Chief Compliant:An 84-year-old male with history of spinal cord stimulator placement for chronic back pain, type 2 diabetes, and atrial fibrillation presented with 1-month history of right upper and mid back pain radiating along the right chest wall.

Initial Imaging: X-ray of cervical and thoracic spines were normal and prior chest computed tomography (CT) was normal.

Treatments: Patient's pain was refractory to multimodal pain regimen including opioids (Table). Intercostal neuralgia was suspected.

Interventions: Patient's pain persisted despite a right erector spinae block, right suprascapular injection, and T7-10 intercostal nerve block followed by radiofrequency ablation (RFA).

Further Plan: Three days post-RFA, patient reported continued pain, and a decision was made to order a CT thoracic spine, which revealed a 3.2 cm destructive lesion in the T1 vertebral body (Figure).

Diagnosis: Patient was immediately sent to the emergency department and was admitted to the hospital. He underwent C4-T3 posterior spinal instrumented fusion with biopsy revealing 20% involvement of plasma cells, yielding a diagnosis of myeloma.

Intercostal neuralgia is defined as pain along the distribution of affected intercostal nerves that is often neuropathic in character and associated with hyperalgesia.

Potential etiologies include herpes zoster infection, diabetic polyneuropathy, vertebral facet joint osteoarthritis, autoinflammatory disease, and metastatic tumors.⁵

Treatment options include pharmacologic management, nerve blocks, and RFA for cases refractory to conservative management.⁶ 

This patient’s continued severe pain unresponsive to opioids and interventional management raised suspicion for neoplastic disease.

80-90% of patients with MM present with spine and rib pain.⁴

The observed lytic lesion at T1 could explain this patient’s upper thoracic pain, but its relationship to the patients lower thoracic radiating pain is unclear.

Additional imaging with superior sensitivity could potentially reveal additional lesions.⁷

Regardless of the relationship between this patient’s pain and imaging findings, incidental lesions are common and occur in 15-30% of all diagnostic imaging,⁸ presenting a challenge to ordering physicians who must initiate further workup and treatment.