Intercostal Cryoneurolysis for Traumatic Rib Fractures After Unsuccessful Weaning of a Thoracic Epidural

Dara Zaerpoor, MD, Rafael Alkabalan, BS, Allison Berndtson, MD, John J. Finneran IV, MD

Figures
Case Description (cont.)

• Weaning of the epidural was attempted over the next few days but unsuccessful due to pain.

• Although not initially considered due to the number of fractured ribs, cryoneurolysis was offered on day 6.

• Ultrasound-guided percutaneous intercostal cryoneurolysis was performed at the left 3rd-7th and right 2nd, 8th - 9th intercostal nerves.

• Each nerve was treated with 2 cycles, each consisting of a 2-minute freeze and 1-minute thaw (fig. 2).

Background

• Rib fractures are associated with significant morbidity due to pain and resultant respiratory complications.1

• Regional anesthesia provides both pain relief and reduction of morbidity and mortality.2

• Epidural analgesia precludes discharge and rib fracture pain commonly persists for weeks following trauma.

• Percutaneous ultrasound guided intercostal cryoneurolysis may provide analgesia for weeks.3,4

  Case Description

• 35-year-old male presented after a car accident with multiple injuries including fractures of the right 2nd, 8th, and 9th ribs and left 3rd-7thth ribs (fig. 1).

• Poorly controlled pain and desaturations requiring oxygen via high-flow nasal cannula.

• Epidural placed at T8-9 on hospital day 2 with good pain control.

Discussion

• This patient was able to be weaned from a continuous thoracic epidural and discharged after percutaneous intercostal cryoneurolysis.

• Cryoneurolysis has the advantage of long duration and no post-block equipment.

• Disadvantages include administration at every intercostal level, increased time, resource requirement, patient discomfort, and cumulative procedural risk.

• Further studies are indicated to quantify the benefit provided and determine the optimal patient population.

References Results

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2. Malekpour M, Hashmi A, Dove J, Torres D, Wild J. Analgesic choice in management

Fig. 1: Coronal chest CT imaging showing multiple left-sided rib fractures. Right-sided rib fractures not included in this slice.

Fig. 2: Intercostal view (A) with anatomy overlay (B). Same view after cryoneurolysis (C, D). Used with permission of John Finneran IV, MD, who retains the rights to this image.

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of rib fractures: paravertebral block or epidural analgesia. Anesth Analg 2017; 124: 1906-11.
Finneran JJ 4th, Kobayashi L, Costantini TW, Weaver JL, Berndtson AE, Haines L, Doucet JJ, Adams L, Santorelli JE, Lee J, Trescot AM, Donohue MC, Schaar A, Ilfeld BM. Ultrasound-Guided Percutaneous Cryoneurolysis for the Treatment of Pain following Traumatic Rib Fracture: A Randomized, Active-Controlled, Participant- and Observer-Masked Study. Anesthesiology. 2024; Epub ahead of print.

Ilfeld BM, Finneran JJ: Cryoneurolysis and percutaneous peripheral nerve stimulation to treat acute pain in the time of the opioid crisis: A Review. Anesthesiology 2020; 133: 1127-1149.