Episode 135: Chest-related Abdominal Wall Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A. I’m your host, Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. You can find me on Twitter and Instagram at hernia doc. Many of you are logged in right now on Facebook as a Facebook Live at Dr. Towfigh or you’re here via Zoom. And remember after this episode, and you can watch all the previous, I believe it’s up to episode hundred 35 on my YouTube channel at Hernia Doc. So today’s, I’m really happy to have a guest. His name is Dr. Joe Forrester. He’s at Stanford. We’ve actually not officially met until today, and I’m super excited because I know him, because he helped one of my patients and that’s why I want to learn from him. And I hope you all learn from him and hear his story. And so welcome Dr. Forrester.

Speaker 2 (00:01:10):

Thank you so much. I appreciate you having me on.

Speaker 1 (00:01:13):

Thanks for your time. You’re on my coast, so hopefully it’s not too late in the day for you yet. But Dr. Forrester is a new dad. Well, he was a dad, but he had a new baby. So congratulations on having two very small kids and balancing that with a very successful surgical career at Stanford. Excellent institution. And what’s unique is you’re also, so you’re a trauma surgeon, trauma critical care. We were talking about this before we went live, but interestingly, Stanford has a chest wall injury center, which I think is great. Every time you find a niche and you kind of promote it, then that can kind of also promote more education and knowledge base and expertise in that very narrow niche. That’s why I like hernias. That’s like my niche. But chest wall injury, very narrow part of what you do. Can you maybe explain why a trauma surgeon would be in charge of a chest wall injury center and what kind of patients you tend to see?

Speaker 2 (00:02:22):

Yeah, definitely. So across the country, rib fractures and sternal fractures are one of the most common injuries that people present with. So anywhere from 10 to 20% of patients admitted across the country will have a rib fracture. And while management strategies for pain associated with rib fractures has improved, I think there’s still a lot of opportunity both to develop techniques for the future and do what we already do better. And so out of that kind of belief sprung the chest wall injury center concept, which really is a comprehensive center-based structure that helps us care for patients with chest wall injury better within the existing trauma infrastructure. So we have a dedicated inpatient team that’s able to provide repair of chest wall injury, usually within about 72 hours, so acute sternal or rib fractures. And then we have an outpatient component where we’re able to provide longitudinal outpatient care for patients who are injured as an inpatient, longitudinal care for our patients who are on clinical trials, as well as a outpatient resource for patients with chronic chest wall conditions that may have resulted as a result of trauma, like costal margin injuries, intercostal hernias, sternum non-unions, or slipped rib syndrome.

Speaker 1 (00:03:49):

That’s a good one. We’ll talk about intercostal hernias too. So I actually got an email from one of my patients who’s watches this every week and he’s like, chest wall, Andrea, how is this related? I need to figure out some questions, but I don’t even know where to start. But the reason why I got to know you is because you actually treat a patient of mine. People come to me with enigmatic abdominal pain, the lower abdominal pain, it’s often hernia related or hip, sometimes gynecologic. And then the upper abdominal pain, it could be GI or again, hernia. But in general surgery we do some thoracic surgery. We don’t really do any, we don’t get that much exposure to orthopedic surgery, spine surgery, et cetera. As a trauma surgeon, probably you do more because those areas can get injured and you’re kind of the boss trying to figure out what’s wrong with the patients.

Speaker 1 (00:04:51):

So I was really excited to hear when my patient called and said, I went to see Dr. Forrester, he figured out he’d operate on me and cured my pain, which was genius. So anyone who could fix my patients, I want to know and be friends with. You’re going to be on my short blacklist of black book of people on speed dial. In fact, I sent you a patient last week, so I’m very grateful for your care. But specifically, these are patients that come to you with upper abdominal pain and they’ll point to either they’re upper left or right upper abdomen, or they also kind of say it kind of wraps around their flank. And so there are no real hernias that can occur there often. They haven’t had surgery there, so it’s not an incisional issue. And sometimes I just see imaging like x-rays and CAT scans, I don’t see a fracture, and yet I know there’s something mechanically there that’s causing the pain. So can you help me or teach me what questions you ask that specifically trigger chest wall injury as the cause of upper abdominal pain and flank pain? So that’s the questions. And then secondly, what do you go through in terms of your physical examination to help narrow it down?

Speaker 2 (00:06:19):

Yeah, great question. So when I’m thinking about someone with either flank pain, who’s coming to my clinic with either flank pain or upper abdominal pain, kind of, there’s two general structures that I’m thinking about that kind of could be causing problems. One is the bony chest wall. So the ribs themselves, whether that be non-union or malunion from a prior injury or the cartilage. And I think the cartilage has historically been fairly underappreciated as a potential cause of pain. But when you think about the structure of the chest wall, your intercostal nerves are running along the ribs, and then as soon as the ribs transition to cartilage, the nerves are still running there up all the way to midline. And so if you have a disruption of the cartilage, which can be harder to see on CT scan, certainly on x-ray, you know you’ll still get pain. It’ll just be harder to see on existing imaging modalities.

Speaker 1 (00:07:13):

Can you clarify where’s the cartilage? Where’s the bone end? Right? Because there’s a transition from bone to cartilage in everyone’s chest wall. Maybe they don’t know that it’s not all bone.

Speaker 2 (00:07:24):

Yeah, and it’s an important distinction because that’s what allows us to breathe. Every time you’re breathing, your chest wall is moving out and up at the same time. So there has to be some flexibility built into the chest wall to enable that volumetric change. Where everyone’s ribs transitions to cartilage is a little bit different. But in general, when you think about you have seven true ribs, which are connected directly to your sternum with a costal sternal cartilage and ribs eight, nine, and 10 all have these long cartilaginous branches essentially that create the costal margin that then fuse and join your sternum, which creates the costal margin. And you can have fractures all along that can cause problems.

Speaker 1 (00:08:11):

And if someone has a trauma, is it more likely they have a bone fracture or a cartilage fracture?

