Thoracic Epidural Steroid Injection for Rib Fracture Pain

Abstract

Treatment for rib fracture pain can be broadly divided into pharmacologic approaches with oral and/or parenteral medication and interventional approaches utilizing neuraxial analgesia or peripheral nerve blocks to provide pain relief. Both approaches attempt to control nociceptive and neuropathic pain secondary to osseous injury and nerve insult, respectively. Success of treatment is ultimately measured by the ability of the selected modality to decrease pain, chest splinting, and to prevent sequelae of injury, such as pneumonia. Typically, opioids and NSAIDs are the drugs of first choice for acute pain because of ease of administration, immediate onset of action, and rapid titration to effect. In contrast, neuropathic pain medications have a slower onset of action and are more difficult to titrate to therapeutic effect. Interventional approaches include interpleural catheters, intercostal nerve blocks, paravertebral nerve blocks, and thoracic and lumbar epidural catheters. Each intervention has its own inherent advantages, disadvantages, and success rates. Rib fracture pain management practice is founded on the thoracic surgical and anesthesiology literature. Articles addressing rib fracture pain are relatively scarce in the pain medicine literature. As life expectancy increases, and as healthcare system modifications are implemented, pain medicine physicians may be consulted to treat increasing number of patients suffering rib fracture pain and may need to resort to novel therapeutic measures because of financial constraints imposed by those changes. Here we present the first published case series of thoracic epidural steroid injections used for management of rib fracture pain.

Effectiveness of intercostal nerve block for management of pain in rib fracture patients

“…Worthley (1985) and Rauchwerger et al (2013) stated that pain could be controlled by injecting anesthetics or steroids into the thoracic epidural space; it was reported to be effective for bilateral rib fractures. The technical methodology of ICNB was reported by Moore and Bridenbaugh (1962); it includes using medical imaging techniques to find the intercostal nerve targeted for blocking on the basis of the pain location, and then injecting a local anesthetic into the target area.…”

“…The advantages of ICNB are as follows: relatively simple for use; no neurological complications due to nausea, vomiting, dizziness, or bleeding; and no complications from possible misjudgment observed in other measures such as thoracic epidural injection or IV PCA. The disadvantages include claims that it must be repeated every 6–8 h because its effects do not last long (Pederson et al, 1983) and the possibility of complications such as pneumothorax or hemothorax (Rauchwerger et al, 2013). Although no complications were observed in this study, significant pain reduction was observed immediately after treatment, a pattern of slowed pain reduction emerged 1 day after treatment, which is thought to be due to depletion of the medication used in ICNB (Wurnig et al, 2002).…”

Pain Managment of Multiple Rib Fractures on the Basis of Early Reduction and Fixation in Patients without Intensive Care Unit.

“…The need for the intercostal blockade is another important parameter showing indirectly the chronicity of pain and failure in pain management. It is the method that we apply if the desired level of pain does not decrease after intravenous or oral use of conventional analgesics [23,24]. It provides a reduction in long-term pain, but not throughout the treatment.…”

Blast-related lung injuries

“…A local anesthetic is administered with or without an opioid; there have been reports of including corticosteroids as well with added benefit [58]. Compared to a paravertebral block, epidural analgesia is more complex to perform and has associated risks of dural puncture, spinal cord injury, and hypotension [56].…”