Intercostal nerve block technique

[schmee90]

I have seen multiple techniques for intercostal nerve block with fluoro, one with walking off the inferior porition of the rib, one with going just stayin on the bone without sliding off inferior portion as a fellow. Not walking off the rib seems to be a much safer approach, is this an inferior technique? Would love to hear some input from the group, thank you in advance as always.

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[Taus]

I have seen multiple techniques for intercostal nerve block with fluoro, one with walking off the inferior porition of the rib, one with going just stayin on the bone without sliding off inferior portion as a fellow. Not walking off the rib seems to be a much safer approach, is this an inferior technique? Would love to hear some input from the group, thank you in advance as always.

Omoigui Diffusion Technique​

 

[schmee90]

Perfect thank you, its nice to find literature on anecdotal attending preferences

 

[RoloTomassi]

I do kind of a hybrid. Caudal tilt quite a bit then touch down on interior aspect without walking off. If you take the tilt off, it looks very low like I walked off

 

[PMROralBoards]

Combination US/Fluoro is what we did in fellowship. Fluoro to identify the level, mark just caudal to bottom border, US to walk needle just posterior to rib while making sure to not pass through pleura

 

[pastafan]

Omoigui Diffusion Technique​

This. Fast, safe, effective.

 

[callmeanesthesia]

Omoigui Diffusion Technique​

Same. I use fluoro for it. I modified it slightly by placing my fingers perpendicular to the ribs on either side of the needle, then hold firm pressure as I inject. Generally can get spread across 3-4 intercostal spaces using 10 mL injectate in 1 site. Also very easy to put a few needles in though since they’re just straight down mid rib.

 

[clubdeac]

I can’t imagine that technique is as good as walking under the rib. Does it really diffuse/spread down over the bone and through the connective tissue and into the intercostal space? Hard to believe

 

[Ducttape]

so the question is what are we blocking with the omoigui block?

there have been several articles talking about other blocks for rib pain.

other blocks - though more for rib fracture pain - include paravertebral block, serratus anterior block, erector spinae block and of course intercostal nerve blocks.

in the right hand, they all seem to work.

i suspect that they all target the same structures - the cutaneous nerves overlying the rib more than the intercostal nerves...



(apparently, the traditional inferior to rib block is called the Bonica technique)

https://www.longdom.org/open-access-pdfs/omoigui-diffusion-technique-of-intercostal-nerve-block-2155-6148.1000344.pdf

 

[GorillaPanic]

In fellowship, we did retrolaminar paravertebrals instead (under fluoro). Several levels of coverage, usually worked pretty well.

 

[Gnarvin]

In fellowship, we did retrolaminar paravertebrals instead (under fluoro). Several levels of coverage, usually worked pretty well.

I am not familiar with this procedure. Can you explain the technique? I did a quick google search but could only find a few articles on ultrasound guided technique. It seems like with fluoro you would just touch down on lamina and inject?

 

[doctoroxygen]

I am not familiar with this procedure. Can you explain the technique? I did a quick google search but could only find a few articles on ultrasound guided technique. It seems like with fluoro you would just touch down on lamina and inject?

This is how we did it, with relatively large volume could cover multiple levels. We also did them at bedside on inpatients with a spinal needle and landmarks.

 

[oreosandsake]

blocks you can try almost anything and enough volume they feel it

the nerves actually travel through the muscles and come cutaneous as well... I will go via US to the inner muscle layer (no need to actually get to innermost) and deposit the medication. RF you cant do these diffusion based techniques.

 

[Orin]

blocks you can try almost anything and enough volume they feel it

the nerves actually travel through the muscles and come cutaneous as well... I will go via US to the inner muscle layer (no need to actually get to innermost) and deposit the medication. RF you cant do these diffusion based techniques.

I agree and would emphasize the last part of this. If you're planning an ablation or stimulation for the next step, I counsel you to find the nerve as directly as you can so you've got the specificity that you need to take that next step.

These days I suspect more people would use the erector spinae plane block approach to cover posterior rib pain and the serratus anterior plane approach to cover anterior rib pain, but I still love a good US guided intercostal in clinic.

 

[nvrsumr]

anterior rib pain is probably costochondritis