Speaker 2 (00:08:20):

Some of it depends on age of the patient. Kids’ walls, kids’ chest walls are super bendy. So we rarely see acute rib fractures in kids. And we see rib fractures commonly in elderly patients, particularly those with osteoporosis. But we tend to pick up rib fractures more because they’re easier to see on x-ray or CT scan. But cartilage fractures can be pretty subtle acutely. And sometimes it’s not until a patient’s out of the hospital and it’s several months down the line where they’re like, wow, I still have this pain on my upper abdomen here when I’m breathing, it’s when I’m pressing in. And you may not even be able to see. Sometimes it can even be pretty subtle to see on CT scan and really requires physical exam and pressing and being like, okay, is this what you’re feeling when I’m pushing here? And you’re feeling a click? Is that what’s eliciting the pain? Oh,

Speaker 1 (00:09:14):

Right click.

Speaker 2 (00:09:15):

Yeah. In that case, there’s oftentimes an anatomic issue that we can fix, and sometimes we’re able to cure people’s pain. Doesn’t happen all the time, but that’s certainly the outcome that we look for.

Speaker 1 (00:09:28):

And the pain is always at the fracture if you go and touch it,

Speaker 2 (00:09:32):

Not necessarily so because the intercostal nerves wrap around the chest wall, sometimes you’ll have some pain at the site, but the pain is actually in the back because of the referred pain cutting, traveling, the length of the nerve. So sometimes we see folks with kind of mild pain up front, but more pain in the back, but they have most of their mobility upfront.

Speaker 1 (00:09:53):

And then what do they say causes the pain? Is it women can’t wear bras or deep breathing hurts or they can’t sleep a certain way? What’s the common kind of scenario?

Speaker 2 (00:10:06):

It’s really variable. I would say it is rare that people get to our clinic for chronic chest wall pain without having gone through several specialists because it’s an uncommon in the scheme of issues that PCPs are dealing with for chest wall pain. It’s a relatively uncommon cause and can be subtle, but I would say the most common complaint is a sharp pain that kind of shoots around and it’s more painful when pressure’s placed, placed on it or a patient feels movement.

Speaker 1 (00:10:48):

And if someone, because sometimes I have the women say they can’t wear a bra, they feel it’s too painful, they either don’t wear a bra or they wear the soft kind of tank tops and stuff. Is that indication that we should think about the chest wall as the reason? I

Speaker 2 (00:11:05):

Definitely think so. Yeah. I mean, I think anytime someone’s coming in with chest wall pain or upper abdominal pain that’s been going on for some time and there’s not obvious imaging findings, I think it’s an important part of any physician’s physical exam to look at the costal margin to palpate the ribcage and make sure that there’s not some obvious anatomic disruption. I, I’ve had several patients in the last couple months who have shown up and said, I’ve been to several physicians, tells me I’m crazy. And then you press on their costal margin and ribs nine, nine and 10 are shifting independently from the rest of their ribcage. And you’re like, well, it’s because you have a costal margin disruption and this is potentially something we can fix.

Speaker 1 (00:11:44):

Got it. And then during COVID, people were coughing so much and I started seeing uptick of people coming to my office with hernias. Did you start seeing more rib pain or even fractures from really bad cough?

Speaker 2 (00:12:01):

Not really. Okay. I think that, I’m

Speaker 1 (00:12:06):


Speaker 2 (00:12:06):

Wondering. Yeah. Well, I say not really because it’s, when you look at the demographic of people that come with either spontaneous costal margin disruption not associated with trauma, it tends to be an older male demographic who are or obese with other multiple medical comorbidities. And unfortunately, a lot of those people, the pandemic hit that demographic pretty hard. Yeah, true. So we did not see a lot of people coming in with hernias as a direct result of COVID

Speaker 1 (00:12:46):

Or rib pain from excessive coughing.

Speaker 2 (00:12:50):

We haven’t yet. But again, it’s one of these things that tends to be a little bit delayed after the initial event. I see folks not in commonly that are a year or two into having chronic chest wall pain by the time they get to us,

Speaker 1 (00:13:05):

The ribs move when you’re breathing. So that’s a really painful and very disruptive to the quality of life because every single breath can be potentially painful, affects your quality of life. Okay. So let’s, what you’re saying is the most common is either rib fracture or a cartilage fracture from direct trauma that you see most, I hear a lot of costochondritis or I think it’s called Tietze syndrome.

Speaker 2 (00:13:35):

Yeah, Tietze syndrome.

Speaker 1 (00:13:36):

Tietze syndrome, which is more of a inflammatory process. Typically women worse during hormonal changes is that

Speaker 2 (00:13:49):

It’s most of the time that tends to be diagnosed by the primary care physicians or internal medicine physicians because surgery doesn’t really help that it’s really an inflammatory issue, not as much a primary anatomic issue. And that’s a challenging diagnosis because it’s frustrating for folks and doesn’t, no good

Speaker 1 (00:14:12):

Studies, no good testing

Speaker 2 (00:14:13):

For it. And it doesn’t always resolve, the NSAIDs don’t always help. But as I mentioned before, the chest wall, part of it’s it’s goal is to move all the time when we’re breathing. And one of the things I’m particularly cautious about is not putting in plates or performing stabilization in areas that are supposed to move unless there’s a really good anatomic indication that it needs stabilization.

Speaker 1 (00:14:42):

Good point. Yeah, good point. Yeah, costochondritis very commonly diagnosed by medical doctors. It’s usually I point tenderness right at the junction. So the junction between where the bone and the cartilage kind of transition

Speaker 2 (00:14:59):

Or right at the journal, the Costal sternal junction where the rib is coming right up adjacent to the sternum

Speaker 1 (00:15:08):

And the anti-inflammatory, maybe C B D cream or something like that can help. So there’s something called slipped ribs and slipping rib syndrome or slipped rib syndrome. Again, these are things I learned after residency. I had no idea what these were before. Can you talk a little bit about that, because that’s definitely a diagnosis that’s treatable, very misdiagnosed, I would say.

