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Introduction: Autologous costal cartilage harvest is a common procedure in craniofacial reconstruction due to its stability, dependability, and diversity. However, such a procedure is associated with severe donor-site pain postoperatively. Therefore, we aim through this study to compare the efficacy of intercostal nerve block in the management of postoperative pain in patients undergoing costal cartilage harvest for craniofacial reconstruction. Method: This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The study systematically reviewed MEDLINE, Cochrane, and EMBASE databases without time-limitation. Results: As a result of reviewing the literature, 33 articles were screened by full-text resulting in 14 articles which met our inclusion/exclusion criteria. However, only four high-quality RCT articles were included in the quantitative synthesis (meta-analysis). The findings of this study suggest that there is no significant difference in pain scores between ICNB and control groups at 12, 24, and 48 h postoperatively, both at rest and with coughing. Therefore, both techniques are considered safe and effective. Conclusion: Our results show evidence of favorable outcome of preventive donor-site analgesia with ICNB for harvesting autologous costal cartilage in multiple studies. However, the overall outcomes were insignificant between the two arms. No Level Assigned: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 [ABSTRACT FROM AUTHOR]

Purpose: This study investigated whether the divided method of multi-level intercostal nerve block (ML-ICB) could reduce the ropivacaine dose required during thoracoscopic pulmonary resection, while maintaining the resting postoperative pain scores. Methods: This retrospective, single-cohort study enrolled 241 patients who underwent thoracoscopic pulmonary resection for malignant tumors between October 2020 and March 2022 at a cancer hospital in Japan. ML-ICB was performed by surgeons under direct vision. The differences in intraoperative anesthetic use and postoperative pain-related variables at the beginning and end of surgery between group A (single-shot ML-ICB; 0.75% ropivacaine, 20 mL at the end of the surgery) and group B (divided ML-ICB, performed at the beginning and end of surgery; 0.25% ropivacaine, 30 mL total) were assessed. The numerical rating scale (NRS) was used to evaluate pain 1 h and 24 h postoperatively. Results: Intraoperative remifentanil use was significantly lower in group B (14.4 ± 6.4 μg/kg/h) than in group A (16.7 ± 8.4 μg/kg/h) (P = 0.02). The proportion of patients with NRS scores of 0 to 3 at 24 h was significantly higher in group B (85.4%, 106/124) than in group A (73.5%, 86/117) (P = 0.02). The proportion of patients not requiring postoperative intravenous rescue drugs was significantly higher in group B (78.2%, 97/124) than in group A (61.5%, 72/117) (P < 0.01). Conclusion: The divided method of ML-ICB could reduce the intraoperative remifentanil dose, decrease the postoperative pain score at 24 h, and curtail postoperative intravenous rescue drug use, despite using half the total ropivacaine dose intraoperatively. [ABSTRACT FROM AUTHOR]

The primary objectives of the study were to analyse the robotic approach and ultrasound-guided paravertebral block compared to thoracoscopic intercostal nerve block after robotic pulmonary lobectomy on postoperative pain and opioids use. The secondary objectives were to analyse and compare patients' necessity of additional antalgic drugs and patients' performance during respiratory therapy, following robotic surgery and in the two groups. Consecutively, 52 patients undergoing robotic pulmonary lobectomies were treated either with ropivacaine-based intercostal nerve block or paravertebral block from February 2022 to October 2022. When necessary, morphine was administered at day 1. Acetaminophen was administered as an additional antalgic drug on demand up to 3 g per day. Pain was measured 1 h after the end of the surgical procedure and daily through the pain numeric rating scale (NRS). Morphine administration rate and per day and total additional administrations of acetaminophen were recorded. Pain and opioids administration was measured 1 month after the procedure. Data were analysed in the overall population and in the intercostal nerve block group VS paravertebral block group. Overall, 34.6% of the patients required morphine administration and 51.7% of the patients required at least daily acetaminophen administration up to discharge. At 1 month postoperatively, four patients presented with chronic pain and one still was under opioid medication. At intergroup analysis, the paravertebral block group demonstrated lower NRS at fixed time points (p < 0.0001) and lower morphine consumption (45.7%VS11.8%; p = 0.02). Acetaminophen rescue administration at fixed time points was lower in the paravertebral block group (p < 0.0001) and mobility and dynamic pain resulted in better results (p = 0.03; p = 0.04). At 1 month, no differences were found between study groups. Similarly to other minimally invasive techniques, postoperative pain may arise after robotic pulmonary lobectomy. Paravertebral bloc can help to reduce postoperative pain as well as morphine and antalgic drugs administration and improve early mobilization. [ABSTRACT FROM AUTHOR]

