
==== Front
Trauma Surg Acute Care Open
Trauma Surg Acute Care Open
tsaco
tsaco
Trauma Surgery & Acute Care Open
2397-5776
BMJ Publishing Group BMA House, Tavistock Square, London, WC1H 9JR

10.1136/tsaco-2024-001575
tsaco-2024-001575
Commentary
1506
Percutaneous cryoneurolysis: new kid on the rib fracture pain ‘Block’
Wang Simeng simeng.wang@me.com
1
Myers Alexandra A amyers19@stanford.edu
1
http://orcid.org/0000-0001-6380-4880
Forrester Joseph D jdf1@stanford.edu
1
1 Department of Surgery, Stanford University Department of Medicine, Stanford, California, USA
Dr; jdf1@stanford.edu
JDF is the PI for the investigator-initiated clinical trial partially funded by Varia; PI for investigator-initiated clinical trial partially funded by Pacira; PI for the industry-initiated clinical trial funded by Eclipse Regenysis.

2024
13 9 2024
9 1 e00157501 9 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

rib fractures
pain management
acute pain
chronic pain
==== Body
pmc Multimodal analgesia is a mainstay of traumatic rib fractures management, using a combination of medications and interventions to synergistically target different pain pathways and minimize adverse effect of a single modality.1 2 Locoregional blocks are especially attractive analgesic adjuncts due to their effectiveness and minimal effect on hemodynamics or the central nervous system.3 4 The blocks involve single-shot injections or continuous infusion of local anesthetics, but their analgesic effects are typically time-limited. Alternatively, cryoneurolysis can target the same nerve pathways but prolong analgesia by causing Wallerian degeneration of peripheral nerves resulting in 3–6 months of analgesia as the nerves regenerate. Interest is rapidly growing for expanding the application of cryoneurolysis to those patients undergoing non-operative and operative management of their rib fractures.5 6

In this article, Villalta et al demonstrated the feasibility of an ultrasound-guided Intercostal cryoneurolysis (ICN) for five patients who presented with traumatic rib fractures.7 After the procedure, the patients showed a trend towards improved inspiratory capacity measured by incentive spirometry and decreased subjective pain score with a duration up to 30 days postdischarge. There was no procedure-related adverse event. Although the small sample size, short follow-up period and lack of control group precluded statistical testing to evaluate the effectiveness or safety profile of this modality, the study illustrated a method allowing ICN to be performed as a bedside, minimally invasive procedure. Our group similarly reported our experience of incorporating CT-guided ICN performed by interventional radiologists as a part of the rib fracture clinical pathway for older adults.6 Together, these studies expanded the potentials of ICN to offer patients timely, long-lasting and effective pain control for rib fractures. As the authors astutely pointed out, future larger, prospective trials are needed to characterize the risk-benefit profile and realize the full potential of percutaneous ICN, the new kid on the rib fracture pain ‘block’.

Acknowledgements

JDF is the principal investigator for an investigator-initiated trial funded by Pacira Biosciences, an investigator-initiated trial funded by Varian, and an industry-sponsored trial funded by Eclipse Regenysis.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Patient consent for publication: Not applicable.

Ethics approval: Not applicable.

Provenance and peer review: Commissioned; internally peer reviewed.
==== Refs
References

1 Mukherjee K Schubl SD Tominaga G Cantrell S Kim B Haines KL Kaups KL Barraco R Staudenmayer K Knowlton LM et al Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society J Trauma Acute Care Surg 2023 94 398 407 10.1097/TA.0000000000003830 36730672
2 Burton SW Riojas C Gesin G Smith CB Bandy V Sing R Roomian T Wally MK Lauer CW PRIMUM Group Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures J Trauma Acute Care Surg 2022 92 588 96 10.1097/TA.0000000000003486 34882599
3 Leasia KN Ciarallo C Prins JTH Preslaski C Perkins-Pride E Hardin K Cralley A Burlew CC Coleman JJ Cohen MJ et al A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures J Trauma Acute Care Surg 2021 91 872 8 10.1097/TA.0000000000003264 33951024
4 Sadauskas V Fofana M Brunson D Choi J Spain D Quinn JV Duanmu Y Serratus anterior plane block improves pain and incentive spirometry volumes in trauma patients with multiple rib fractures: a prospective cohort study Trauma Surg Acute Care Open 2024 9 e001183 10.1136/tsaco-2023-001183 38881827
5 Marturano MN Thakkar V Wang H Cunningham KW Lauer C Sachdev G Ross SW Jordan MM Dieffenbaugher ST Sing RF et al Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days Injury 2023 54 10.1016/j.injury.2023.05.034
6 Wang S Earley M Kesselman A Vezeridis AM Picel AC Kothary N Forrester JD Percutaneous Cryoneurolysis for Pain Control After Rib Fractures in Older Adults JAMA Surg 2024 e242063 10.1001/jamasurg.2024.2063 39110467
7 Villalta CI Mian RK Grossman Verner HM Farsakh D Browne TC Goldstein ZS McDaniel C Bedside percutaneous cryoneurolysis technique for management of acute rib fracture pain in adult trauma patients Trauma Surg Acute Care Open 2024 9 e001521 10.1136/tsaco-2024-001521 39185271
