Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay.

BACKGROUND AND OBJECTIVES: Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS: Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS: Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS: In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.

Deep parasternal intercostal plane nerve block: an anatomical study.

INTRODUCTION: The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ultrasound-guided DPIP block in a human cadaveric model. METHODS: Five ultrasound-guided DPIP blocks were performed in four unembalmed human cadavers using an in-plane approach with a linear transducer oriented in a transverse plane adjacent to the sternum. Twenty milliliters of 0.1% methylene blue were injected between ribs 3 and 4 into the plane deep to the internal intercostal muscles and superficial to the transversus thoracis muscle layer. The chest muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and mediolateral directions. RESULTS: The transversus thoracis muscle slips were stained in all cadavers from 4 to 6 levels. Intercostal nerves were dyed in all specimens. Four levels of intercostal nerves were dyed in each specimen with variability in number of levels stained above and below the level of the injection. CONCLUSIONS: The DPIP block spreads along the tissue plane above the transversus thoracis muscles to multiple levels to dye the intercostal nerves in this cadaver study. This block may be of clinical value for analgesia in anterior thoracic surgical procedures.

Carbon-Assisted Minimally Invasive Transtubular Approach for Intercostal Nerve Schwannoma.

BACKGROUND AND OBJECTIVES: The intraoperative localization of an intercostal nerve schwannoma (INS) is extremely difficult because the lesion is generally not palpable, and the fluoroscopic visualization of anatomic landmarks in the ribs is unsatisfactory. Using activated carbon suspension to mark the soft-tissue approach could improve INS localization. We present a novel, simple, reproducible carbon-assisted minimally invasive transtubular approach for an INS. METHODS: The patient was a 57-year-old man with a painful 12th left INS arising below the floating rib. A computed tomography image-guided, tumor-to-skin marking with aqueous carbon suspension was performed 48 hours before surgery. A minimally invasive transtubular approach following the carbon path allowed a precise tumor location. RESULTS: The INS was completely removed. The patient's thoracic radicular pain was immediately relieved after surgery. He was discharged the following day with residual numbness on the left thoracic side. At the 5-year follow-up, no tumor recurrence was noted in the control MRI. CONCLUSION: This article presents an alternative novel technique for resecting an intercostal schwannoma. Using a transtubular approach with carbon-marking assistance allowed a tumor gross total resection with immediate pain relief and a successful outcome.

The effect of ultrasound-guided intercostal nerve block on postoperative analgesia in thoracoscopic surgery: a randomized, double-blinded, clinical trial.

BACKGROUND: Intercostal nerve block (ICNB) is a very effective analgesic method. We aimed to explore the effect of preemptive analgesia with ultrasound-guided intercostal nerve block on postoperative analgesia in thoracoscopic surgery. METHODS: 126 patients, aged 18-70 years, with American Society of Anesthesiologists (ASA) physical status I-II and scheduled for thoracoscopic pulmonary resection were enrolled in this study. 119 patients were left for final analysis. Patients were randomly allocated to group ICNB and group CONTROL. Patients in CONTROL group were administered sufentanil with patient-controlled analgesia device after operation In group ICNB, patients received ropivacaine ICNB prior to surgery and patient-controlled analgesia device after operation. The primary outcome is visual analog scale pain score (VAS) at rest at 0,4, 8,16,24,48,72 and 168 h postoperatively and they were compared. Surgical outcomes and rescue analgesia requirement were also recorded. RESULTS: VAS scores were statistically significantly lower for ICNB group compared to control group at 0, 4, 8, 16, 24 and 48 h postoperatively. The duration of insertion of chest tube in ICBN group was shorter than that in control group, and the difference was statistically significant (4.69 ± 2.14 vs. 5.67 ± 2.86, P = 0.036). The postoperative hospital stay, incidence of nausea and vomiting and postoperative pulmonary infection rate in ICBN group were all lower than those in the control group, but there were no statistical differences. The frequency of rescue analgesia during 48 postoperative hours was different between the two groups (ICNB vs. Control; 9.83% vs. 31.03%, P = 0.004). CONCLUSIONS: For patients undergoing thoracoscopic surgery, ultrasound-guided ICNB is simple, safe, and effective for providing acute postoperative pain management during the early postoperative stage. TRIAL REGISTRATION: Chinese clinical trials: chictr.org.cn, ChiCTR1900021017. Registred on 25/01/2019.

