Background:

• Intercostal neuralgia is characterized by neuropathic pain along distribution of intercostal nerve. It can manifest along ribs, chest or abdomen
• Treatment mainstays:

o   Gabapentinoids, SNRIs, TCAs, Opioids

o   Ultrasound or fluoroscopic guided nerve blocks 

• Current therapies are limited in efficacy/duration of effect

Case:

• 75 y.o. Male with 10 year history of anterior chest pain worsening over the last year
• Sharp, burning pain along the 3rd and 4th intercostal space. 
• No obvious mechanical cause on imaging studies
• Failed conservative management including mainstay treatments above
• Short but profound relief with anterior intercostal nerve blocks and costochondral steroid injections
• Anterior chest wall peripheral nerve stimulation offered as treatment given response to intercostal nerve block

Op Note:

• Appropriate anatomy located sonographically 
• Incision was made anteriorly between the 3rd and 4th intercostal space and guide wire was tunnelled below pec major
• PNS deployed after test stimulation and elicited left anterior chest wall paresthesias

Outcome:

• Patient reports 50% pain relief on POD 1 
• 50% relief sustained at 2 week follow up visit
• Continues to report sustained benefit at 2 year follow up visit with no complications

Discussion:

• Refractory intercostal neuralgia can be debilitating and difficult to treat
• After failure of conservative management, peripheral nerve stimulate may be a safe and viable option for analgesia in these patients
• PNS placement for refractory intercostal neuralgia warrants further investigation to elucidate overall safety and efficacy 

References:

• Yakovlev AE, Peterson AT. Peripheral nerve stimulation in treatment of intractable postherpetic neuralgia. Neuromodulation. 2007;10(4):373-375. doi:10.1111/j.1525-1403.2007.00126.x
• Billet B, Wynendaele R, Vanquathem NE. A Novel Minimally Invasive Wireless Technology for Neuromodulation via Percutaneous Intercostal Nerve Stimulation for Post-Herpetic Neuralgia: A Case Report with Short-Term Follow-up. Pain Pract. 2018;18(3):374-379. doi:10.1111/papr.12607
• Strand N, D'Souza RS, Hagedorn JM, et al. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res. 2022;15:2483-2504. Published 2022 Aug 23. doi:10.2147/JPR.S362204
• Xu J, Sun Z, Wu J, Rana M, Garza J, Zhu AC, Chakravarthy KV, Abd-Elsayed A, Rosenquist E, Basi H, Christo P, Cheng J. Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician. 2021 Mar;24(2):E131-E152. PMID: 33740342; PMCID: PMC8897810.