Costocondrite, diagnóstico e tratamento

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Costocondrite, diagnóstico e tratamento

Mensagem  mairalmf em Seg Mar 04, 2013 4:39 pm

Costosternal syndromes (costochondritis) — A majority of patients with musculoskeletal chest wall syndromes have a more diffuse pain syndrome, in which multiple areas of tenderness are found that reproduce the described pain. The upper costal cartilages at the costochondral or costosternal junctions are most frequently involved [16,21-23].The areas of tenderness are not accompanied by heat, erythema, or localized swelling.
A variety of diagnostic terms have been used in this group of patients, including costochondritis, costosternal syndrome, and anterior chest wall syndrome. The diagnosis is based solely upon the ability to reproduce pain by palpation of tender areas. In some studies, certain maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuvers, have also been found to be useful.
Although the costosternal syndrome is a frequent diagnosis in patients with noncardiac chest pain, the causes, natural history, and treatment of this condition are poorly documented. A number of measures, including analgesics, local injections, and stretching exercises may be helpful [24]. Most cases follow a self-limited course with occasional exacerbations. The coexistence of fibromyalgia should be considered in patients with persistent symptoms.

Therapeutic interventions for musculoskeletal disorders affecting the chest are generally similar to those for musculoskeletal pain elsewhere in the body. However, in the case of chest pain, a common patient concern, stated or unstated, that the pain is due to heart disease, must be addressed as well. In this regard, the physical examination itself, particularly the examiner's ability to reproduce or exacerbate the chest pain by palpation or with various maneuvers, helps the patient understand the noncardiac nature of the problem.

Costochondritis and Tietze's syndrome are both associated with tenderness of one or more of the costochondral joints. Although there is some controversy over whether these two disorders are truly distinct, in this discussion the term Tietze's syndrome is used for the combination of pain, tenderness and swelling, while costochondritis is used when swelling is absent.
Sternalis syndrome is a rare disorder characterized by localized tenderness found over the body of the sternum, often with tenderness that causes radiation of pain bilaterally.
Xiphoidalgia or xiphoidynia is also a rare syndrome with localized pain and tenderness over the xiphoid process.
Sternocostoclavicular hyperostosis is a syndrome characterized by a unique arthropathy that frequently involves the anterior chest wall and is associated with a spectrum of neutrophilic skin lesions. The acronym SAPHO syndrome has been proposed as a unifying term to include the various features that may occur: synovitis; acne; pustulosis; hyperostosis; and osteomyelitis.
Lower rib pain syndromes go by many different names such as slipping or clicking rib syndrome, rib-tip syndrome, or twelfth rib. Pain can be diffuse or localized, and is accompanied by tenderness on the costal margin that reproduces the pain.
Fibromyalgia is a common chronic musculoskeletal pain syndrome that presents with diffuse myalgias, multiple tender points, sleep disturbance, and fatigue. Many patients report tenderness over the costochondral junctions.

THERAPEUTIC INTERVENTIONS — Patients with musculoskeletal chest pain may benefit from one or more of the following interventions:
Patient education and reassurance
Physical measures
Topical agents
Nonsteroidal antiinflammatory drugs (NSAIDs)
Muscle relaxants
Local glucocorticoid and/or anesthetic injections
Disease modifying anti-rheumatic drugs (DMARDs)
Psychiatric evaluation
Narcotic analgesics

Patient education — Once a musculoskeletal cause for chest pain has been established and immediate life-threatening disorders have been excluded, a careful explanation of the diagnosis and reassurance may be therapeutic for some patients. For them, watchful waiting without any other specific intervention may be appropriate.

Follow up and advice are helpful to such patients and may be appropriately scheduled four to six weeks after the onset of symptoms [1]. A follow up appointment with a doctor in primary care provides an opportunity for further discussion and may identify patients with uncontrolled symptoms who require further evaluation or additional treatment.

Physical measures — Overload and overuse, as during weight training, may cause muscle strain. If possible, any activity that causes or reliably exacerbates the problem should be stopped, at least temporarily. This is particularly important for patients with spontaneous sternoclavicular subluxation. Anecdotal reports of benefit from physical interventions are widespread although not assessed in the scientific literature. For muscle spasm, application of heat may be helpful. If no muscle spasm is present, application of cold may reduce swelling and discomfort.

