Intercostal Nerve Blocks
An intercostal nerve block is one of the techniques used to treat pain syndromes, whether acute or chronic, in the vicinity of the chest. In 1907, Heinrich Braun was the first to describe the procedure. Intercostal nerves course underneath the lower margins of the ribs. Intercostal nerve blocks require the injection of a local anesthetic, with or without a steroid, in the area adjacent to intercostal nerves. The procedure is part of an integrative approach to the treatment and management of pain. Intercostal nerve blocks are seldom the only treatment prescribed and are paired with other avenues of treatment such as anti-inflammatory medication, physical therapy (PT), anticonvulsive medication, oral or intravenous opioids (narcotics), occupational therapy (OT), and antidepressants.
Intercostal nerve blocks are usually therapeutic, but can be diagnostic in some situations. If pain is not relieved with injection, an intercostal nerve is probably not the root of the problem. If pain relief is transient, an intercostal nerve may be the culprit with inadequate pain coverage rendered by the co-administered steroid. If pain relief is achieved for a prolonged period of time (hours, days weeks, or months), an intercostal nerve is indeed the culprit. If this is the case, repeat injections of the local anesthetic, with or without a steroid, are indicated.
Intercostal-Nerve-1Intercostal nerve blocks should be avoided in patients affected by the following:
Allergy to a local anesthetic being administered
Active infection, whether bacterial or viral
Influenza A or B
Poorly controlled hypertension
Treatment with anticoagulants (blood thinners) such a Coumadin, Plavix, aspirin, or Pletal
Poorly controlled diabetes, type 1 or 2
In the case of treatment with anticoagulants, it is recommended treatment be terminated at least five days to one week before the procedure.
Intercostal nerve blocks are not without the possibility of complications. These may include:
Bruising or soreness at injection site
Collapsed lung (pneumothorax)
Systemic toxic reactions
Elevated blood sugars
Death (very rare)
An intercostal nerve block is commonly administered as an outpatient procedure, with the patient being discharged home the same day. Prior to treatment, patients should be thoroughly evaluated by way of medical history, physical examination, and imaging studies (if needed). The patient should sign an informed consent before the procedure.
Prior to the procedure, the patient is usually administered a sedative. The patient is then positioned laterally on the side opposite the affected area. The physician performing the procedure will clean the area to be injected with an antiseptic solution. A local anesthetic and steroid are injected just below the lower edge of a rib. The intercostal nerve block can be performed at multiple levels, if needed. Guidance of the needle for proper positioning can be aided with fluoroscopy, ultrasound, or other radiological studies in some cases. The procedure is not time consuming and in many cases completed in under 30 minutes.
Procedure-PreperationMost patients report some degree of pain relief as soon as 15 to 20 minutes after the intercostal nerve block, which is usually the effect of the local anesthetic. The onset of pain relief attributed to the steroid normally occurs two to three days after the procedure. If effective, the intercostal nerve block may be repeated every few weeks with no more than three injections in a 12-month period.
The patient should be driven home via a chaperone, as driving by a patient is not recommended for at least 24 hours after an intercostal nerve block. Activity should also be curtailed for at least 24 hours post-procedure. A regular diet and prior medications can be restarted shortly after the nerve block. Intermittent administration of ice is recommended post procedure to reduce inflammation and swelling at the injection site. The occurrence of alarming symptoms should be reported immediately to a medical professional for evaluation.
Conditions treated with intercostal nerve block treatments include:
Post-traumatic pain from rib fracture, shingles (herpes zoster), or post herpetic neuralgia
Postoperative pain from chest wall surgeries or procedures
Chronic non-malignant pain
Pain from malignancies involving the chest wall
The conditions mentioned above give rise to intercostal nerve compression or inflammation, which produces pain in the chest wall.
Intercostal nerve blocks are used in the treatment and management of pain involving the chest wall. An intercostal nerve block involves the injection of a local anesthetic, usually with a steroid, beneath the lower lip of a rib. The nerve blocks are either diagnostic or therapeutic. Guidelines exist as to who is prohibited from receiving intercostal nerve blocks. Although frequencies are low, complications can occur. Intercostal nerve blocks are but an element of a multi-pronged approach to the problem of acute and chronic pain.