Costovertebral Joint Dysfunction: Another Misdiagnosed Cause Ofatypical Chest Pain J.F
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Postgrad Med J: first published as 10.1136/pgmj.68.802.655 on 1 August 1992. Downloaded from Postgrad Med J (1992) 68, 655 - 659 C) The Fellowship of Postgraduate Medicine, 1992 Missed Diagnosis Costovertebral joint dysfunction: another misdiagnosed cause ofatypical chest pain J.F. Arroyo, Ph. Jolliet and A.F. Junod' Department ofInternal Medicine and 'Department ofInternal Medicine & Division ofPneumology, Geneva University Hospital, 1211 Geneva 4, Switzerland Summary: The diagnostic work-up of atypical chest pain frequently leads to invasive procedures. However, this painful symptomatology can sometimes be of benign origin and respond to simple therapeutic manoeuvres. A number of musculoskeletal conditions such as costovertebral joint dysfunc- tions should be carefully considered. We report five cases in which patient discomfort and high costs could have been avoided if awareness of these conditions had led to a correct diagnosis upon initial physical examination. Introduction Atypical chest pain unrelated to a cardiac or this time located in the left basi-thoracic region. pleuro-pulmonary cause is a common symptom Routine diagnostic work-up was unrevealing. by copyright. particularly in the emergency room.'4 However, Since the patient was in the postoperative period, little attention has been drawn in the medical pulmonary embolism was suspected. She was literature to musculoskeletal causes.2'5'6 This can anticoagulated with heparin. An isotopic vent- lead to repeated, sometimes invasive and often ilation/perfusion lung scan indicated low pro- costly medical investigations.7 Even though emo- bability for pulmonary embolism. Nonetheless, in tional factors can play a role in such symptoms,",7'8 view of the high degree of clinical probability, it seems important to identify specific local pulmonary angiography was performed, which musculoskeletal causes of atypical chest pain, was normal. As the pain continued, the patient which can be easily detected and treated.5'6"0 We underwent a complete physical examination by a report five cases of atypical chest pain related to a rheumatologist. An exquisitely tender thoracic http://pmj.bmj.com/ characteristic cause of rib strain: costovertebral paravertebral region at the T7 level was identified, joint dysfunction. whose palpation and rib mobilization precisely reproduced the patient's symptoms. There was an accompanying muscular contraction and cuta- Case reports neous tenderness. The diagnosis was a T7 costo- vertebral joint dysfunction. The pain disappeared Case I after intercostal nerve block with lidocaine and the on September 27, 2021 by guest. Protected patient was discharged from the hospital 48 hours A 54 year old female patient underwent a right later. artroscopic meniscectomy under general anaes- thesia. In the recovery room, she experienced three Case 2 episodes of atypical precordial pain, independent of respiratory movements. Clinical examination A 42 year old woman with a history of slight chest and electrocardiogram (ECG) were normal. Nitro- contusion one month previously was admitted to glycerin produced no relief, and the pain subsided the emergency room with a severe left basithoracic after a few minutes. She was transferred to the pain, increased by breathing movements, and ward. Twenty-four hours later, the pain recurred, accompanied by dyspnoea and tachycardia. Physical examination and laboratory and blood gas analyses were normal. The ECG revealed atrial Correspondence: Jesus F. Arroyo, M.D., Medecin- fibrillation with a heart rate ranging from 120 to Adjoint, H6pital Universitaire de Geriatrie, rte de 145/min, spontaneously reverting to a normal sinus Mon-Idee, 1226 Thonex/Geneva, Switzerland. rhythm. Pulmonary embolism was suspected. The Accepted: 30 March 1992 pulmonary scan yielded a low probability, promp- Postgrad Med J: first published as 10.1136/pgmj.68.802.655 on 1 August 1992. Downloaded from 656 J.F. ARROYO et al. ting pulmonary angiography, which was normal. A at the T8 level. Palpation at that level reproduced complete diagnostic work-up including echo- the patient's pain. After various dorsal musculo- cardiographic examination, serological testing for skeletal physical examination procedures, the viral infection, vertebral X-rays and isotopic bone patient described partial relief of his symptoms. scan was normal. Upon re-examination, a left Costovertebral dysfunction was diagnosed, and a paravertebral muscular contracture extending treatment of non-steroidal anti-inflammatory from T4 to T7, with cutaneous hyperalgesia, was drugs and muscle relaxants started. The symptoms discovered. There was exquisite tenderness of the disappeared within 48 hours, and the patient left T6-T7 region as well as upon mobilization of the the hospital. 