Speaker 2 (00:15:39):

Yeah. One, it’s, it’s a challenging diagnosis too. So slipped, like I mentioned, the costal margin is made of cartilage and it’s supposed to move. Now across the spectrum of people, there’s a, there’s variability in how mobile people’s costal margin is. And for some people when their ribs usually ribs 8, 9, or 10, the ribs that make up the costal margin, for some people they have hypermobility in that area. And that hypermobility in some folks results in irritation and intercostal nerve of the rib above. So when we take that mechanical, repeated mechanical trauma of that rib that’s hyper mobile and slipping under the rib above, when we take it and fix it to the rib, secure it to the rib above, we can reduce that inflammation or eliminate that inflammation.

Speaker 1 (00:16:35):

I see.

Speaker 2 (00:16:36):

And that’s really what slipping rib syndrome is, and it’s challenging because it’s really a diagnosis of exclusion. No, unfortunately, there’s no imaging study where we can say, yes, you have slipping rib syndrome. And when I do surgery, the imaging finding will go away. Right. It’s not like a hernia where you have a pretty clear evidence whether you repair worked or not. It really is a symptom resolution of symptoms that,

Speaker 1 (00:17:04):

Yeah, I’ve diagnosed a couple of those and sent them actually to our orthopedic surgeon. We don’t have a chest wall injury center, but we sent ’em to our orthopedic surgeon who’s able to help. But because our thoracic surgeons don’t do that, they just do lung cancer and those kind of things, they don’t do chest wall necessarily. So I think every institution’s a little bit different as to who takes care of these patients. But they come in and they’re like, they feel like a tightness in their upper abdomen around the flank area. And classically they kind of want to curve their fingers under their ribs and just open it up or pry it open. That’s what they say. They just want to. And so I guess surgically that’s what you’re doing is you are preventing the two ribs from rubbing against each other? Is that what it is?

Speaker 2 (00:17:56):

Yeah, we’re preventing the rib below from kind of subluxing under the rib above. And so we’re, there’s a couple different surgical options that are offered. So historically you could remove the costal cartilage as a way to prevent that irritation and the nerve. And then Adam Hansen, who was down in southern California for a while now in West Virginia, he kind of pioneered this method of suturing the rib below to the rib above to help reduce the inflammation.

Speaker 1 (00:18:25):

And what do you suture with?

Speaker 2 (00:18:28):

It’s a permanent suture. We use tiger tape sutures. Yeah. But I am generally a proponent of not respecting the costal margin because I do find that inpatients who have had either marginal resections or have had injuries that have left their cough margin disrupted, the long-term implications of that can be considerable. So my general practice is to do what we call the handsome procedure where we take the rib below and then suture it to the above.

Speaker 1 (00:19:00):

And what’s the recovery of that?

Speaker 2 (00:19:03):

It’s variable by a patient. I’ve had some patients who two weeks after surgery say, I like this is the best I’ve ever felt. I have no pain. But I’ve had other patients who sometimes take 6-8 weeks. I like to describe it as recovery existing along the bell curve. They’re patients on the far end of the bell curve that experience a hundred percent pain resolution. There are the majority of the patients that are in the middle part of the bell curve where they experience like some resolution, but not a hundred percent. And then there are some patients who really don’t get any pain resolution. And I think what that speaks to is it’s probably wasn’t an underlying mechanical issue that was causing their pain in the first part. And it kind of speaks to the challenge of the the entity.

Speaker 1 (00:19:52):

Sure. There’s a question from one of our audience that says, do you violate the periosteum to attach the ribs together?

Speaker 2 (00:19:59):

No. Yeah. I mean, you do with the suture, you have to put the suture through the cartilage, but you’re not resecting anything or scraping it in any way. And the blood supply to the cartilage and the bone remains in intact.

Speaker 1 (00:20:13):

Now, there are patients that have connective tissue disorders. Ehlors Danlos syndrome is the most kind of classic common one, but they have very lax ligaments and so on. Do you see that those patients are more prone to chest wall pain

Speaker 2 (00:20:31):

And it’s a very challenging patient population. Those folks are dealing with a, that is a hard situation to be in for any person. And when I see folks with Ehlors Danlos, I have a very frank conversation with them if I’m offering them surgery that anytime you stabilize the, anytime you stabilize the rib, you may be paying for it somewhere else. We could stabilize it front and your pain may go away upfront, but

Speaker 1 (00:21:05):

Now you’re imbalance,

Speaker 2 (00:21:06):

It may shift to somewhere else. And so I approach patients with connected tissue disorders with particular caution because it’s very much a situation where if you do a stabilization intervention some someplace, that’s probably going to mean it’s going to destabilize something else.

Speaker 1 (00:21:27):

Yeah, that’s really smart that you’re so cautious because these patients are naturally, they’ve, they’re double jointed, so to speak, and they don’t heal very well because they don’t have the collagen to really lay down good scar tissue and then now, and they’re so flexible at the joints and so on, and then you’re stabilizing one area which potentially unstables the next level. Yeah. Tell me a little bit about dislocations. What do you know about dislocations?

Speaker 2 (00:22:02):

So usually anteriorly, it’s not as much a, I mean it is dislocation in that the joint is disrupted, but it’s actually fairly, we can fix those in a manner similar to how we would fix a rib fracture. So we can stabilize it with a plate and then it will heal up and do just fine. The one caveat, anytime we’re plating over a joint, and really the costal sternal junction is a joint, is that you have more movement there. So there’s always a higher risk of plate failure. And so there’s always a chance that, you know, might have to go back in later and remove a plate if for some reason the plate fracture was symptomatic.

Speaker 1 (00:22:52):

Yeah, we talked about this earlier. So I have a patient that it seems he’s got some type of instability where the rib joins the spine, so there’s a joint there, and for any of you that have that problem, so he has some pain in the front, kind of upper abdominal pain. But if you really ask him, and he actually also has, if you follow that area towards the back, he has pain and on exam, very swollen to the side of the spine where the vertebral body, the bone of the spine connects to the rib. And so we got imaging, it looked normal, unfortunately. That’s how I was, but I was told you have, you’re supposed to get a spect CT, and I don’t know your experience about spect CT, but that’s supposed to light up an area where it may be inflamed. And then that not only confirm that that’s the focus of the pain, but then it’ll will guide the pain doctor to inject the area he would any other kind of inflamed or a joint problem. And then, from what I understand, they just cut out the joint. So now you have, what is it? You have a floppy rib.