[Entrapment syndromes of the intercostal nerve and its branches]. / Síndromes por atrapamiento del nervio intercostal y sus ramas.

Musculoskeletal chest pain poses a broad differential diagnosis, among which intercostal nerve involvement stands out. Its entrapment or that of any of its branches can resemble visceral pain and therefore can easily go unnoticed. With a good examination and the use of dynamic ultrasound, the diagnostic approach can be simpler. We present a 40-year-old man evaluated in a rehabilitation department for right lower rib pain, triggered by certain movements and associated with a pectus excavatum type thoracic deformity. Using dynamic ultrasound maneuvers, he was diagnosed with neuralgia of the 7th right intercostal nerve secondary to dynamic entrapment in the context of a thoracic deformity with costal hypermobility. We describe the clinical presentation, ultrasound imaging, treatment, and evolution after treatment. In this case, we describe entrapment syndromes of the intercostal nerve and its branches, their clinical and ultrasound diagnosis, and their therapeutic approach.

A case for ultrasound-guided peripheral nerve stimulation in intractable anterior cutaneous nerve entrapment syndrome.

Aim: This case report documents the use of peripheral nerve stimulation in the setting of entrapment of the anterior cutaneous branches of the intercostal nerves, with pain rated by the patient as severe during exacerbation episodes. Materials & methods: Under ultrasound guidance, two permanent leads were implanted caudad to cephalad, along and superficial to the lateral aspect of the rectus abdominis, distal to the umbilicus (1 lead per side). Results: At the 6 month follow-up, the patient reported near complete resolution of baseline pain, as well as fewer, sporadic pain exacerbation episodes, rated as mild-to-moderate. Conclusion: This case report suggests that peripheral nerve stimulation might be a valuable treatment option for previously intractable abdominal pain due to entrapment of the anterior cutaneous branches.

Anterior cutaneous nerve entrapment syndrome is a peculiar, a largely disregarded pain condition. Current management algorithms rely mostly on local injections followed by surgical anterior neurectomy. This case report presents a case of longstanding, anterior cutaneous nerve entrapment syndrome, unresponsive to first-line treatment, that was successfully treated with peripheral nerve stimulation technology targeting the anterior cutaneous branches.

Patient-Controlled Intravenous Analgesia with or without Ultrasound-Guided Bilateral Intercostal Nerve Blocks in Children Undergoing the Nuss Procedure: A Randomized, Double-Blinded, Controlled Trial.

Background: Two analgesic strategies have been described for pain treatment after the pectus excavatum surgery: the patient-controlled intravenous analgesia (PCIA) and ultrasound-guided intercostal nerve block. In this prospective, randomized and double-blinded trial and the short and long-term outcomes were compared in patients after surgery. Methods: The children were randomized to either the intercostal or control group. Ultrasound-guided intercostal nerve block was with 0.25% ropivacaine and 5 mg dexamethasone in the intercostal group, while the control group was with 0.9% normal saline. The block was performed in the intercostal space corresponding to the lowest depression of the sternum and repeated bilaterally in the spaces above and below. Postoperatively, the children in the two-groups received PCIA with fentanyl for 48 hours. The primary outcome was a pain score on the postoperative day 1, as measured by the Visual Analogue Scale (VAS). Results: Sixty children undergoing the Nuss procedure were enrolled in the trial. The mean differences in VAS scores between the two groups were 3.2 in the PACU (p < 0.001), 1.7 on postoperative day 1 (p < 0.001) and 0.7 on postoperative day 2 (p=0.015). The opioid consumption was significantly lower in the intercostal group during the postoperative 48 hours (p < 0.05). The anxiety and QOL scores in the intercostal group were significantly improved on some points of time (p < 0.05). The incidence of adverse events was markedly lower in the intercostal group during the postoperative 48 hours (p < 0.05). Conclusions: Our results suggest ultrasound-guided intercostal nerve block with PCIA may be more effective than PCIA alone in children who underwent the Nuss procedure.

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations.

In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.

Parascapular Sub-Iliocostalis Plane Block: Comparative Description of a Novel Technique for Posterior Rib Fractures.

