Cryoneurolysis of Intercostal Nerve for Rib Trauma and Intercostal Neuralgia in the Emergency Department: A Multidisciplinary Approach



      Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae.

      Case Report

      We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5–T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of −70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions.
      Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.


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      1. National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables–Table 10. 2009. Available at: Accessed 11/08/2021.

        • Stochkendahl MJ
        • Christensen HW.
        Chest pain in focal musculoskeletal disorders.
        Med Clin North Am. 2010; 94: 259-273
        • Thiruvenkatarajan V
        • Cruz Eng H
        • Adhikary SD
        An update on regional analgesia for rib fractures.
        Curr Opin Anaesthesiol. 2018; 31: 601-607
        • Luftig J
        • Mantuani D
        • Herring AA
        • Dixon B
        • Clattenburg E
        • Nagdev A.
        Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block.
        Am J Emerg Med. 2018; 36: 1391-1396
        • Coary R
        • Skerritt C
        • Carey A
        • Rudd S
        • Shipway D.
        New horizons in rib fracture management in the older adult.
        Age Ageing. 2020; 49: 161-167
        • Vossler JD
        • Zhao FZ.
        Intercostal nerve cryoablation for control of traumatic rib fracture pain: a case report.
        Trauma Case Rep. 2019; 23100229
        • Abd-Elsayed A
        • Lee S
        • Jackson M
        Radiofrequency ablation for treating resistant intercostal neuralgia.
        Ochsner J. 2018; 18: 91-93
        • Simon JB
        • Wickham AJ.
        Blunt chest wall trauma: an overview.
        Br J Hosp Med (Lond). 2019; 80: 711-715
        • Benzon HT.
        Complications associated with neurolytic blocks.
        in: Neal JM Rathmell JP Complications in regional anesthesia & pain medicine. W.B. Saunders, Philadelphia2007: 273-285
        • Ziegler DW
        • Agarwal NN.
        The morbidity and mortality of rib fractures.
        J Trauma. 1994; 37: 975-979
        • Beard L
        • Holt B
        • Snelson C
        • Parcha C
        • Smith FG
        • Veenith T.
        Analgesia of patients with multiple rib fractures in critical care: a survey of healthcare professionals in the UK.
        Indian J Crit Care Med. 2020; 24: 184-189
        • Ho AM
        • Karmakar MK
        • Critchley LA.
        Acute pain management of patients with multiple fractured ribs: a focus on regional techniques.
        Curr Opin Crit Care. 2011; 17: 323-327
        • Decosterd I
        • Hugli O
        • Tamchès E
        • et al.
        Oligoanalgesia in the emergency department: short-term beneficial effects of an education program on acute pain.
        Ann Emerg Med. 2007; 50: 462-471
        • Rupp T
        • Delaney KA.
        Inadequate analgesia in emergency medicine.
        Ann Emerg Med. 2004; 43: 494-503
        • Tulay CM
        • Yaldiz S
        • Bilge A.
        Do we really know the duration of pain after rib fracture?.
        Kardiochir Torakochirurgia Pol. 2018; 15: 147-150
        • Gordy S
        • Fabricant L
        • Ham B
        • Mullins R
        • Mayberry J.
        The contribution of rib fractures to chronic pain and disability.
        Am J Surg. 2014; 207: 659-663
      2. Fazekas D, Doroshenko M, Horn DB. Intercostal neuralgia. [Updated August 29, 2021]. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. Available at: Accessed 11/08/2021.

        • Forero M
        • Adhikary SD
        • Lopez H
        • Tsui C
        • Chin KJ.
        The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain.
        Reg Anesth Pain Med. 2016; 41: 621-627
        • Piccioni F
        • Droghetti A
        • Bertani A
        • et al.
        Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic Surgery (PACTS) part 2: intraoperative and postoperative care.
        Perioper Med (Lond). 2020; 9: 31
        • Abdelhamid K
        • ElHawary H
        • Turner JP.
        The use of the erector spinae plane block to decrease pain and opioid consumption in the emergency department: a literature review.
        J Emerg Med. 2020; 58: 603-609
        • Durant E
        • Dixon B
        • Luftig J
        • Mantuani D
        • Herring A.
        Ultrasound-guided serratus plane block for ED rib fracture pain control.
        Am J Emerg Med. 2017; 35: e3-e6
        • Bhoi S
        • Chandra A
        • Galwankar S.
        Ultrasound-guided nerve blocks in the emergency department.
        J Emerg Trauma Shock. 2010; 3: 82-88
        • Herring AA.
        Bringing ultrasound-guided regional anesthesia to emergency medicine.
        AEM Educ Train. 2017; 1: 165-168
        • Kot P
        • Rodriguez P
        • Granell M
        • et al.
        The erector spinae plane block: a narrative review.
        Korean J Anesthesiol. 2019; 72: 209-220
        • Elsabeeny WY
        • Ibrahim MA
        • Shehab NN
        • Mohamed A
        • Wadod MA.
        Serratus anterior plane block and erector spinae plane block versus thoracic epidural analgesia for perioperative thoracotomy pain control: a randomized controlled study.
        J Cardiothorac Vasc Anesth. 2021; 35: 2928-2936
        • Malekpour M
        • Hashmi A
        • Dove J
        • Torres D
        • Wild J.
        Analgesic choice in management of rib fractures: paravertebral block or epidural analgesia?.
        Anesth Analg. 2017; 124: 1906-1911
        • El-Boghdadly K
        • Wiles MD.
        Regional anaesthesia for rib fractures: too many choices, too little evidence.
        Anaesthesia. 2019; 74: 564-568
        • Mansour NA
        • Al-Mahdy Al-Belasy F
        • Abdel-Monem MT
        • Marzook HA
        Ropivacaine versus bupivacaine in postoperative pain control.
        J Biotechnol Biomater. 2012; 2: 137
        • Capdevila X
        • Pirat P
        • Bringuier S
        • et al.
        Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients.
        Anesthesiology. 2005; 103: 1035-1045
        • Ilfeld BM
        • Preciado J
        • Trescot AM.
        Novel cryoneurolysis device for the treatment of sensory and motor peripheral nerves.
        Expert Rev Med Devices. 2016; 13: 713-725
        • Gaudet AD
        • Popovich PG
        • Ramer MS.
        Wallerian degeneration: gaining perspective on inflammatory events after peripheral nerve injury.
        J Neuroinflammation. 2011; 8: 110
        • Finneran JJ IV
        • Gabriel RA
        • Swisher MW
        • et al.
        Ultrasound-guided percutaneous intercostal nerve cryoneurolysis for analgesia following traumatic rib fracture–a case series.
        Korean J Anesthesiol. 2020; 73: 455-459
        • Ilfeld BM
        • Gabriel RA
        • Trescot AM.
        Ultrasound-guided percutaneous cryoneurolysis providing postoperative analgesia lasting many weeks following a single administration: a replacement for continuous peripheral nerve blocks?: a case report.
        Korean J Anesthesiol. 2017; 70: 567-570