Objectives: Autologous costal cartilage is commonly used as a graft material in plastic surgery. However, after autologous costal cartilage removal, the pain at the surgical site is particularly strong. We conducted this controlled clinical study to verify the efficacy of methylene blue (MB) in intercostal nerve block after autologous costal cartilage removal and to provide a reference for the application of MB in postoperative analgesia after autologous costal cartilage removal. Methods: In this study, 90 adolescent patients with congenital microtia who underwent autologous rib cartilage graft for auricular reconstruction were randomly allocated to one of three groups (Group A: intercostal nerve block was performed with 0.75% ropivacaine; Group B: intercostal nerve block was performed with 1% MB; and Group C: intercostal nerve block was performed with 1% MB and 0.75% ropivacaine mixture). Two trained researchers observed and recorded the pain status of the children at 6 hours (T1), 24 hours (T2), 48 hours (T3), and 72 hours (T4) after surgery, respectively. Numerical rating pain scale (NRS) was used for scoring. And adverse reactions such as nausea, vomiting, and skin itching were recorded. Results: In this study, there was no statistical difference in age and gender of patients in Groups A, B, and C (P >0.05). In terms of NRS comparison, 6 hours after operation (T1), Group B > Group A > Group C (P< 0.05); 24 hours after operation (T2), Group B > Group A > Group C (P< 0.05); 48 hours after operation (T3), Group B > Group A > Group C (P< 0.05); 72 hours after operation (T4), Group A > Group B > Group C (P< 0.05). There were no statistically significant differences in postoperative nausea, vomiting, and skin itching among the three groups (P>0.05). Conclusion: The analgesic effect of IV self-controlled analgesia combined with ropivacaine is quick, but the maintenance time is short. The analgesic effect of IV self-controlled analgesia combined with MB is slow to onset but long to maintain. The analgesic effect of IV self-controlled analgesia combined with MB and ropivacaine mixture is quick and maintained for a long time. Therefore, in patients after removal of costal cartilage, we recommend the analgesic treatment method of IV self-controlled analgesia combined with MB and ropivacaine mixture. Level of Evidence I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Special Topic. [ABSTRACT FROM AUTHOR]

A comment was made on a small-sample randomized controlled trial that evaluated the postoperative analgesic efficacy of a combination of continuous paravertebral block (PVB) and multilevel single-shot intercostal nerve block (ICNB) compared to PVB alone for patients who underwent thoracotomy. The comment raises several issues that need clarification, such as the lack of information on the thoracotomy approaches and surgical types, the difference in the administration of the blocks, and the clinical significance of opioid sparing with the combination of PVB and ICNB. The comment suggests that adding ICNB to an erector spinae plane block may be worth considering for pain control after thoracotomy. [Extracted from the article]

This document is a letter to the editor of the Journal of Anesthesia, commenting on a study that compared different intercostal nerve block modalities for postoperative analgesia in patients undergoing thoracoscopic pulmonary resection. The authors of the letter raise several concerns about the study, including the use of high concentration ropivacaine, the lack of incisional local anesthetic infiltration in the control group, the assessment of postoperative pain levels, the clinical significance of the opioid-sparing effect, and the inconsistent use of non-opioid basic analgesics. The authors also note that the results of the multivariable logistic regression analysis were not provided. It is important for library patrons to consider these limitations and potential biases when interpreting the findings of the original study. [Extracted from the article]