6th rib. These painful symptoms were identical to those experienced by the patient during the Case S previous days. A diagnosis of T6 costovertebral joint dysfunction was made. Intercostal nerve A 70 year old female patient presented with sudden block with lidocaine completely relieved the symp- left basithoracic pain, increased by breathing toms. movements. She had been experiencing similar, although less intense, symptoms for one month. Case 3 The pain was usually deep, dull, and increased by inspiration and anterior flexion of the torso. At A 23 year old male patient was admitted to the times, she felt intensely dyspnoeic. The dyspnoea emergency ward for acute dorsal and latero- was accompanied by palpitation and diaphoresis. thoracic pain, with a probable diagnosis of peri- As with the other four patients, the initial carditis. His history was free of recent 'flu-like emergency ward evaluation was inconclusive, but symptoms, cough or chest pain. He complained of the symptoms were interpreted as possibly related severe, burning pain, increased by breathing and to pulmonary embolism, and the patient was movements of the torso, the latter producing left anticoagulated with heparin. An isotopic ven- antero-lateral radiation. The initial diagnostic tilation/perfusion lung scan was normal. Anti- by copyright. work-up was inconclusive, and the patient was coagulation was stopped. Further evaluation hospitalized. He described a similar episode one revealed left paravertebral muscular contracture at year previously, for which he had also been hos- the T5-T7 levels. Skin-pinch testing caused pitalized. No clue had been found as to the cause of dysaesthesia and local hyperalgesia, and palpation the symptoms, which had spontaneously disap- of the posterior left 6th rib reproduced the pain peared. He indicated that his present symptoms with its characteristic antero-lateral radiation. had appeared after having spent a few hours Costovertebral dysfunction was diagnosed and the studying in a prone position, followed by stretching symptoms were totally relieved by an intercostal exercises. There was a paravertebral muscular nerve block at the T6 level, and the patient left the contracture in the T5-T8 region. A skin-pinch test hospital after 48 hours. http://pmj.bmj.com/ produced localized dysaesthesia. Posterior palpa- tion ofthe 6th left rib initiated sharp pain, radiating anteriorly. Costovertebral dysfunction of the 6th rib was diagnosed. An intercostal block with Discussion lidocaine relieved the patient immediately. He left the hospital after 48 hours, asymptomatic. We have reported five characteristic cases of atypical chest pain due to a misdiagnosed mus- on September 27, 2021 by guest. Protected Case 4 culoskeletal aetiology, which led to needless, and sometimes invasive, investigations. Patients were A 36 year old male patient presented with right hospitalized for a cumulative number of26 days. A latero-thoracic pain of acute onset. He had no past total of 14 ECGs, seven chest and spine X-rays, cardio-respiratory problems. He described his pain four isotopic ventilation/perfusion lung scans, two as mostly dull and deep, with occasional sharp, pulmonary angiographies, one cardiac echography knife-like, characteristics. He was dyspnoeic. Dor- and one isotopic bone scan were performed. sal or right lateral decubitus decreased the symp- All patients presented with atypical chest pain toms. The emergency ward evaluation was that ofa related to a poorly known aetiopathogenic cause: possible pulmonary embolism. Anticoagulation costovertebral joint derangements.9' 4 This condi- with heparin was started. However, an isotopic tion refers to an abnormal mobility and/or a ventilation/perfusion lung scan was normal, and posterior subluxation of the rib producing a func- heparin was thus discontinued. A physical re- tional disruption between the rib and its two examination indicated that the pain appeared upon vertebral joints: costovertebral and costotransver- inspiration and rotation of the torso. There was a sal articulations (the latter is nonexistent in the two paravertebral muscular contracture and tenderness floating ribs). Both these joints are reinforced by a Postgrad Med J: first published as 10.1136/pgmj.68.802.655 on 1 August 1992. Downloaded from COSTOVERTEBRAL JOINTS/CHEST PAIN 657 strong ligamental apparatus and are under control Nevertheless, in some cases, a differential diag- of certain muscles (especially ilio-costalis). nosis must be considered, with regards to other Poorly recognized by physicians, costovertebral such musculoskeletal conditions: Firstly, dysfunctions, as a particular posterior rib strain, intervertebral facet joint derangements can also be are well described in manual medicine test- a potent