Speaker 2 (00:24:08):

Yeah. I mean that’s essentially what you set yourself up for is that, yeah. You know, have a rib that’s potentially moving dissynchronously with the rest of the chest wall. Although oftentimes that will be stabilized by the intercostal muscles that

Speaker 1 (00:24:22):

There’s muscle attachments and it’s usually not a lower rib, it’s rib, it’s like a middle rib. So it’s not that big of a deal. Well, let’s talk about these ribs that are not attached, right. 12th rib for sure. And 11, is it 11th rib?

Speaker 2 (00:24:36):


Speaker 1 (00:24:37):

So what do you see problems with those ribs?

Speaker 2 (00:24:41):

So it, it’s less common in general. So sometimes we’ll see fractures there that we’ve plated. In general, ribs 11 and 12 don’t involve, aren’t as involved with your respiration. So yeah, acutely we’re less likely to stabilize them because kind of the benefit really isn’t there for someone’s breathing. Yeah. I have seen patients where they have a really long 11th rib or a really long 12th rib, and then they’ll get impingement on their pelvis and that calm thing

Speaker 1 (00:25:16):

When they’re sitting.

Speaker 2 (00:25:18):

Yeah, they’re bending

Speaker 1 (00:25:19):

Over, twisting, bending, bending. Wow.

Speaker 2 (00:25:21):

Yeah, it’s

Speaker 1 (00:25:23):


Speaker 2 (00:25:24):

Yeah. I have heard surgery described to remove the 11th and 12th ribs for that indication. I

Speaker 1 (00:25:32):

Mean, there are rumors like Cher removed her ribs or something like that, but yeah, she would have a huge scar, right?

Speaker 2 (00:25:37):

I mean, yeah, you definitely have a scar, but I have found in those situations that physical, good physical therapy actually has helped in the rare cases that I’ve seen so far. But wow, surgery, I know folks who have done surgery to remove either a long 11th or along 12th rib with some success, but I haven’t done ’em myself.

Speaker 1 (00:26:04):

So as a hernia surgeon, one of the more complicated ones that I do are these flank hernias that are often due to exposure for spine surgeons. So they do this X lift or kind of a lateral exposure for spine surgery. They’re usually, it’s for fusions, and those muscles on the lateral side are very thin already, so it’s not very good closure. They’re higher, more prone to hernias. And many of them, depending on the level they go there, because it’s kind of a mid to higher level lumbar disease, it’s not like a four, five or S 1. So what happens is they about the 12th rib, so there there’s literally rib and then incision, and then when they close, there’s no muscle to close sometimes, or they entrap the 12th rib. And so these patients not only have a hernia, but they can also have a 12th rib neuralgia, like a nerve entrapment.

Speaker 1 (00:27:14):

And recently I had a patient that I repaired that flank hernia robotically. You got to use Mesh for it. You close the hole and you do these retroperitoneal, extra peritoneal meshes. We call it a R TAPP robotic TAPP, but her diaphragm was really low and so she had basically overlap of Mesh with her diaphragm, destroyed her. Every breath was like this constricted painful situation. I eventually had to go in and take it out. And she had also had a 12th rib injury, sorry, the 12th rib nerve. So intercostal nerve 12th injury from the incision that she had from the spine surgery. So that nerve pain plus the diaphragm irritation really debilitated her. And that was all because of a spine operation.

Speaker 2 (00:28:10):

And honestly, that’s one of my, the reasons that I’m, I try and see if there’s a way to get a patient to a good quality of life with physical therapy. I think in my mind, because if you have a hernia in that area can become very challenging to manage. Removing the 12th and the 11th rib are less ideal situations except in extreme circumstances

Speaker 1 (00:28:37):

And there are consequences to that. There’s a reason why that rib is there. There’s nerves nearby that run along it, and I’ve seen for access for again spine surgery, they actually cut out part of the 12th rib, but that nerve gets injured as part of the cut or part of the retraction maybe. And so it gives chronic nerve pain. So you get this kind of local pain and then it shoots around towards the front of the upper abdominal wall or kind of abdominal wall can be very painful. All of our specialties overlap so much, and yet when we’re trained, at least in the United States, our training is very vertical. Trauma’s different in that by the time you’re a seasoned trauma surgeon, you kind of understand what the orthopedic surgeons do, what the spine surgeons do, you see them in the operating room and so on. But I think as a resident and then going into just general surgery, you don’t appreciate gynecology, urology, all these other specialties that can overlap.

Speaker 2 (00:29:45):

Oh yeah. I mean think that’s the benefit of working in an environment where you can go into a different specialties and just ask to sit and watch because you learn so much when you watch a different specialty operate no matter no what it is. Yeah.

Speaker 1 (00:29:59):

I call the OR our country club because if I’m bored, I’ll just go like to, if I’m waiting in between cases, I’ll just go to another board, Hey, what are you guys doing? Oh, that’s pretty cool. And I’ll like learn from it. I get to hang out with friends I haven’t seen before or seen for a long time. It’s like a country club.

Speaker 2 (00:30:16):

Yeah. What makes the job exciting.

Speaker 1 (00:30:19):

Yeah, I agree. I agree. Here’s another question. It says, can you please ask Dr. Forrester does, going back to the question about the periosteum sutures, does the needle in suture have to traverse the periosteum of the bone to connect the ribs? Or are you only suturing the condral cartilage which has no periosteum?

Speaker 2 (00:30:41):

Yeah, so it depends a little bit on the severity of the slip, whether it’s slip drip syndrome or if we’re doing an acute repair, tons margin disruption. So we can drill through the bone and then put sutures through the bone as well, which I’ll do in a intercostal hernia with intercostal margin disruption to provide, I like to do a bilevel Mesh repair that was originally kind of put forward sandwich. Yeah, it’s a sandwich to help kind of offload the costal margin because if you just close the costal margin and don’t provide any additional support with the other ribs, those repairs will tend to break down.