Purpose of Review: Intercostal nerve blocks are indicated for multiple chronic pain and acute pain conditions including rib fractures, herpes zoster, post-thoracotomy pain syndrome, and intercostal neuralgia. Intercostal neuralgia is a type of neuropathic pain that is in the distribution of intercostal nerves. The purpose of this review is to evaluate the different techniques used to perform intercostal nerve blocks and review their efficacy and safety including blind technique using anatomical landmarks, and fluoroscopically guided and ultrasound-guided intercostal nerve blocks. Recent Findings: Literature search was performed with the keywords including intercostal neuralgia, treatment, intercostal nerve blocks, and radiofrequency ablation on PubMed and Google Scholar. Three studies and one case report were identified. Literature review revealed that ultrasound-guided techniques and fluoroscopically guided techniques are superior to landmark-based technique in terms of efficacy. There was no difference in efficacy and complication rates between ultrasound and fluoroscopic guidance. Summary: Ultrasound-guided techniques and fluoroscopically guided techniques can both be performed safely and effectively for various chronic pain conditions. Ultrasound guidance has its advantages of direct visualization of nerves, vessels, muscles, and the lung. It is potentially a superior technique in terms of improving accuracy and decreasing complications. Further large population randomized control studies should be conducted to compare the efficacy of intercostal nerve blocks performed under ultrasound and fluoroscopy. [ABSTRACT FROM AUTHOR]

Rib fractures are the most common injuries in blunt chest trauma. Rib fractures can cause a lung injury or may occur in the form of an isolated rib fracture. Isolated rib fractures that are broken in single point are usually followed at home with analgesic treatment. In our study, we aimed to investigate the effect of intercostal nerve blockage on pain, quality of life, return to work, and grip strength in patients with isolated single point rib fracture that did not cause lung damage. Between March 2020 and August 2020, a total of 61 patients with the diagnosis of isolated rib fractures were included and divided into two groups. Group 1 (n=29) received one session of intercostal nerve blockage (0.5% bupivacaine 3mL and 5 μg epinephrine) and acetaminophen 500 mg b.i.d. +celecoxib 100 mg b.i.d., while group 2 (n=32) received acetaminophen 500 mg b.i.d. +celecoxib 100 mg b.i.d. Pain severity was evaluated using the Visual Analog Scale quality of life using the Short Form-36, and grip strength using a hand dynamometer at baseline, 1 week, and 1 month. On the second day of evaluation, the patients with Visual Analog Scale score of <3 were allowed to return to work. Of the patients, 44 (72.13%) were men and 17 (27.87%) were women with a mean age of 41.8 SD8.91 (range, 22 to 56) years. There was a statistically significant decrease in the VAS scores in all groups, after treatment compared to baseline, although only the grip strength and Short Form-36 subscale scores were significantly higher (p<0.05). There was also significant difference in the all scale scores in group 1 than group 2. We found significant correlation between the Visual Analog Scale and Short Form-36 subscales after the treatment. These results suggest that oral analgesia with intercostal nerve blockage is more effective than only oral analgesia on pain, quality of life, time to return to work, and grip strength in patients with isolated rib fractures. [ABSTRACT FROM AUTHOR]