We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateral-posterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. No complications were reported. The efficacy of the PSIP block may potentially depend on different mechanisms of action: (1) direct action in the fracture site by craniocaudal myofascial spread underneath the erector spinae muscle (ESM); (2) spread to deep layers through tissue disruption caused by trauma, to reach the proximal intercostal nerves; (3) further medial spread through deeper layers to the midline to block the posterior and ventral spinal nerves; (4) medial spread below the ESM, to reach the posterior spinal nerves (more reliably than rhomboid intercostal / sub-serratus [RISS] block); and (5) lateral spread in the sub-serratus (SS) plane to reach the lateral cutaneous branches of the intercostal nerves; while avoiding significant negative hemodynamic effects associated with techniques such as the paravertebral block (PVB), erector spinae plane (ESP) block or its variations, or thoracic epidural analgesia (TEA). A comparative comprehensive overview of the regional techniques described for posterior chest trauma is presented, including TEA, PVB, ESP block, retrolaminar block, mid-point to transverse process block, costotransverse foramen block, RISS, and serratus anterior plane (SAP) block.

Evaluation of the effect of ultrasound guidance on the accuracy of intercostal nerve injection: a canine cadaveric study.

OBJECTIVE: To develop an ultrasound-guided approach to intercostal nerve injection and to compare the success rate of intercostal nerve injections using blind or ultrasound-guided technique in canine cadavers. STUDY DESIGN: Prospective, randomized, descriptive, experimental anatomic study. ANIMALS: A total of 14 mid-sized adult canine cadavers. METHODS: Ultrasound landmarks were identified by dissection of four cadavers and used to develop an ultrasound-guided technique. The remaining 10 cadavers were randomly assigned to blind (five cadavers) or ultrasound-guided (five cadavers) injections of the third to the ninth intercostal nerves bilaterally with 0.03 mL kg-1 of colorant per injection. The target for intercostal injections was the caudal border of the respective rib, between the internal intercostal membrane and the parietal pleura. Additionally, displacement of the parietal pleura without visible intramuscular distribution was considered the end point for ultrasound-guided injections. For each cadaver, a practitioner in training performed the blocks on one hemithorax, while an experienced practitioner performed the blocks on the opposite hemithorax. Injections were considered successful if ≥1 cm of the target nerve was stained with colorant upon dissection. Success rates and length of nerve staining were analyzed with Fisher's exact and t tests, respectively. Data were considered statistically different with p < 0.05. RESULTS: Success rates of blind and ultrasound-guided technique were 57.1% and 91.4%, respectively (p < 0.0001). The length of intercostal nerve staining was 3.1 ± 1.2 cm and 3.6 ± 1.0 cm using blind and ultrasound-guided techniques, respectively (p = 0.02). No differences were observed between the two practitioners for blind (p = 0.33) and ultrasound-guided techniques (p = 0.67). CONCLUSIONS AND CLINICAL RELEVANCE: Ultrasound guidance improves the accuracy of intercostal nerve injections when compared with blind technique, independently of the level of expertise in regional anesthesia.

Are Thoracic Wall Blocks Efficient After Video-Assisted Thoracoscopy Surgery-Lobectomy Pain? A Comparison Between Serratus Anterior Plane Block and Intercostal Nerve Block.

OBJECTIVES: Video-assisted thoracoscopy surgery-lobectomy is less invasive than conventional thoracotomy and is associated with fewer complications. However, the pain related is classified as moderate and requires adequate treatment. Ultrasound-guided serratus anterior plane block (SAPB) provides analgesia by blocking the lateral branches of the intercostal nerves, avoiding the complications of epidural analgesia and paravertebral block. The aim of the present study was to evaluate the efficacy and safety of the SAPB compared with the intercostal nerve block (ICNB). DESIGN: This was a non-randomized prospective study, in which surgery-lobectomy pain after video-assisted thoracoscopy was treated with the following multimodal approach: SAPB or ICNB, morphine-patient controlled analgesia, and paracetamol. SETTING: The study was undertaken in a single community hospital. PARTICIPANTS: The study comprised 40 patients. INTERVENTIONS: Execution of ultrasound-guided SAPB. MEASUREMENTS AND MAIN RESULTS: Nineteen (47.5%) men and 21 (52.5%) women were enrolled, and the mean age was 67.22 ± 11 years. Both groups showed any visual analog scale values >4, which was significantly lower in the SAPB group at the 6th hour and at the 12th and 24th hours only during coughing (p < 0.05). The sedation score was significantly lower in the ICNB group at 0 and at the 2nd and 4th hours; it was lower in the SAPB group at the 6th hour. All patients had a sedation score <1, and they all were awake and oriented. After 24 hours, the total morphine requirement was 19.3 ± 14.4 mg and 11.3 ± 8.5 mg (p = 0.038); after 48 hours, it was 12.2 ± 7.9 mg and 8.2 ± 5.8 mg in the ICNB and SAPB groups, respectively. CONCLUSIONS: The multimodal approach of SAPB, morphine-patient controlled analgesia, and paracetamol is effective, safe, and time efficient.