Speaker 1 (00:31:23):

Got it.

Speaker 2 (00:31:25):

But yeah, you can drill through the rib and put sutures through the periosteum or just go straight through the cartilage, you know, can do either. Technically.

Speaker 1 (00:31:35):

Here’s a question. My second Mesh is subxiphoid. I was told that I have intercostal nerve pain. If one were to ask me where my pain is, I would say it is in the lower ribcage. I’ve had three medial nerve branch procedures. I dunno what that means, five level cryo ablations and rib pain steroid shots, and I’m on my third spinal cord stimulator. Wow. I believe this patient had, remind me, the operation had, I think you had matched removal right after a tummy tuck. But yeah, what do you think about intercostal nerve pains and do you see those?

Speaker 2 (00:32:23):

Yeah, so we’ll see folks. I mean with any number of chest wall issues when they show up myself, if there’s not an underlying anatomic reason or kind of culprit that I can then I’ll oftentimes loop in one of our pain medicine colleagues right here at Stanford or a pain medicine physician closer to home to help manage that. We typically follow folks who have a clearly defined anatomic issue for the pain. But yeah, that sounds like a really challenging situation that patient’s dealing with the, it’s interesting because cryo neurolysis is

Speaker 1 (00:33:11):

Freezing the nerve.

Speaker 2 (00:33:12):

Yeah. It’s something that we’ve actually started doing for, we have two clinical trials where we’re doing bedside for people 18 to 65 with traumatic rib fractures. Then CT guided for people 65 years of age or older. And we, so

Speaker 1 (00:33:30):

Wait, hold on. You’re burning the nerve way back approximately by the closer to the back than where the injury was.

Speaker 2 (00:33:40):

Yeah, and it’s so tempting to say burning, but it’s actually freezing. Sorry,

Speaker 1 (00:33:43):


Speaker 2 (00:33:45):

I do the same thing. I do the same thing like I always want to say, say burning, but yeah, so we actually go about three centimeters from the transverse process and then we freeze the intercostal nerve and essentially that will give people three to six months usually of analgesia while the nerve regrows and got it. So far we’ve seen pretty good results.

Speaker 1 (00:34:09):

Got it. What do you know about ACNES or anterior cutaneous nerve entrapment syndrome? Is that something that crosses your table?

Speaker 2 (00:34:19):

Not really, no, but I’m happy to be educated.

Speaker 1 (00:34:22):

Okay. Well, I’m happy to educate. This is pretty cool. I get to switch places. So ACNES, AC N E S is the acronym for anterior cutaneous nerve entrapment syndrome. These are typically T 11 or T 12 nerves, but it can be along any of the thoracic abdominal, anterior abdominal nerves. So the nerves start in the back, they come to the front and they run through the muscle. And then just at the outer edge of the rectus muscle, it has to pierce through a little fascia where it transitions from the obliques to the rectus muscles and then runs behind the rectus muscle as it pierces through that itsty bitsy little hole. You can kink it there. So some people get pain exactly over the lateral outer border of their rectus muscle, and the pain can be with usually any engagement of the muscle. So coughing, laughing, bending, twisting.

Speaker 1 (00:35:30):

Classically they’re twisting to grab a bag from the backseat and it catches that same nerve, kind of runs behind the rectus muscle and then it splits, sorry. And then it goes through the muscle to the anteriorly. So it starts behind the muscle, it goes through the middle of the muscle entry, and then it splits into a medial lateral border. And each time it takes any of these turns, it can also kink. We have no idea why people get this. It’s unrelated to anything age, gender, surgical procedure, weight, no relation. They just all of a sudden start developing pain. So the pain, that second pain would be more towards the middle-ish of the rectus muscle. So if you ever see anyone with abdominal wall pain, either right at the rectus border or mid rectus, you have to inject their anterior cutaneous nerve. I do it right at the right before it transitions from oblique to rectus muscle. We always think Spigelian hernia, right? It’s in the Spigelian area, but it’s a nerve, it’s not a hernia. So you got to rule out the hernia. Assuming it’s not a hernia, then you do injections. And most people just need injections until that nerve calms down. If they don’t get better long-term with injections, they can go in there and just skip that nerve. It’s a inconsequential nerve, it’s just a sensory nerve, but it does come from the back.

Speaker 2 (00:37:07):

Cool. Interesting. Well learn something new every

Speaker 1 (00:37:09):

Day. Yeah, yeah. It’s one of those things where people go to your doctor and I’ve got abdominal pain to that same patient, similar to your patients who’ve got the multiple surgeons and doctors. So they’ll go to their doctor and they’ll say, oh, GI, of course it’s not GI, it’s mechanical abdominal wall. They all get colonoscopy, they get CAT scan, which going to be normal. They are given narcotics, which that doesn’t help. And eventually they go to the pain doctor who’s like, oh, and some of them tell ’em to do a stimulator, like a nerve stimulator, spinal stimulator. I’m like, that’s ridiculous. It’s a very treatable problem. And so this other patient that was talking about with the complicated story and the third spinal stimulator, so she says she has T five through T nine pain from prior sutures. So sutures can entrap the nerve as well. These are nerves we don’t really look at or see as very uncommon to trap sutures to have sutures, entrap nerves in the abdominal wall, but it can happen. But that’s where you need to know your anatomy. Yeah, anatomy is so important. I always teach my residents talk to me about intercostal hernias. So these are also hernias, but I don’t tend to treat them because they’re above my level of work. Tell me why people get intercostal hernias and then how do you treat them?

Speaker 2 (00:38:50):

Yeah, so we see intercostal hernias for kind of a couple different causes. One is people will get a costal margin disruption and then over time because they lost the integrity of their costal margin, their ribs will start spreading. And so they’ll have a costal margin disruption and then their muscle will weaken and they’ll get an intercostal hernia there as well.

Speaker 1 (00:39:13):

Oh, is that why? Yeah. So is that a true hernia where it’s a hole or it’s just a weakness where it bulges?

Speaker 2 (00:39:21):

It ends up being a, it’s a little bit different in that there’s not a fascial layer, but what happens is the you’ll have pleura and lung come up,

Speaker 1 (00:39:32):

Right? Right. The rib beyond the ribs. So your lung is protruding beyond the rib border and is that dangerous?