Stretching exercises may benefit patients with musculoskeletal chest pain of various causes, particularly if muscle spasm is present. The specific exercises should address the muscle groups involved (eg, pectoralis major versus sternal head of the sternocleidomastoid). For certain patients with intractable symptoms, a short course of physical therapy with a goal of an independent home program is worth the investment of time.

Topical agents — Topical agents such as capsaicin cream or salicylate-containing creams or gels may be tried with application three to four times daily for a two week trial period [2,3]. These agents are widely available at local pharmacies. Where available, topical NSAID preparations (eg, one percent topical diclofenac gel or diclofenac patch) or ethyl chloride spray may also provide some relief and can be used several times per day. Topical use of NSAIDs may be associated the same risks of adverse effects as may occur with systemic use. (See 'Nonsteroidal antiinflammatory drugs' below.)

Local pain also often may respond to a lidocaine patch.

Nonnarcotic analgesics — Patients with mild symptoms and no evidence of an inflammatory disorder (eg, muscle strain, costochondral tenderness without swelling, etc) and/or those who have a relative or absolute contraindication to the use of NSAIDs, may benefit from a nonnarcotic analgesic such as acetaminophen (up to 3 grams/day in divided doses in adults).

Nonsteroidal antiinflammatory drugs — Over-the-counter NSAIDs (eg, ibuprofen, naproxen) are often used, and may be more appropriate than simple analgesics for patients with signs of inflammation. Most patients' symptoms due to musculoskeletal chest problems improve over the course of a few weeks or months.

Patients with uncontrolled symptoms from Tietze's syndrome, SAPHO syndrome, costochondritis, sternalis, xiphoidalgia, or the lower rib pain syndromes may require prescription strength NSAIDs. If a maximum dose of a particular NSAID does not relieve symptoms or efficacy wanes, anecdotal reports suggest that switching classes of NSAIDs may prove helpful (from an acetic acid to a propionic acid for example) (table 3) [4].

Patients should be cautioned that use of NSAIDs may precipitate renal insufficiency, gastritis, peptic ulcer disease, and gastrointestinal bleeding. Those at high risk of NSAID-induced gastroduodenal damage and those requiring concomitant low-dose aspirin therapy for cardiovascular disease may benefit from ulcer prophylaxis with a proton pump inhibitor or misoprostol. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".) Interference by some NSAIDs with the beneficial anti-platelet effects of aspirin may be a concern for those taking low doses of aspirin for prophylaxis or treatment of cardiovascular disease. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease" and "Nonselective NSAIDs: Adverse cardiovascular effects".)

Use of a selective cyclooxygenase-2 (COX-2) inhibitor may also be considered for patients at high risk of gastroduodenal damage and for those receiving anticoagulants. (See "Overview of selective COX-2 inhibitors" and "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity", section on 'Selective COX-2 inhibitors'.)

Intramuscular injection of ketorolac (15 to 30 mg) followed by oral ketorolac (up to 10 mg four times daily) for up to five days may be valuable in moderate to severe acute musculoskeletal pain. However, parenteral administration of this NSAID does not avoid the risk of gastroduodenal damage or of causing acute renal failure in high risk patients.

Muscle relaxants — Cyclobenzaprine, methocarbamol, and benzodiazepines may be beneficial for treating musculoskeletal chest pain, particularly if there is associated muscle spasm. Muscle relaxants are not recommended for elderly patients or those patients prone to misuse of the drugs. Long-term therapy for musculoskeletal chest pain with muscle relaxants should generally be avoided.

Cyclobenzaprine — Cyclobenzaprine at doses of 5 to 10 mg three times daily is more efficacious than placebo in the treatment of neck and low back pain [5]. There are no data that specifically address the efficacy of this agent in chest wall pain. If used, cyclobenzaprine is typically started at a dose of 10 mg PO three times daily and increased if necessary to a maximum daily dose of 60 mg per day. Patients should be warned about drowsiness with this agent and cautioned to avoid hazardous activities while taking it.

