Saturday, March 29, 2014

The MS Hug (also called intercostal neuralgia) is a constellation of neurological symptoms of the torso. In simplest terms, the MS Hug is a tight, often painful banding sensation around, or partly around, the rib cage that is caused by spasms of the intercostal muscles (located between each rib) that are caused by lesions and/or inflammation in the cervical and/or thoracic spinal cord. 

MS Hug symptoms can be felt as high as the shoulders and as low as the waist and hips, but other muscles can be similarly affected by cord lesions and inflammation: scalp, neck, arms, hands, chest wall, abdomen, legs, and feet. Both sensory and motor nerves can be affected.

The MS Hug can feel different to every patient. It can fully remit or leave a patient with lasting damage. It can feel different from hour to hour and day to day. 

Patients have reported feeling only mild symptoms to feeling as if their entire rib cage was being squeezed by a massive boa constrictor, their chest was being crushed by a 500-lb elephant, their sides were being gnawed by voracious sharks, their lower rib cage and/or between their shoulder blades were being stabbed by sharp knives, their torso was being hacked in half by axes, their breast tissue was being stabbed by jagged, broken ribs, and their insides were being twisted by a giant's fist.

Patients have also reported going to the emergency room because of chest pain so extreme, they thought they were having a heart attack. Some patients are dismissed or labeled with anxiety because some ER doctors don't understand MS Hug pain, especially in undiagnosed MS patients. Always be prudent with chest pain, and immediately seek medical help.

Note: MS Hug symptoms can also be experienced due to spinal trauma and other demyelinating conditions, such as Transverse Myelitis (TM).

Itching - Usually on back. Lyrica and neurontin might help. Can be early symptoms of MS Hug.
Hiccups - Involve the diaphragm and intercostal muscles.
 When severe, Baclofen administration in an ER setting can help.
Truncal Dystonia - Sustained "directional" contractions of trunk muscles bending, stretching, twisting, and holding abnormal postures/positions. 
Abdominal Wall Dystonia - Sustained "directional" contractions of abdominal muscles bending, stretching, twisting, and holding abnormal postures/positions.
Sternum Pressure - Can feel like costochondritis, painful.
Tightness/Spasticity- Spasms or sustained contraction of chest wall, intercostal, and/or abdominal muscles.
 - Abdominal cramps, can be severe. 
Numbness - Usually on back, patchy. Can be early symptom of MS Hug. Lyrica and neurontin might help. 
Pnuemonia - Caused when aspirating or when coughing up secretions becomes difficult leading to bacterial or viral pneumonia. 
Constipation - Gastrointestinal tract may become involved and gastroparesis can happen. Can be chronic.

Esophageal Spasms - Swallowing can be painful and interfere with eating and proper nutrition.
Pins and Needles - Usually on back. Lyrica 
and neurontin might help. Can be early symptom of MS Hug.
Connective Tissue Tears - Small tears caused by tight muscles within thoracic cavity, very painful.
Shallow Breathing - Caused by tight, painful intercostal muscles and/or weak or paralyzed diaphragm; possible low oxygen levels. Inform surgeons and anesthesiologists about impaired breathing.
Pain and Spasticity - Can be focal, diffuse, steady, intermittent, 
wave-like, acute, chronic, and/or band-like. Quality of pain can feel electrical, deep, shallow, sharp, and/or dull. Intensity of pain can range from mild to suicidal. Duration of pain can be from minutes to hours to months to years.


Skeletal muscles - tightness, tenderness, soreness, achiness, electric-like, and pressure; squeezing, slicing, crushing, burning, strangling, stabbing, tearing, throbbing, gnawing, boring, pulling, gouging, and buzzing.
Osseous (bone) - Ribs feel bruised, fractured. Deep, aching pain.
Cutaneous (skin) - Dysesthesias include prickling, itching, stinging, pins and needles, numbness, burning, freezing, flaying, and allodynia (light touch pain).
Visceral (organs) - Liver, gallbladder, stomach, intestinal, esophageal, bladder, and kidney pain and spasticity of smooth muscles. Should be considered for pwMS before exploratory abdominal surgery is performed. Stomach spasms can prevent food from entering stomach, cause vomiting of contents from stomach, and be extremely painful. Left-sided, low rib cage pain can be from Splenic Flexure Syndrome (SFS) of the large colon which can be extremely painful and feel like a heart attack. Right-sided, low rib cage pain from "floating" 
12th rib can be mistaken for painful gallbladder attack. 

                                     Nerves of the spine
(To enlarge, press "CTRL" and "+" keys at same time)


TREATMENTS: In order of invasiveness, imo. 
Heat & ice packs - when tolerable.
Muscle stretching - Yoga & massages.
Lidoderm 5% script - Lidocaine patches. A 3% cream is also available.
Acupuncture & TCM - Eastern vs Western. 
Trigger pt. injections - for back of ribcage. Lidocaine with steroid.

Botox (tm) injections - for all ribcage areas.
Intercostal nerve block - for front of ribcage. See graphic below.

Medicinal marijuana! :) - for pain and spasms. 
Big-pharma medications - for pain and spasms. See list below.
Radiofrequency ablations - for pain and spasms.
Epidural steroid injections - I will not recommend. 
Neurolysis A.K.A. Rhizotomy - sensory nerves killed.
Spinal Cord Stimulator  (SCS) - very invasive surgery.
Baclofen/pain Pump by Biogen - very invasive surgery.

                                        Intercostal Nerve Block


Heat, cold, illness, fever, fatigue, stress, constipation, full bladder, UTI, tight clothing, malpositioning, over-doing activities, other pain sources (e.g., hemorrhoids, tooth ache), and lack of sleep.

IVSM - Intravenous Solu-Medrol steroid for new attacks.
Pain Control - Opiods, such as Oxycontin, Hydrocodone, morphine, methadone, and Lortab might be required.
Neuropathic Pain Control - Lyrica (pregabalin), neurontin (gabapentin). 
Antispasmodics - Baclofen (Lioresal), Xanaflex (tizanidine), Valium (diazepam); dicyclomine (for smooth muscles of gut); papaverine (for visceral spasms); Botox (injections for focal spasticity).

Nebulizer - to treat bacterial and viral pneumonia.
Cough medicine - to treat dry (suppressant) or productive (expectorant) coughs.
Antibiotics/antivirals - to treat bacterial and viral pneumonia.
Incentive spirometer - to help improve lung function.
Cough assist machine - to help bring up secretions and phlegm.

Fractured rib(s), heart attack, pulmonary embolism and other pathology (e.g., pleurisy), 
gallbladder attack, renal pathology, biliary tract pathology, duodenal and gastric ulceration, heartburn, ovarian tumor, GERD, costochondritis, intestinal problems, spinal problems (X-rays are recommended), and nerve entrapment. 

Always under construction.