Cadaveric study identifying clinical sonoanatomy for proximal and distal approaches of ultrasound-guided intercostobrachial nerve block.

BACKGROUND AND OBJECTIVES: The intercostobrachial nerve (ICBN) has significant anatomical variation. Localization of the ICBN requires an operator's skill. This cadaveric study aims to describe two simple ultrasound-guided plane blocks of the ICBN when it emerges at the chest wall (proximal approach) and passes through the axillary fossa (distal approach). METHODS: The anatomical relation of the ICBN and adjacent structures was investigated in six fresh cadavers. Thereafter, we described two potential techniques of the ICBN block. The proximal approach was an injection medial to the medial border of the serratus anterior muscle at the inferior border of the second rib. The distal approach was an injection on the surface of the latissimus dorsi muscle at 3-4 cm caudal to the axillary artery. The ultrasound-guided proximal and distal ICBN blocks were performed in seven hemithoraxes and axillary fossae. We recorded dye staining on the ICBN, its branches and clinically correlated structures. RESULTS: All ICBNs originated from the second intercostal nerve and 34.6% received a contribution from the first or third intercostal nerve. All ICBNs gave off axillary branches in the axillary fossa and ran towards the posteromedial aspect of the arm. Following the proximal ICBN block, dye stained on 90% of all ICBN's origins. After the distal ICBN block, all terminal branches and 43% of the axillary branches of the ICBN were stained. CONCLUSIONS: The proximal and distal ICBN blocks, using easily recognized sonoanatomical landmarks, provided consistent dye spread to the ICBN. We encourage further validation of these two techniques in clinical studies.

Ultrasound-Guided Intercostal Peripheral Nerve Stimulator Implantation: Technique Report and Feasibility Study in a Cadaver.

OBJECTIVE: This study aimed to describe and validate a novel ultrasound-guided intercostal peripheral nerve stimulator implantation technique. METHODS: The fifth to tenth ribs on both sides of an unembalmed cadaveric specimen were localized using a 15-6-MHz linear array transducer, counting distally from T-1 bilaterally. A single interventionist then implanted 12 peripheral nerve stimulators on the fifth through tenth ribs, six MicroLeads on the left side and six StimRouters on the right side, using an in-plane lateral to medial approach to the inferior border of the corresponding rib. After all the stimulators were implanted, their location was confirmed using fluoroscopy. Gross anatomic dissection was later performed for each of the stimulators placed, and the distance of the lead from the intercostal nerve and pleura was noted. RESULTS: All leads were noted in an accurate position in the plane between the inner and innermost intercostal muscle, without any intrapleural placement. The distance of the leads from the intercostal nerves was on average 2.3 mm and 1.1 mm for MicroLead and StimRouter, respectively. CONCLUSIONS: To our knowledge, this study is the first to determine the feasibility of ultrasound-guided peripheral nerve stimulator placement in close proximity to the pleura. All the stimulator leads were accurately placed using our ultrasound-guided technique and were within 0.5-3 mm from the intercostal nerve. Although this technique might prove technically challenging, the use of ultrasound for intercostal peripheral nerve stimulator implantation appears feasible and warrants further investigation to establish this as an acceptable technique for patients.

A prospective, randomized comparison of ultrasonographic visualization of proximal intercostal block vs paravertebral block.

