Current Issue - January 2021 - Vol 24 Issue 1


  1. 2021;24;E45-E50Treatment and Management of Twelfth Rib Syndrome: A Best Practices Comprehensive Review
    Comprehensive Review
    Ivan Urits, MD, Nazir Noor, MD, Nathan Fackler, BS, Luc Fortier, BS, Amnon A. Berger, MD, PhD, Hisham Kassem, MD, Alan D. Kaye, MD, PhD, Marc A. Colon, MD, Sumitra Miriyala, PhD, and Omar Viswanath, MD.

BACKGROUND: Twelfth rib syndrome, or slipping of the 12th rib, is an often overlooked cause for chronic chest, back, flank, and abdominal pain from irritation of the 12th intercostal nerve. Diagnosis is clinical and follows the exclusion of other causes of pain. This syndrome is usually accompanied by long-suffering, consequent psychiatric comorbidities, and increased health care costs, which are secondary to the delayed diagnosis.

OBJECTIVES: This manuscript is a review of twelfth rib syndrome and its management options. The review provides etiology, pathophysiology, and epidemiology of twelfth rib syndrome. Additionally, diagnosis and current options for treatment and management are presented.

STUDY DESIGN: This is a narrative review of twelfth rib syndrome.

SETTING: A database review.

METHODS: A PubMed search was conducted to ascertain seminal literature regarding twelfth rib syndrome.

RESULTS: Conservative treatment is usually the first line, including local heat or ice packs, rest, and oral over-the-counter analgesics. Transcutaneous stimulation and 12th intercostal nerve cryotherapy have also been described with some success. Nerve blocks can additionally be tried and are usually effective in the immediate term; there is a paucity of evidence to suggest long-term efficacy. Surgical removal of all or part of the 12th rib and possibly the 11th rib, as well as the next line of therapy, may provide long-lasting relief of pain.

LIMITATIONS: Further large scale clinical studies are needed to assess the most effective management of twelfth rib syndrome.

CONCLUSIONS: Twelfth rib syndrome is usually diagnosed late and causes significant morbidity and suffering. The actual epidemiology is unclear given the difficulty of diagnosis. Nerve blocks and surgical rib resection appear to be effective in treating this syndrome, however, further evidence is required to properly evaluate them. Familiarity with this syndrome is crucial in reaching a prompter diagnosis.

KEY WORDS: Slipped rib, chronic pain, abdominal pain, chest pain, back pain, neuropathy, injection therapy, nerve block