Speaker 2 (00:39:41):

Not so dangerous, but it’s not in that it’s like immediately, but it’s infect your respiratory mechanics.

Speaker 1 (00:39:52):

Got it. Is it painful?

Speaker 2 (00:39:54):

It can, yeah. Mostly there. It’s painful because of as your costal margins, stretching, tugging on your intercostal nerve that are going up and forming and coming under your costal margin.

Speaker 1 (00:40:09):

Got it.

Speaker 2 (00:40:10):

And then we have people who have intercostal hernias from, who’ve had thoracic surgery and had

Speaker 1 (00:40:17):

Surgical institutional hernia

Speaker 2 (00:40:19):

And Or

Speaker 1 (00:40:20):

They’re stabbed there.

Speaker 2 (00:40:21):

Or they’re stabbed. Right. It’s traumatic, right? You have someone who gets a bull their hoof through their chest and then you’ve got a good sized defect. But chronically what we see more commonly is some sort of cost margin disruption and then a concomitant intercostal hernia.

Speaker 1 (00:40:42):

What about from bad bronchitis or bad coughing? Do you get herniations for that?

Speaker 2 (00:40:48):

Yeah, we definitely do. Again, they tend to be associated with some sort of costal margin disruption as well. It’s unusual for one us to see one of those in the ribs one through seven. Got it. Cause there’s so much structural integrity with the joint usually to the sternum that we don’t see it or I don’t see it as commonly there. I see it more commonly in the lower ribs, particularly when there’s involvement in the costal margin.

Speaker 1 (00:41:16):

And what do you mean exactly by costal margin disruption?

Speaker 2 (00:41:19):

Yeah, so your costal margin. See if I can, well, I’ll just stand up a little bit. Maybe that’ll be easier. So your costal margin comes right here.

Speaker 1 (00:41:28):

And so yeah, the lower border of your ribs in the front. Yeah.

Speaker 2 (00:41:32):

And if you break that, then you have a disruption in your costal margin.

Speaker 1 (00:41:37):

Oh, so is it broken at the junction between the bone and the cartilage or it’s just a rib fracture?

Speaker 2 (00:41:46):

It can be junction break at the junction of the cartilage and the bone. I see that, and I’ve seen it actually kind more commonly in surfers, but kind of the more common issue is it’s actually the cartilage itself that’s broken because the costal margin is all cartilage. Yeah,

Speaker 1 (00:42:03):

True, true, true. By the way, you’re very well dressed for a trauma surgeon.

Speaker 2 (00:42:07):

Oh, well, yeah. I was on call last week. Today was mostly an admin day.

Speaker 1 (00:42:11):

Okay, great. So when I was a resident, we had rib belts, which was someone had a rib fracture. We felt that if they breathe a lot, it’s going to prevent the rib from healing, so we would wrap their chest. I know we don’t do that anymore, but I do use belts for my hernia patients. So you can go to Amazon and buy a rib belt and it’s unique because it’s narrower than the typical abdominal binder. And there’s a little area that’s cut out for women for their breasts. So if they have an epigastric or upper abdominal hernia and I want to put some type of compression over it, maybe reduce seroma or whatever, I have them use the rib belts. Do you ever use belts for anything?

Speaker 2 (00:43:00):

I don’t use belts for anything on the chest, but now I may start using that on patients who I operate on for hernias because that’s, yeah,

Speaker 1 (00:43:07):

For upper abdomen it’s very hard to get a good binder up there. And the rib belt works really well.

Speaker 2 (00:43:13):

Yeah, no, I’ll have to take that one, one home.

Speaker 1 (00:43:16):

Sounds good. Sounds good. I lost my train of thought. Oh, do you work together with orthopedic surgeons or thoracic surgeons or spine surgeons for any of your work?

Speaker 2 (00:43:32):

Yeah, we will. So we do, for the acute cases, we will do basically all of the chest wall stuff, but we will do concomitant surgeries with our spine surgeons, particularly if someone will actually do stage surgeries. If someone has a bad chest wall injury, but they have to go prone for their back, we’ll actually do the chest wall surgery now increasingly upfront to stabilize their chest wall. So it makes it easier while they’re

Speaker 1 (00:43:58):

Laying when they go.

Speaker 2 (00:43:59):


Speaker 1 (00:44:00):


Speaker 2 (00:44:01):

And then our orthopedic surgeons are, our spine surgeons are excellent. Our orthopedic surgeons are excellent. They able to put together stuff that

Speaker 1 (00:44:12):

So amazing.

Speaker 2 (00:44:13):

Yeah, it’s pretty remarkable. So for our bad patients with polytrauma, we work closely with them.

Speaker 1 (00:44:20):

Yeah. Here’s a question that goes back to the cryo ablation. So you said you freeze the nerve just beyond where it comes out of the nerve root. So that nerves function is to serve not only with skin level sensation, but also the muscles in between the ribs, right?

Speaker 2 (00:44:45):

Yeah. It’s interesting. You actually don’t get any kind of chronic Oh, okay. Even when you’re freezing multiple layers. Interesting too, because when we apply the cryo probe, the vein artery and nerve are running right next to each other. Correct. You’re applying negative 80 degrees Celsius there for a minute and a half. So

Speaker 1 (00:45:04):

You’re turning the vessels too, right?

Speaker 2 (00:45:06):

There’s no vessel damage. The vascular, it all stays intact. So

Speaker 1 (00:45:13):

It’s kind of cool. Are you really good at it? I mean, you would think that there’s literally right there, it’s all together as one bundle.

Speaker 2 (00:45:22):

Yeah. I think the blood passing through the vessel acts as a heat sink, and so it maintains the integrity of the vessel

Speaker 1 (00:45:30):

Very so as limited as possible to just the nerve and not any other tissues around it. And you don’t get degradation of that muscle. Very interesting.

