slipping ribs syndrome(티에체 증후군)의 진단과 수기치료법

[문형철]

아는만큼 보인다.

흉추의 관절

1.  후면쪽으로 7 joint system

- 추간판, 2개 후관절, 2개 costovertebral joint, 2개 costotransverse joint

2. 흉곽의 전면부 쪽

1) 1-7늑골은 흉골과 관절 true rib

2) 8-10늑골 - 연골-7번 늑연골 false rib

3) 11-12늑골 - floating rib

티에체 증후군, 늑골연골 통증증후군, slipping rib syndrome

치료법 “hooking maneuver”

The Slipping Rib Syndrome

In 1921, Alexander Tietze first described a syndrome characterized by a painful affliction of the costochondral cartilages (area between the ribs and costal cartilages).1 He described a benign, painful, nonsuppurative swelling involving one or more of the costochondral or sternoclavicular junctions. The following year, Davies-Colley described two women in whom severe abdominal pain was caused by atraumatic, spontaneous overriding of the ninth and tenth ribs.2 This syndrome has been dubbed Tietze syndrome, costal margin syndrome, clicking rib, rib tip syndrome, and now commonly slipping rib syndrome.3-5 Even though this disorder was described more than 60 years ago, it is often overlooked in the differential diagnosis of abdominal or chest pain.6,7 This article will review the diagnosis and treatment of the syndrome and present case examples.

- 1921년 알렉산더 티에체가 언급한 늑연골 통증, 티에체 증후군 

- 최근 slipping rib syndrome로 ...

Pathophysiology

The pathophysiology of the syndrome was further clarified by Holmes in 1941, and later by McBeath and Keene in 1975.3,4 They examined the gross and microscopic anatomy of the costochondral, sternal, and subcostal regions in normal individuals and identified recurring subluxation (dislocation) of the costal margins of the eighth, ninth, and tenth ribs due to hypermobility of their anterior edges. Actually, the rib tips do not sublux unless the fragile, fibrous articulations are disrupted. Unlike ribs one to seven, which are attached to the sternum, the eighth, ninth, and tenth ribs are attached only to each other by loose fibrous tissue. Paradoxically, when the fibrous tissue between the ribs is incised, they come in contact with each other and become locked behind the adjoining rib.

- 늑연골, 흉골, 늑골의 gross and microscopic 해부학적 구조를 조사함.

- 늑골 8, 9, 10번 늑골 마진의 아탈구, 탈구는 늑골 전방 edge의 과운동성때문임. 

- 사실상 연골이 파열되지 않으면 늑골의 끝은 어긋나지 않음. 늑골 1-7번과 다르게 8, 9, 10번 늑골은 loose 섬유성 조직에 의해서 연결되어 있음. 

- 역석적으로 섬유성 조직이 늑골사이에서 어긋날때 , 인접한 늑골아래에서 잠김이 발생함. 

 Holmes’ anatomic studies revealed that the cartilage ends curl upward inside the ribs so that they come in close relationship to the intercostal nerves.8 The fibrous hammocks surrounding the synovial membranes of the interchondral cartilages of the eighth, ninth, and tenth ribs also involve the terminal branches of the intercostal nerves. These nerves are particularly vulnerable to even trivial trauma. On careful examination, Holmes did not find the synovial membranes to be pathologic; thus, he concluded that the cause of the pain was recurrent, repetitive irritation of the intercostal nerves, not a synovitis of the interchondral cartilages. These factors support the hypothesis that direct or indirect trauma is the cause of the syndrome. The trauma may, at times, be completely covert and not directly implicated.4,9

- 홀름은 intercostal nerve의 해부학적 연구를 시행함.8, 9, 10의 늑연골은 intercostal nerve의 끝가지와 연결됨.

- 이 신경은 작은 타박상에도 쉽게 손상됨. 홀름의 연구에 의하면 intercostal nerve의 반복적인 염증이 발생함. 

- 이러한 원인은 직접적 또는 간접적 타박상이 이 증상의 원인임. 

