Bedside percutaneous cryoneurolysis technique for management of acute rib fracture pain in adult trauma patients.

Background: Acute pain due to rib fractures causes significant in-hospital morbidity and impacts patients' quality of life after discharge. Intraoperative transthoracic cryoneurolysis of the intercostal nerves can improve postoperative pain; however, non-surgical patients are provided limited analgesia options. Here, we describe our experience with a bedside cryoanalgesia technique for management of acute rib fracture pain.

Methods: Five patients at a single level I trauma center completed bedside intercostal nerve cryoneurolysis (INC) using a handheld cryotherapy device and ultrasound guidance. Relative pain ratings (scale 0-10/10) and maximal incentive spirometry (IS_max) volumes were taken prior to the procedure as a baseline. Patients were observed for 24 hours after procedure, with relative pain ratings and IS_max recorded at 1, 8, 16, and 24 hours after procedure.

Results: Our patients were 29-88 years old and had one to five single-sided rib fractures. At baseline, they had high pre-procedure pain ratings (7-10/10) and IS_max volumes of 800-2000 mL. Many had improvements in their pain rating but little change in their IS_max at 1 hour (1-5/10 and 1000-2000 mL, respectively) and 8 hours (1-5/10 and 1250-2400 mL, respectively). IS_max volumes improved by 16 hours (1500-2400 mL) with comparable pain ratings (0-5/10). At 24 hours, pain ratings and IS_max ranged from 0 to 8/10 and from 1500 mL to 2400 mL, respectively. Each patient had improved pain control and IS_max volumes compared with their pre-procedure values. All patients reported the procedure as an asset to their recovery at discharge.

Conclusions: Our study demonstrates patients with rib fractures may experience improved pain ratings and IS_max values after INC. Percutaneous INC appears to be a viable adjunct to multimodal pain control for patients with rib fractures and should be considered in patients with difficult pain control. Further studies are required to fully assess INC safety, efficacy, post-discharge outcomes, and utility in patients with altered mental status or on mechanical ventilation.

Level of evidence: Level V, case series.