Speaker 2 (00:45:41):


Speaker 1 (00:45:42):

So one of the other patients that I had, which was had this enigmatic kind of mysterious upper abdominal pain and could never figure it out until you finally, someone ordered, I forget what was ordered, but they finally saw an itsy bitsy, little bit of a diaphragm hernia, not your typical diaphragm hernia that you see that you’re born with sometimes, or that you could develop as an adult. Not, she never had a car, like a bad trauma car accident, but that was causing the pain. Do you treat diaphragm hernias? Is that part of what you do?

Speaker 2 (00:46:20):

We treat them acutely when patients come in as traumas and then I’ll treat them in a chronic fashion as well when people have been dealing with them for a while. I think one thing that we see is that there are probably a lot of small hernias that develop after rib fractures, poke the diaphragm after one trauma. So even if you have a rib fracture and it pops out and comes back in, you know, may have a small diaphragmatic hernia that is not visible on imaging or probably wouldn’t even be visible on direct physical exam if you were in the chest. But

Speaker 1 (00:46:54):

Yeah, good

Speaker 2 (00:46:55):

Point. Give it 10 or 20 years. I’ve seen now more than a handful of patients where they have evidence of a healed fracture and they’re coming in for a chronic diaphragmatic hernia that they otherwise would have no reason for.

Speaker 1 (00:47:09):

I should have asked that history in retrospect, I’m not sure. I always ask about trauma, car accidents, seatbelt injuries, et cetera, stab wounds. One of my prior medical students, he was stabbed while he was a checker at the, or not a bagger at a grocery store. Oh man. Man. Yeah. So even you want to have to be kind of a, on the edges of society to be stabbed. You can just be a medical student, you can be stabbed. So I always ask that based on that history, but I didn’t ask actually for a fracture of the rib. I’m going to do that now. This is very, very helpful. On that note, do you know Jim Murray, the, he’s kind of the one from USC that wrote about diaphragm injuries that need to be ruled out If you’ve had a chest injury, or sorry, if you’ve had a stab wound to between the nipple and the right.

Speaker 2 (00:48:13):

Yeah, yeah,

Speaker 1 (00:48:15):

Yeah. We used to call ’em, yeah,

Speaker 2 (00:48:16):

The nips, I call it the nips to the tips like nipples for the tip of the scapula. I don’t know if that’s like the correct, but yes. Nips to the tips on the side. Yes,

Speaker 1 (00:48:26):

That’s a good one. We called it Marie’s box at USC was I started, my first job was at USC in 2002 and he was my office mate. Jim Murray was a trauma guy. I was like the non-trauma person didn’t know. He wrote this very influential kind of paper about, so what they would do is, let’s say you got stabbed below the level of the nipple and therefore got some type of chest injury. What people didn’t appreciate is that below the diaphragm can go as high as the nipple and therefore you can actually have a intraabdominal injury. So if that doesn’t show, it’s possible that you had a diaphragm injury, right? That’s right. The border chest wall. So they would go in laparoscopically right before the patient went home and just double check that. Is that something you guys do now? Two or,

Speaker 2 (00:49:17):

Yeah. So protocol. Yeah. Yeah. Any patient with a stab wound to the flank, essentially levels of the nipple over the tip of the scapula and then down below the costal margin to a diagnostic laparoscopy to look at the diaphragm and make sure that there’s not a diaphragmatic injury.

Speaker 1 (00:49:33):

Yeah, we call it Murray’s box. It was a larger box on the left and then the smaller box on the right because the rib kind of protects you. Makes it less likely.

Speaker 2 (00:49:43):

Yeah, the, well the liver on the

Speaker 1 (00:49:45):

Right, on the right. Yeah. Yeah. Did I say left? I meant right.

Speaker 2 (00:49:48):

Yeah, no, I think you said rib.

Speaker 1 (00:49:50):

Oh yeah. The liver kind of protects a lot of those issues. Well, we’re getting towards the end. I have some questions that were sent in. Let me make sure that, let’s see. These are all about ACNES, which we already talked about. Yeah. One question was, does chest related abdominal wall pain always have a neuropathic origin?

Speaker 2 (00:50:19):

That, that’s a good question. I would say that, does it always, I’m always hesitant to say always medicine. I would say the vast majority of the patients that we see have some sort of anatomic issue that’s resulting in yes, neuropathic pain, neuropathic being some sort of mechanical, repeated mechanical distress to either the intercostal nerve or some other cutaneous nerve.

Speaker 1 (00:50:52):

Got it. What imaging do you typically, do you stop at x-ray? Do you stop at CT scan? Is MRI helpful?

Speaker 2 (00:51:01):

Yeah, the good question. It depends a little bit on the underlying pathology. So for slip rib syndrome, most of the time the people will have come to me with a bazillion different images and really I base my decision to operate on physical exam.

Speaker 1 (00:51:16):


Speaker 2 (00:51:17):

So imaging I think is less useful in that situation for patients with a costal margin disruption in intercostal hernia, I can base a lot of my decision to operate based on physical exam alone because it’s pretty obvious. But I would say kind of our go-to workhorse image is the non-con CT chest because that provides enough image, enough detail about the bony infrastructure of the chest. And once you get used to looking at cartilage, it actually gives you a pretty good sense of what the cartilage looks like

Speaker 1 (00:51:44):

Too. Got it. Do you think the radiologist have specialists to look at it? Or what is the average general radiologist could pick up a fracture of the cartilage?

Speaker 2 (00:51:53):

The cartilage is tricky. Even, I mean, now that I know what I’m looking for and that, that’s such a large portion of my patient population, I tend to pick it up more. Good to know. But it, it’s can be really subtle. The cartilage fractures can be really subtle cause they just don’t show up the same way that rib fractures do it. And there’s ways that you can improve the way you visualize the cartilage, but it’s still hard and it just takes time to go through the image, go through each of the cartilages connections and see if there’s something that looks anatomically off.

Speaker 1 (00:52:31):

And how’s the outcome of the operations that you do? Do they have chronic pain or nerve injury or lung injury or anything like that?