Upon physical examination, the pain is clinically recreated when the rib margins are displaced upwards and anteriorly; thus, the “hooking maneuver” can be used to corroborate the diagnosis (Figures 1 and 2). In all our cases, local anesthesia intercostal blockade relieves the pain. We have found that the relief could be prolonged by infiltration of the subcostal rib margins. In several cases, this has completely relieved the pain permanently.

- 이학적 검사상, 통증은 늑골 마진이 어긋날때 발생함. 그래서 hooking 수기치료는 적절한 진단법과 치료법으로 사용됨. 

Our Clinical Experience

The slipping rib syndrome should be considered whenever a patient is referred with a complaint of upper quadrant abdominal pain of obscure and uncertain etiology, especially if it involves the subcostal upper quadrants of the abdomen. Most often all diagnostic studies had ruled out underlying visceral pathology. In many cases, the patients had already undergone abdominal explorations with negative findings. The pain is often confused with cholecystitis, subphrenic abscess, pleurisy, or hepatic pathology. As in many cases, the pain may radiate to the right lower quadrant mimicking appendicitis or renal lithiasis. In some cases, it may create epigastric symptoms of such proportion that myocardial infarction is suspected.

The diagnosis often can be made by physical examination. Palpation of the tips of the eighth, ninth, and tenth ribs or of the posterior intercostal margins often reproduces the pain. A sensation of clicking or slipping is felt beneath the examining hand when the hooking maneuver is applied. The hooking maneuver often aggravates or recreates the typical pain sensation, but often cannot be done due to severe sensitivity of the subcostal margins. If the pain is absent, the maneuver may reproduce it. The condition is most often unilateral10 and performing the maneuver on the contralateral side will not evoke a pain response. The diagnosis is further confirmed by intercostal local anesthesia nerve blockade of the eighth, ninth, and tenth ribs as well as subcostal infiltration. After the block has taken effect, the hooking maneuver will not evoke pain.

If a conduction block is used for diagnostic purposes only, then another block may be performed using the combination of local anesthesia 0.5% bupivacaine and 40 mg triamcinolone. This has been found to relieve the problem unless further trauma recreates the pathology. If residual pain persists, or should reoccur, then follow-up with another local anesthesia steroid blockade may be performed.

Prolotherapy also has been used with great success and prolonged amelioration of the syndrome.11 A more profound blockade may be obtained by the use of the extract of the pitcher plant (Sarapin). The duration of the anesthesia may be prolonged in difficult cases by use of a neurolytic block with phenol 6%. Alcohol should not be used due to the potential for severe neuritis. Our cases all responded to local anesthesia and steroids. Surgery and further injections were unnecessary.

Case Reports

First Case Example

A 34-year-old woman was referred to our pain clinic complaining of right upper quadrant pain of 4 months duration. The pain prevented her from teaching school and performing her activities of daily living. She rated her pain as 10 out of 10 on visual analog scale (VAS).

There was no history of trauma. The subcostal abdominal pain was aggravated by distention of the abdominal wall and there was associated nausea without vomiting. There were no other gastrointestinal (GI) symptoms. The pain was not affected by eating or taking antacids, belladonna, cimetidine, or other GI medication.

All laboratory and radiological studies, including abdominal computed tomography scan, were negative. A short trial of non-steroidal anti-inflammatory indomethacin 50 mg 3 times daily and supplemental hydrocodone 10 mg every 4 hours, did not alter the symptom complex. Deep palpation produced pain in the right upper quadrant, with pain radiating posteriorly to the upper dorsal back. Palpation of the margins of the eighth, ninth, and tenth ribs and anterior displacing of the rib margins enhanced the pain. Characteristic snapping or clicking was not induced when performing the hooking maneuver.

Based on the history, clinical, and laboratory findings, the patient was diagnosed with slipping rib syndrome and treated with intercostal blockade of the eighth, ninth, and tenth ribs in conjunction with subcostal local anesthetic and steroid infiltration.