Intercostal nerve cryoablation for control of traumatic rib fracture pain: A case report

Vossler, John D.; Zhao, Frank

doi:10.1016/j.tcr.2019.100229

Cited by 14 publications

(9 citation statements)

References 7 publications

(7 reference statements)

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“…91 Case reports suggest that cryoneurolysis of solely the involved intercostal nerves may provide potent analgesia, thus avoiding the need for hospitalization, obviating opioid requirements, improving breathing/coughing, and therefore decreasing the risk of pulmonary comorbidity. 52,53 Three patients who received cryoneurolysis of the second to fifth intercostal nerves before uni-or bilateral mastectomy reported a near-painless postoperative course without any opioid requirements or sleep disturbances, a significant improvement over historic controls. 54 Ultrasound-guided percutaneous cryoneurolysis may also be used in the extremities, such as to provide analgesia *This retrospective study reported a dramatic difference between the treatment (cryoneurolysis) and control groups, but due to a very small sample size (n = 6), statistics were not applied to the data.…”

Section: Percutaneous Application To Acute Painmentioning

confidence: 99%

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Ilfeld¹,

Finneran²

2020

Anesthesiology

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Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

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Section: Percutaneous Application To Acute Painmentioning

confidence: 99%

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Ilfeld¹,

Finneran²

2020

Anesthesiology

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“…The other reason to implement cryoablation is the fact that the patient is already undergoing a surgical procedure, so separate arrangements for the procedure would not be required. The effectiveness of cryoablation in pain management was confirmed by previously published studies and includes rapid pain relief, reduction of narcotic medication, and long-term chest-wall analgesia 19 , 20 . Depending on the extent of the fractures, we ablate from the third up to the ninth intercostal nerve (Fig.…”

Section: Step 2: Preoperative Preparationmentioning

confidence: 54%

Surgical Stabilization of Rib Fractures

Fokin

Hus

Rodríguez

et al. 2020

JBJS Essential Surgical Techniques

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Background: Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality 1 , 2 . Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes 3 - 5 . Description: Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture, as such cases may result in thoracic wall instability. For surgical stabilization of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle-sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical stabilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within the first 3 days 6 - 8 . Alternatives: Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis 9 , 10 ; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block ...

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“…Furthermore, various treatments of the intercostal nerves were described. These differences are not surprising, since literature on intercostal nerve treatment during SSRF is scarce [ 21 ]. The current sample size was too small to detect differences in clinical and patient-reported outcomes for the various surgical techniques, although it suggests that striving for bridging callus formation in all rib fracture nonunions is associated with a better outcome in terms of pain reduction, which has not previously been reported.…”

Section: Discussionmentioning

confidence: 99%

“…Alternatively, intercostal nerve cryoablation could be considered in this group, given the current rise in positive results for the combination of SSRF with cryoablation. In cryoablation, the intercostal nerve bundles are frozen which induces temporary nerve injury known as axonotmesis, resulting in prolonged analgesia [ 21 , 22 ]. Nevertheless, it should be noted that cryoablation has not been previously investigated specifically in patients with rib fracture nonunion.…”

Section: Discussionmentioning

confidence: 99%

Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series

Wijck

Lieshout

Prins

et al. 2022

Eur J Trauma Emerg Surg

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Purpose This study aimed to determine the long-term level of pain after surgical treatment of one or more symptomatic rib fracture nonunions. Secondary aims were to evaluate the occurrence of adverse events, satisfaction, and activity resumption. The final aim was to assess the association between pain and the presence of bridging callus at the nonunified fracture. Hypothesized was that thoracic pain would diminish after surgery. Methods This retrospective case series included adults who underwent surgery for a symptomatic rib fracture nonunion from three hospitals. Symptomatic nonunion was defined as persistent pain associated with nonbridging callus of ≥1 rib fractures on a chest CT scan at ≥3 months after the initial injury. Patients completed questionnaires about pain, satisfaction, and activity resumption ≥3 months postoperatively. Results Thirty-six patients (26 men, 10 women), with a median age of 55 (P25–P75 49–62) years and 169 acute rib fractures were included. Nonunion occurred in 98 (58%) fractures of which 70 (71%) were treated surgically. After a median of 11 months (P25–P75 7–21), 13 (36%) patients reported severe pain, in contrast to 26 (72%) preoperatively. Patients who underwent intercostal neurectomy or neurolysis in addition to surgical stabilization less often reported pain reduction. Twenty-six (72%) had postoperative complications, for which 12 (33%) underwent additional surgery, mostly for persistent pain. The majority (n = 27; 75%) was satisfied with their functional recovery. Of patients who had paid work pre-trauma, 65% had resumed working. Conclusion Most patients reported less pain and better daily functioning after surgical stabilization of symptomatic rib fracture nonunions, although causality cannot be proven with this retrospective case series. Additional intercostal nerve treatment was not associated with pain relief. Despite surgery-related complications being common, patient satisfaction was high. Level of evidence: Level V. Study type: Therapeutic.

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Intercostal nerve cryoablation for control of traumatic rib fracture pain: A case report

Cited by 14 publications

References 7 publications

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Surgical Stabilization of Rib Fractures

Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series

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