MCC 5074: Intercostal Nerve Cryoneurolysis for

Traumatic Rib Fracture Pain

Anuj Bapodra MD, Hunter Shaller MD, Piyush Gupta MD, Gary Schwartz MD

Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY

Cryoneurolysis refers to the application of extreme cold to targeted nerve tissue. This thermal neurolytic technique disrupts the conduction of pain signals from the periphery to the central nervous system to eliminate or diminish the experience of pain.

  Modern cryoprobes pass gas at a relatively high pressure down their shaft, through a small orifice and into the closed distal tip at a much lower pressure. Based on the Joule–Thomson effect, a dramatic temperature decrease occurs when the gas moves from the high to low pressure state causing rapid expansion and absorption of heat. The gas is then evacuated back up through a larger-diameter tube in the middle of the shaft; importantly, this closed circuit permits no gas to remain within the body. The extreme cold that is created (approximately −70 °C) induces Wallerian degeneration—a reversible destruction of the nerve axon but retention of the endo-, peri- and epineurium.

   The real-time imaging of ultrasound guidance enables the precise application to specific peripheral nerves, raising the possibility of cryoneurolysis for long-lasting site-specific pain management.1 Emerging evidence suggests that cryoanalgesia may be superior to regional anesthesia for duration of analgesia and side effects profile.2 Cryoanalgesia will likely be most applicable to painful conditions expected to last weeks or even months.

  In this case, we describe cryoneurolysis for acute rib fracture and postoperative pain management of a trauma patient.

  Cryoneurolysis has been described in the literature for the treatment of acute and chronic pain. Chest wall injuries such as rib and sternal fractures, can cause severe acute pain ranging from several days to years. Ultrasound guided intercostal cryoneurolysis using a hand-held device has emerged as a potential technique providing prolonged and targeted analgesia for acute pain compared to current modalities. A few studies exploring the use of cryoneurolysis following thoracotomy demonstrated opioid-sparing analgesia, improved pulmonary functional outcomes, and decreased length of hospital stay.

  Regional anesthesia with local anesthetic nerve blocks has limited duration and may not provide effective pain relief for patients with rib fractures. Percutaneous cryoneurolysis of the intercostal nerves may be an excellent adjuvant or substitute for local anesthetic-based nerve blocks. In the case of our patient, the regional block was mildly effective, while the thoracic epidural was very effective in reducing the patient’s pain. Once the thoracic epidural was capped, the patient continued to experience pain that was not well controlled with oral medication. After cryoneurolysis, the patient’s pain was remarkably reduced, and he was appropriate for discharge.

  Cryoneurolysis may serve as a promising technique given its safety profile and effectiveness in many acute and chronic pain conditions. We believe our case contributes to the growing literature in support of cryoneurolysis for addressing rib fracture pain and acute pain in the trauma setting.