Objectives: To explore the best strategy for combatting pain after thoracoscopic lobectomy for cancer. Methods: We conducted a randomized-controlled trial to compare two major analgesic procedures—intercostal nerve block and epidural analgesia—in patients scheduled to undergo thoracoscopic lobectomy and lymphadenectomy. High-dose oral celecoxib was started 3 h after operation in intercostal nerve block group or after withdrawal of epidural analgesia in epidural analgesia group. The primary endpoint was postoperative pain and adverse events, and the secondary endpoint was the length of the analgesic procedure and physiological function on postoperative day 1. Results: This study was closed before accumulating the necessary sample size. We eventually analyzed 21 patients undergoing intercostal nerve block and 22 patients undergoing epidural analgesia. Although the incidence of postoperative adverse events and postoperative complications was comparable between the groups, the incidence of procedure-related troubles was significantly higher in the epidural analgesia group than in the intercostal nerve block group. The length of the analgesic procedure was significantly shorter in the intercostal nerve block group than in the epidural analgesic group. The postoperative pain during postoperative days 0–7, as evaluated by a visual analog scale, was not significantly different between the groups. Likewise, postoperative physiological function, as evaluated by vital capacity and walking distance, was not significantly different between the groups. Conclusion: Although our limited sample size compromised our ability to draw definitive conclusions, intercostal nerve block followed by high-dose oral celecoxib seems to be an option for patients undergoing thoracoscopic lobectomy for lung cancer. [ABSTRACT FROM AUTHOR]

This document is a response to a letter regarding a study on the use of intercostal nerve blocks (ICB) for video-assisted thoracoscopic surgery (VATS) for malignant tumors. The authors of the study acknowledge the helpful comments and address some of the concerns raised. They mention that there was no protocol for anesthesia, including perioperative opioids, in their retrospective study, and agree that future validation is needed with a unified anesthetic protocol. They also note that there was no protocol for postoperative rescue analgesia and suggest converting the dose of rescue drugs to morphine milligram equivalents in future studies. The authors mention that the numerical rating scale (NRS) was only recorded at specific times and that their study aimed to optimize the ICB method. The document concludes with declarations of no conflict of interest and no funding received. [Extracted from the article]

Objective: Clinical evidence comparing paravertebral (PVB) and continuous intercostal nerve (ICB) blocks for pain management post video-assisted thoracic surgery (VATS) is limited. This study confirms the analgesic effect of ICB using two catheters is not inferior to that of PVB under direct vision.Methods: Fifty patients who underwent VATS lobectomy from July 2015 to March 2016 were prospectively recruited and randomly assigned to PVB and ICB groups. Postoperative pain was assessed using the visual analog scale (VAS). VAS score at rest at 24 h was the primary endpoint. Data on time required for catheter insertion, adverse effects, and frequency of additional analgesics as secondary endpoints were also collected. Noninferiority was assessed by adding a VAS margin of 15 mm to the PVB group.Results: No significant differences were observed between the VAS scores of the two groups except at 48 h after surgery, with a margin noted for the PVB group. No significant differences were detected in the frequency of additional analgesics and occurrence of adverse effects.Conclusions: Our results could not clearly establish noninferiority of ICB to PVB. Improvements in ICB may be necessary for it to be used as an alternative method to PVB. [ABSTRACT FROM AUTHOR]

Background: In breast augmentation with implant, there is severe pain due to damage from expansion of breast tissue and the pectoralis major. Therefore, the authors conducted this study to analyze the effectiveness of postoperative intercostal nerve block (ICNB) in reducing postoperative pain after breast augmentation with implant. Method: Forty-four female patients were enrolled in the study. Just before awaking from general anesthesia, 34 cases were injected with 0.2% ropivacaine to both third, fourth, fifth, and sixth intercostal spaces. We compared them (ICNB group) with the control group for VAS scores at the time of arrival in the recovery room, after 30, 60, and 120 min. Result: The average VAS scores per time of the control group and ICNB group were 7.1 ± 0.74 and 3.50 ± 1.81 at arrival time in the recovery room, 7.00 ± 0.67 and 3.03 ± 1.47 after 30 min, 5.50 ± 0.71 and 2.68 ± 1.49 after 60 min, and 4.60 ± 0.84 and 2.00 ± 1.35 after 120 min. VAS scores of two groups were significantly different at each time and decreased overall. Also, time and group effect of the two groups were significantly different, especially between 30 and 60 min. Conclusion: ICNB just before awaking from general anesthesia showed a statistically significant reduction in VAS score, and this means postoperative pain was reduced effectively and time to discharge could be shortened. Therefore, it can be a good way to reduce postoperative pain after augmentation mammoplasty with implant. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors . [ABSTRACT FROM AUTHOR]