BACKGROUND: Thoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery. However, real-time ultrasound visualization of landmarks in the paravertebral space remains challenging. We aimed to compare ultrasound-image quality, performance times, and clinical outcomes between the traditional parasagittal ultrasound-guided paravertebral block and a modified approach, the ultrasound-guided proximal intercostal block. METHODS: Women with breast cancer undergoing mastectomy (n = 20) were randomized to receive either paravertebral (n = 26) or proximal intercostal blocks (n = 32) under ultrasound-guidance with 2.5 mg/kg ropivacaine prior to surgery. Block ultrasound images before and after needle placement, and anesthetic injection videoclips were saved, and these images and vidoes independently rated by separate novice and expert reviewers for quality of visualization of bony elements, pleura, relevant ligament/membrane, needle, and injectate spread. Block performance times, postoperative pain scores, and opioid consumption were also recorded. RESULTS: Composite visualization scores were superior for proximal intercostal compared to paravertebral nerve block, as rated by both expert (p = 0.008) and novice (p = 0.01) reviewers. Notably, both expert and novice rated pleural visualization superior for proximal intercostal nerve block, and expert additionally rated bony landmark and injectate spread visualization as superior for proximal intercostal block. Block performance times, needle depth, opioid consumption and postoperative pain scores were similar between groups. CONCLUSIONS: Proximal intercostal block yielded superior visualization of key anatomical landmarks, possibly offering technical advantages over traditional paravertebral nerve block. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02911168. Registred on the 22nd of September 2016.

Ultrasound-guided percutaneous intercostal cryoanalgesia for multiple weeks of analgesia following mastectomy: a case series.

BACKGROUND: Acute post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration measured in multiple weeks. CASE: We report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy. Across all postoperative days and all three patients, the mean pain score on the numeric rating scale was 0 for each day. Similarly, no patient required any supplemental opioid analgesics during the entire postoperative period; and, no patient reported insomnia or awakenings due to pain at any time point. This was a significant improvement over historic cohorts. CONCLUSIONS: Ultrasound-guided percutaneous cryoanalgesia is a potential novel analgesic modality for acute pain management which has a duration that better-matches mastectomy than other currently-described techniques. Appropriately powered randomized, controlled clinical trials are required to demonstrate and quantify both potential benefits and risks.

Ultrasound-guided percutaneous intercostal nerve cryoneurolysis for analgesia following traumatic rib fracture -a case series.

BACKGRUOND: Rib fractures are a common injury in trauma patients and account for significant morbidity and mortality within this population. Local anesthetic-based nerve blocks have been demonstrated to provide significant pain relief and reduce complications. However, the analgesia provided by these blocks is limited to hours for single injection blocks or days for continuous infusions, while the duration of this pain often lasts weeks. CASE: This case series describes five patients with rib fractures whose pain was successfully treated with cryoneurolysis. CONCLUSIONS: Ultrasound-guided percutaneous cryoneurolysis is a modality that has the potential to provide analgesia matching the duration of pain following rib fractures.

Interventional Pain Treatments in the Management of Oncologic Patients With Thoracic Spinal Tumor-Related Pain: A Case Series.

BACKGROUND: Advanced tumors of the thoracic spine are difficult to treat and can lead to complex pain syndromes. Following conventional oncologic treatments, pharmacologic therapy may be insufficient to manage pain. Minimally invasive interventional procedures offer alternatives to treat malignant thoracic spinal pain. METHODS: Thirteen patients with metastatic disease and poorly controlled thoracic axial and/or radicular pain were identified via a retrospective chart review. Patients were either treated with radiation, surgery, chemotherapy, or a combination of these. Then, the patients were organized into groups based on their diagnoses, anatomical disease locations, symptoms, prior treatments, and interventional pain procedures offered. RESULTS: All cases of intercostal nerve, costotransverse junction, erector spinae plane, and paravertebral blocks resulted in pain relief without any reported complications. A patient who received a thoracic epidural injection had a complete resolution of pain when combined with radiation therapy 2 weeks after the injection. One patient who underwent repeat thoracic epidural injections eventually had an intrathecal pump placement, resulting in reduced opioid usage. Finally, 1 patient who received a thoracic medial branch block with a relief of thoracic axial pain reported greater pain relief with a medial branch nerve cryoablation. CONCLUSION: We propose a treatment algorithm to manage patients with thoracic spinal tumor-related pain. Interventional thoracic axial procedures may be safe and efficacious pain treatments for patients with cancer.