for her suffering. Numerous laboratory and imaging studies were employed in order to elucidate the cause of her condition. After numerous visits and unnecessary delay, the diagnosis was finally made by a physician fully versed in the field of torso wall pain. The focused physical examination disclosed abdominal cutaneous nerve entrapment syndrome as the diagnosis, and anesthetic infiltration led to immediate alleviation of her pain. Why Should an Emergency Physician Be Aware of This? Cutaneous nerve entrapment is a common cause of abdominal pain that is reached on the basis of thorough history and physical examination alone. Knowledge dissemination of the various torso wall syndromes is imperative for prompt delivery of suitable care. All emergency physicians should be fully aware of this entity because the diagnosis is based solely on physical examination, and immediate relief can be provided in the framework of the first visit. Wider recognition of this syndrome will promise that such mishaps are not repeated in the future.

Chronic chest wall infections may occur in soft tissue, cartilage, and bone. They may present as localized chest wall pain, a discrete mass initially mistaken for neoplasm, a superficial infection, or a draining sinus. Chronic chest wall infections are typically non-necrotizing and associated with lower morbidity than their more acute and necrotizing counterparts. Effective management of chest wall infections ranges from antimicrobial administration to wide surgical resection and subsequent reconstruction.