Intercostal Nerve Block and Neurolysis, Tips and Tricks

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  Review the anatomy of the intercostal nerves, including relation to vascular structures, branching pattern, and dermatomes.
  



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  Describe the indications for an intercostal nerve block or neurolysis.
  



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  Summarize the steps of performing an intercostal nerve block or neurolysis, highlighting tips and tricks for optimal technique through clinical cases.
  

An intercostal nerve block is a useful primary or adjunct intervention that can treat a variety of acute and chronic pain conditions, including rib fractures, incisional pain from breast or thoracic surgery, or cancer-related pain due to rib or pleural metastases. Intercostal nerve blocks have also been used as a perioperative analgesic for several procedures commonly performed by interventional radiology, such as chest tube placement or percutaneous cryoablation of lung tumors. For definitive or long-term pain control, intercostal neurolysis can be performed using a similar technique.

Clinical Findings/Procedure Details:

Our nerve block cocktail consists of a mixture of Bupivicaine 0.5% solution and Kenalog (triamcinolone 40 mg/mL) in a 6:1 ratio with a small volume (< 1 mL) of iodinated contrast for visibility if being done under CT or fluoroscopic guidance. We perform the majority of our procedures under CT guidance, however fluoroscopic and ultrasound guidance are used when concurrent procedures dictate their use. The patient is positioned in a prone or treatment side decubitus position. Under imaging guidance, a 25-gauge needle is inserted in a caudocranial orientation to the underside of the rib at the level of interest, approximately 2-4 inches lateral to the spinous process. After confirmation of needle tip position, 2-3 mL of the nerve block agent are injected at each level. CT guidance allows visualization of agent diffusion along the neurovascular bundle. At a minimum, block of the intercostal nerves above and below the level of interest should be performed due to radiating innervation from adjacent levels. For permanent intercostal neurolysis, 15 minutes time is allowed for the block to take effect, and then 1.5-2 mL of dehydrated ethanol is injected at each level.

Conclusion and/or Teaching Points:

Intercostal nerve block and neurolysis are valuable tools available to the interventional radiologist that are easy to learn, cost-efficient, safe, and quick to perform. Incorporating these techniques when performing a procedure requiring percutaneous access through an intercostal dermatome can help to achieve optimal analgesia for the patient in the perioperative setting, and potentially in the long-term if neurolysis is performed.