Introduction: Intercostal nerve block and neurolysis are widely used procedures, but their injectate spread has not been well understood. Previous studies have reported unexpected outcomes (paravertebral or epidural anesthesia) and spinal cord injury after intercostal nerve block and neurolysis. To investigate a possible mechanism for these complications, we aimed to visualize the flow of liquid injected near the intercostal nerve, using cadavers.Methods: We performed a simulated intercostal nerve block study using two Thiel-embalmed cadavers. Dye was injected into the interfascial plane between the internal and innermost intercostal muscles under ultrasound guidance (blue, 10 ml) or under direct vision (green, 5 ml).Results: Dye leakage began with injection of only 0.5-2 ml and occurred between the innermost intercostal muscle fibers. The dye injected around the intercostal nerve penetrated into the extrapleural space and reached the paravertebral space.Conclusions: Injectate placed around the intercostal nerve easily penetrate the extrapleural space and reach the paravertebral space. Intercostal nerve block or neurolysis has a risk of impairing at least the sympathetic chain and conceivably affecting the central nervous system. [ABSTRACT FROM AUTHOR]

Chronic pain is a common medical condition. Patients who suffer uncontrolled chronic pain may require interventions including spinal injections and various nerve blocks. Interventional procedures have evolved and improved over time since epidural injection was first introduced for low back pain and sciatica in 1901. One of the major contributors in the improvement of these interventions is the advancement of imaging guidance technologies. The utilization of image guidance has dramatically improved the accuracy and safety of these interventions. The first image guidance technology adopted by pain specialists was fluoroscopy. This was followed by CT and ultrasound. Fluoroscopy can be used to visualize bony structures of the spine. It is still the most commonly used guidance technology in spinal injections. In the recent years, ultrasound guidance has been increasingly adopted by interventionists to perform various injections. Because its ability to visualize soft tissue, vessels, and nerves, this guidance technology appears to be a better option than fluoroscopy for interventions including SGB and celiac plexus blocks, when visualization of the vessels may prevent intravascular injection. The current evidence indicates the efficacies of these interventions are similar between ultrasound guidance and fluoroscopy guidance for SGB and celiac plexus blocks. For facet injections and interlaminar epidural steroid injections, it is important to visualize bony structures in order to perform these procedures accurately and safely. It is worth noting that facet joint injections can be done under ultrasound guidance with equivalent efficacy to fluoroscopic guidance. However, obese patients may present challenge for ultrasound guidance due to its poor visualization of deep anatomical structures. Regarding transforaminal epidural steroid injections, there are limited evidence to support that ultrasound guidance technology has equivalent efficacy and less complications comparing to fluoroscopy. However, further studies are required to prove the efficacy of ultrasound-guided transforaminal epidural injections. SI joint is unique due to its multiplanar orientation, irregular joint gap, partial ankylosis, and thick dorsal and interosseous ligament. Therefore, it can be difficult to access the joint space with fluoroscopic guidance and ultrasound guidance. CT scan, with its cross-sectional images, can identify posterior joint gap, is most likely the best guidance technology for this intervention. Intercostal nerves lie in the subcostal grove close to the plural space. Significant risk of pneumothorax is associated with intercostal blocks. Ultrasound can provide visualization of ribs and pleura. Therefore, it may improve the accuracy of the injection and reduce the risk of pneumothorax. At present time, most pain specialists are familiar with fluoroscopic guidance techniques, and fluoroscopic machines are readily available in the pain clinics. In the contrast, CT guidance can only be performed in specially equipped facilities. Ultrasound machine is generally portable and inexpensive in comparison to CT scanner and fluoroscopic machine. As pain specialists continue to improve their patient care, ultrasound and CT guidance will undoubtedly be incorporated more into the pain management practice. This review is based on a paucity of clinical evidence to compare these guidance technologies; clearly, more clinical studies is needed to further elucidate the pro and cons of each guidance method for various pain management interventions. [ABSTRACT FROM AUTHOR]