Methocarbamol — Data are also lacking to assess the efficacy of methocarbamol for musculoskeletal chest pain; however, we use it for acute exacerbations of pain. Methocarbamol doses range from 750 mg to 1500 mg three times daily. As with other muscle relaxants, patients should be warned about sedative effects.

Benzodiazepines — Because of the potential for abuse, benzodiazepines should be avoided for the treatment of isolated musculoskeletal chest pain in the absence of psychiatric indications. Patients should be cautioned about possible sedation and the potential for dependence or addiction.

Antidepressants — Tricyclic antidepressants such as amitriptyline, nortriptyline, or imipramine have been used for chest pain of neuropathic origin. They may also be useful for treatment of subacute or chronic chest pain of musculoskeletal origin, particularly that due to chronic costochondritis or fibromyalgia. A low dose of a tricyclic at bedtime is used initially. The dose may be increased weekly to the maximum tolerated or the equivalent of 150 mg of amitriptyline daily. Adverse effects of tricyclics are common (table 4). (See "Overview of the treatment of chronic pain".)

Selective serotonin reuptake inhibitors (SSRI) or bupropion have also been used to treat symptoms of chronic pain. Overall they may be somewhat less effective in relieving pain than the tricyclic antidepressants [6]. However, the advantage in safety of SSRIs over the tricyclics may make an SSRI the antidepressant of choice, particularly if anxiety or depression is present, or if comorbidities (eg, coronary heart disease) that are relative contraindications to the use of tricyclics are present. (See "Overview of the treatment of chronic pain".)

Anticonvulsants — The anticonvulsant gabapentin has been used to treat chronic pain syndromes. The mechanism by which gabapentin produces pain relief is unknown. Somnolence and dizziness are common side effects [7]. An empiric trial of gabapentin might be considered for a patient with chronic chest wall pain that did not respond to other forms of therapy and prior to resorting to more invasive approaches such as local injection. Other anticonvulsants have also been used to treat chronic pain. (See "Overview of the treatment of chronic pain".)

Local glucocorticoid injections — Therapy with one or more local injections of a mixture of a glucocorticoid and a local anesthetic may be helpful for patients with arthritis, Tietze's syndrome, costochondritis of one or two joints, xiphoidalgia, or one of the lower rib pain syndromes such as slipping rib or rib-tip syndrome.

Local injection of the manubriosternal joint, sternoclavicular joint, or the costochondral junctions must be performed with caution in order to reduce the risk of pneumothorax or laceration of blood vessels in the chest wall or mediastinum.

Sternoclavicular joint injection — The approach to injection of the sternoclavicular joint is similar to aspiration and injection of larger joints. (See "Joint aspiration or injection in adults: Technique and indications".) Careful palpation of bony margins prior to skin preparation is helpful. The joint line of the sternoclavicular joint runs obliquely laterally from superior to inferior and may be identified while the patient retracts the shoulder. For injection of this joint, the patient should lie with the ipsilateral arm in lateral rotation [8].

To minimize discomfort, lidocaine (one to two mL of 1 or 2 percent solution without epinephrine) should be injected into the skin and subcutaneous tissues. After local anesthesia is achieved, using a 23-gauge or 25-gauge needle and sterile technique, an attempt should be made to aspirate the joint. Any aspirated fluid should be sent for total white cell count, differential white cell count, polarized-light microscopy for crystals, gram stain, and culture if possible. (See "Synovial fluid analysis and the diagnosis of septic arthritis".)

After septic arthritis of the sternoclavicular joint has been excluded injection of corticosteroids and a local anesthetic may proceed. Choices of glucocorticoid include:

Hydrocortisone acetate (20 mg)
Methylprednisolone (20 mg)
Triamcinolone hexacetonide (10 mg)

Lidocaine (1 mL of a one or two percent solution without epinephrine) may be mixed with the glucocorticoid.

Relief of local symptoms within a few minutes of the injection affirms the correct placement and offers reassurance that the chest pain was indeed due to a sternoclavicular joint disorder.