Speaker 2 (00:52:41):

It depends. For the acutely injured patients, it depends entirely on what their injury burden is. Some people were able to get completely pain free, I would say in general. And having been a victim of trauma myself repeatedly in my twenties, teens and twenties. Wow. You almost never get back to,

Speaker 1 (00:53:00):

Is that part of your exploration kind of

Speaker 2 (00:53:04):

Oh yeah. Yeah. I’ve been a climber for far longer than I’ve been a surgeon, but it is, you almost never get a hundred percent full function to what you had injured. There’s ways that your body can compensate and we get you really close. For patients with the chronic chest wall injury, I usually have a pretty frank discussion with them that if you’ve been dealing with pain for a year or two years, we, I am confident that I can fix the underlying anatomic issue and the vast majority of time pain will get better. Whether that pain goes away is a lot harder to predict. And even with a perfect anatomic outcome, there still may be issues with pain that can be a result of other pathways that I can’t control. So I like to set expectations.

Speaker 1 (00:53:53):

So these patients with, let’s say cartilage fractures, do those just never heal or is expected to heal and some people don’t heal?

Speaker 2 (00:54:03):

So some people it definitely heals. Cartilage is the healing. I would say that what we know about cartilage healing is decades behind what we know about bone healing. I think that if you look across a population, there’s probably a lot of people that have cartilage fractures that go on to heal. There’s a subset of people who have cartilage fractures that don’t go on to heal, that aren’t symptomatic. And then there’s probably a smaller proportion of patients who develop cartilage fractures, don’t go on to heal and are then symptomatic from it.

Speaker 1 (00:54:38):

Do any of these chest wall problems cause weird blood pressure variations and other problems, swallowing problems? I asked you this because I have this one patient that I’m really trying to help. She can’t, can’t life. So she has a lot of what I’m going to call rib pain. She can’t wear, she never wears a bra. She has these weird kind of really high blood pressures sometimes and she can’t lie flat. So she sits to sleep. Horrible quality of life. Have you seen any of these other symptoms?

Speaker 2 (00:55:27):

I haven’t seen those symptoms, but the chest walk, chest wall issues can masquerade in kind of perplexing ways. I know one person through the chest wall injury society who had a patient who had persistent issues with nausea and GI distress. And when they scoped her, you could actually see the costal cartilage poking into the stomach.

Speaker 1 (00:55:51):

Pressing the

Speaker 2 (00:55:52):

Stomach. And so when that was how the patient showed up in his office and when he fixed that, the GI symptoms went away. I think that’s the, that’s exception rather than the rule. But it can

Speaker 1 (00:56:04):

Definitely, yes. Well she’s clearly going to be the exception because she’s had every single test possible. And I always wonder if it’s just missing an actual mechanical chest wall thing. She’s lost, she’s like under 90 pounds now because she can’t eat. She’s always nauseated. And once she eats all the, I feel like when she eats her abdominal wall expands and that somehow also expands a chess wall a little bit and causes too much pain. You want me to send her to you?

Speaker 2 (00:56:35):

I’m always happy to see folks.

Speaker 1 (00:56:36):

Okay, very good. Any departing thoughts? Do you take patients, let’s say from out of state or do you do zooms in state, anything like that?

Speaker 2 (00:56:49):

Yeah, chest wall cases, whether acute, we see them in the hospital, but chronic, I see folks in clinic first because I, physical exam is such a kind vital component and I don’t want to waste someone’s time by seeing them by zoom and then having to have to come in anyway for a physical exam. But yeah, I see patients essentially up and down the west Coast, so I’m always happy to see people.

Speaker 1 (00:57:25):

Yeah. Well you’re on my list. I really am so glad to meet you. And I don’t think our path will cross too much cause I only do hernias. Yeah, well

Speaker 2 (00:57:35):

I do enough trauma stuff that I’m sure there’ll be some Southern California hernias that could be funny.

Speaker 1 (00:57:42):

Exactly. But one thing I love about what I do is I do get to interact with urologists, gynecologists, pain doctors, orthopedic surgeons, trauma surgeons, pain. Pain doctors. I think I mentioned because there’s overlap with everything we do. I like to learn and a patient comes to me with, help me figure this out. I should be able to say, oh, I think it’s chest wall. Go see Dr. Forrester because he knows. Yeah. And he, you’re, you clearly enjoy the specialty. You clearly enjoy your little niche within a niche. So congratulations on doing that.

Speaker 2 (00:58:26):

Thank you. No, it’s, it’s a privilege to be able to help folks out. So

Speaker 1 (00:58:30):

Yeah, really appreciate Dr. Forrester, director of the Stanford Chest Wall Injury Center and great trauma surgeon. Actually, I’m giving a talk at one of the trauma trauma meetings, so I may see you there. Oh,

Speaker 2 (00:58:45):

Okay. Which one?

Speaker 1 (00:58:47):

There’s a trauma course at ACS in Boston this year, right?

Speaker 2 (00:58:51):

Yeah, I’ll be out there.

Speaker 1 (00:58:52):

And the USC trauma.

Speaker 2 (00:58:55):

Okay. I don’t know if I’m going to USC trauma, but I’ll definitely be at ACS.

Speaker 1 (00:58:59):

Okay. All. Maybe we’ll see each other in Boston. All the same state. I haven’t see you in Boston.

Speaker 1 (00:59:07):

All right. Well thank you very much and thank you all of you who joined us and asked questions and hopefully learned something. It was my pleasure to do this hour. I’ve been looking forward. You guys don’t know this. I’ve been looking forward to this talk for months, but Dr. Forrester decided to have a baby and needed paternity leave, so I had to delay it until now, but I really have been very much looking forward to it. So thank you for your time. Of course. And thank you all of you. Please subscribe to my YouTube channel because you’ll get to listen to and share today’s talk and all prior talks on my channel at Hernia Doc. Thanks to everyone who follows me on Facebook at Dr. Towfigh. And again, I share everything on Twitter and Instagram at Hernia doc. Hope you enjoyed it. See you all in a couple weeks. I will be traveling a lot, so go to our Twitter because I’ll be live tweeting all the meetings I’m going to be going to in the next two weeks. And I hope to see you in three weeks or so. Thanks everyone. Thanks again for your time. Bye.