What are potential causes of chronic paraspinal pain wrapping around the lower ribs bilaterally in an adult with a history of multiple surgeries, which has worsened acutely?

Differential Diagnosis for Bilateral Paraspinal Pain Wrapping Around Lower Ribs

Your differential diagnosis must prioritize life-threatening conditions first, then structural causes related to prior surgeries, followed by musculoskeletal etiologies. Given the chronic nature with acute worsening and surgical history, this presentation demands systematic evaluation for serious pathology before attributing symptoms to benign causes.

Life-Threatening Causes to Rule Out Immediately

• Thoracoabdominal aortic aneurysm with vertebral erosion: Chronic pulsatile trauma from an aneurysm can cause vertebral body erosion (VBE) presenting as lower back pain that wraps around the ribs bilaterally. This is particularly critical in patients with prior surgeries and chronic pain that suddenly worsens. 1
• Paraspinal abscess with osteomyelitis: Can present as sharp lateral rib pain with radiation to anterior thorax and around the back, especially in post-surgical patients. Methicillin-sensitive Staphylococcus aureus is commonly isolated. 2
• Spinal epidural abscess: Must be excluded in any patient with chronic paraspinal pain and surgical history, particularly if there are any systemic signs or neurological changes.

Structural/Post-Surgical Causes

• Rib fracture or resection complications: Prior surgeries may have involved rib resection or caused iatrogenic rib injury. The 12th rib syndrome (or 9th-11th rib syndromes) occurs when severed or hypermobile ribs impinge on intercostal nerves, causing pain in the lower chest, upper abdomen, and flank that wraps around bilaterally. 3
• Slipping rib syndrome (SRS): An under-recognized cause of upper abdominal and lower thoracic pain that should be considered if the patient's history includes previous trauma or abdominal surgery. This presents as intermittent sharp rib pain with rigid protrusion. 4
• Post-surgical spinal instability: Late deterioration following laminectomy or fusion may be related to postoperative instability, causing bilateral paraspinal pain. 5
• Adjacent segment disease: Following spinal fusion, adjacent levels can develop pathology causing bilateral radicular or axial pain patterns. 6, 5
• Recurrent disc herniation or inadequate decompression: Can cause radicular pain that wraps around the torso in a dermatomal distribution. 7

Musculoskeletal Causes

• Myofascial pain syndrome with trigger points: Paraspinal muscle strains or trigger points are common pain generators in the cervical, thoracic, and lumbar spine, particularly in patients with prior surgeries and altered biomechanics. 8
• Costochondritis or costovertebral joint arthritis: Can cause bilateral chest wall pain, though typically more anterior. 1
• Facet joint syndrome: Chronic axial spine pain from facet joints can refer bilaterally around the lower ribs, though interventional procedures are strongly recommended against for chronic pain. 1
• Intercostal neuralgia: Nerve impingement between ribs causing sharp, wrapping pain that follows dermatomal patterns bilaterally. 3

Systemic/Inflammatory Causes

• Axial spondyloarthritis: Anterior chest wall pain affects 30-60% of patients with axial spondyloarthritis and may involve sternoclavicular and manubriosternal joints in up to half of patients. This can be the first manifestation in 4-6% of cases. 1
• Metastatic disease to ribs or spine: Must be considered in any patient with chronic pain and prior surgeries, particularly if there is acute worsening. Bone scintigraphy can detect neoplastic lesions. 1

Critical Diagnostic Approach

Obtain CT angiography immediately to rule out aortic aneurysm with vertebral erosion, especially given the acute worsening of chronic symptoms. 1

Order MRI of the thoracic and lumbar spine to evaluate for paraspinal abscess, osteomyelitis, recurrent disc herniation, spinal instability, or adjacent segment disease. 6, 5, 2

Perform focused physical examination looking for:

• Reproducible pain with pressure on specific ribs (9th-12th) suggesting rib syndrome 3
• Rigid protrusions along the rib cage suggesting slipping rib syndrome 4
• Focal tenderness over paraspinal muscles with palpable trigger points 8
• Neurological deficits suggesting nerve root compression 7

Laboratory evaluation should include inflammatory markers (ESR, CRP) and complete blood count to assess for infection or inflammatory conditions. 2

Common Pitfalls to Avoid

• Do not attribute chronic pain with acute worsening to benign musculoskeletal causes without imaging to exclude life-threatening pathology like aortic aneurysm or infection. 1, 2
• Do not order routine imaging without specific clinical indications once serious pathology is excluded, as it does not improve outcomes and increases expenses. 5
• Avoid epidural steroid injections and radiofrequency ablation for chronic spine pain, as recent high-quality guidelines strongly recommend against these interventions due to lack of benefit on mortality, morbidity, and quality of life. 1