Patients should be cautioned regarding the following:

The immediate pain relief due to the local anesthetic will last for minutes to hours.
Pain is likely to return and for up to 24 hours the joint may be more painful than it was prior to the injection. Use of an analgesic such as acetaminophen (up to 3 grams/day in divided doses in adults) or an NSAID may be needed for a few days following the injection.
It may take several days for the benefit of the glucocorticoid to become apparent.
Sports activities should be limited for five to seven days following injection [9].
Longer acting steroids (eg, methylprednisolone and triamcinolone) may lead to fat atrophy and/or depigmentation of the overlying skin.
There is a small risk of septic arthritis following joint injection. This risk has been estimated to range from 1 in 2000 to 1 in 15,000 procedures. Symptoms or signs of infection should be watched for and reported immediately if they develop. (See "Joint aspiration or injection in adults: Complications", section on 'Iatrogenic septic arthritis'.)

Manubriosternal joint — The manubriosternal joint is typically located at or near the 2nd costochondral junction. Local injection of the manubriosternal joint may be valuable in the setting of rheumatoid arthritis [10]. The joint is located by palpating for the angulation between the sternum and the manubrium. The choice type and amount of glucocorticoid is the same as for sternoclavicular joint injection. (See 'Sternoclavicular joint injection' above.)

Costochondral junctions — Infiltration of the region of the costochondral junctions may be beneficial for the patient with one or two tender areas due to costochondritis or Tietze's syndrome. The best evidence to support the effectiveness of this approach was an observational study in which ultrasonography was used to confirm the diagnosis of Tietze's syndrome in nine patients [11]. The point of maximal tenderness and/or ultrasonographically enlarged costochondral joint was injected with a mixture of 15 mg of triamcinolone hexacetonide and 1 mL of two percent lidocaine. Complete resolution of swelling and tenderness was noted after one week in eight patients and "substantial" improvement was noted in the one remaining patient.

As with sternoclavicular joint injection, caution is required to avoid inadvertent puncture of the underling lung, blood vessels or heart. If the treating physician is not experienced with costochondral joint injection and if less invasive treatments (eg, rest, heat, NSAIDs) have been ineffective, referral to a pain management specialist, orthopedist, or rheumatologist for the procedure may be appropriate.

Intercostal nerve block — Severe pain due to one or more fractured ribs or malignant disease affecting the chest wall may respond to intercostal nerve block using a local anesthetic for short term pain relief or phenol, a cryogenic probe, or other means for longer-term control of chest wall pain. These approaches are generally arranged though a pain treatment or anesthesia service. (See "Peripheral nerve block: Techniques", section on 'Intercostal nerve block' and "Psychological, rehabilitative, and integrative therapies for cancer pain".)

Disease modifying antirheumatic drugs — Use of disease modifying anti-rheumatic drugs (DMARDs) may be useful for patients with systemic rheumatic disease that is causing chest pain as a result of arthritis of the costovertebral, sternoclavicular, manubriosternal, or costochondral joints.

For patients with rheumatoid arthritis agents such as hydroxychloroquine, sulfasalazine, methotrexate, or anti-tumor necrosis factor (anti-TNF) agents alone or in combination may be beneficial. (See "General principles of management of rheumatoid arthritis in adults".)
Patients with spondyloarthropathies, such as ankylosing spondylitis, may benefit from use of sulfasalazine or anti-TNF agents. (See "Assessment and treatment of ankylosing spondylitis in adults".)
When sternoclavicular arthritis is present along with other features of the SAPHO syndrome, DMARDs or anti-TNF therapies may be useful adjuncts to treatment. (See "Major causes of musculoskeletal chest pain", section on 'Sternocostoclavicular hyperostosis (SAPHO syndrome)'.)

Psychiatric evaluation — Concomitant psychiatric problems such as anxiety, depression, panic attacks, or abnormal health beliefs may influence the outcome of treatment of non-cardiac chest pain. Psychiatric referral should be considered for these patients. Evidence from controlled trials has shown an advantage with cognitive behavioral therapy [12-14], and antidepressant drugs in selected populations [15].

Narcotics — Use of long-acting narcotics should be avoided in patients with chest pain of musculoskeletal etiology. For isolated acute exacerbations, short-acting mild narcotics such as codeine may be used judiciously. Patients should be cautioned regarding sedation and potential for dependence when using narcotics



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