Percutaneous Cryoneurolysis for Postoperative Analgesia:
Could Cryoanalgesia Replace Continuous Peripheral Nerve Blocks for Various Surgical Procedures?
Introduction. Cryoneurolysis—the use of low temperature to reversibly halt nerve conduction (Figure 1)—has been used for years to treat chronic pain . Originally, treatment required the target nerve to be surgically exposed, greatly limiting applicability to acute pain management. However, newly-available small, hand-held cryoneurolysis devices, at times combined with ultrasound guidance, now permit percutaneous administration, with a method strikingly similar to application of peripheral nerve blocks using local anesthetic . Although this technique, to date, has been described almost exclusively for chronic pain states, there are theoretical benefits to employing cryoanalgesia to treat postoperative pain, primarily due to an analgesic duration measured in weeks or months . We now report on the use of percutaneous cryoneurolysis to provide analgesia for 5 patients who would have otherwise received a continuous peripheral nerve block (cPNB) following major joint surgery.
Case Report. The local Institutional Review Board (University of California San Diego, San Diego, CA) waives any review requirements for case reports or short series. Zero to 7 days prior to surgery, patients underwent percutaneous cryoneurolysis with a rechargeable, hand-held cryoneurolysis device, disposable probe, and a disposable cartridge of nitrous oxide (Iovera, Myoscience, Fremont, CA). Following sterile preparation and draping, the cutaneous entry point(s) for the probe(s) were anesthetized with lidocaine (1-3 mL). For rotator cuff repair of the shoulder (n=2), the suprascapular nerve was ablated just cephalad to the suprascapular notch under ultrasound guidance with a 5.5 cm probe inserted through a 20 g angiocatheter. For total knee arthroplasty (n=3), the infrapatellar branch of the saphenous nerve was ablated under ultrasound guidance with a 5.5 cm probe just distal to its origin from the femoral nerve through a 20 g angiocatheter (n=3) . For all procedures, three 2-minute cryoablation cycles separated by 1-minute thaw periods were applied.
All 5 patients experienced excellent postoperative analgesia with pain scores consistently < 2 on the 0-10 Numeric Rating Scale; and, requiring significantly less opioid for a dramatically decreased period of time relative to historic controls. For the shoulder repair patients, there was full return of motor function by the time that the patients began aggressive physical therapy. For patients having knee surgery, no gross motor deficits were noted relative to historic controls and skin sensation returned within 4 months. There were no adverse events related to the cryoneurolysis.
Discussion. Percutaneous cryoneurolysis may be a practical alternative analgesic modality to cPNB for the treatment of post-surgical pain. Theoretical benefits of cryoneurolysis over cPNB include an ultra-long duration of action measured in weeks to months, no catheter management/removal, the lack of an infusion pump and anesthetic reservoir to carry, a dramatically lower risk of infection, and no risk of local anesthetic toxicity, catheter dislodgement or leakage. Prospective, randomized, controlled clinical trials are required to identify the relative benefits and risks of cryoneurolysis for a multitude of possible surgical procedures .
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Figure Legend. A modern cryoneurolysis probe (“cannula”) produces extremely cold temperatures at its tip due to the Joule-Thomson effect resulting from gas flowing from high- to low-pressure [used with permission from Brian M. Ilfeld, MD]. Inset: an ice ball.