intercostal RFA

[likeaboss]

I have a 19 yo patient with a 1+ year history of severe costochondral junction pain (tietze), which i believe is nociceptive and not neuropathic pain. he has tried just about every medication, lots of PT, and had no pain for a few hours with costochondral joint injections with steroid. I tried a diagnostic unilateral T3-T7 intercostal nerve blocks which gave him significant relief on that side.

here are my questions:

1. should i do thermal RFA, or just go with pulsed? he is otherwise healthy, so i worry about causing neuritis, a partial burn with more pain, or intercostal muscle weakness with a thermal burn. i am leaning toward going with pulsed because i just dont want anything to go wrong. when doing an thermal RFA of 5 intercostal nerves, i feel like the chances of getting a partial burn on one of the five is pretty high
2. would pulsed RFA even work for something which i suspect is nociceptive, non-neuropathic pain?
3. i am open to any other suggestions for treatment...

thank you everybody for your help

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[lobelsteve]

Pretty rare problem. Pretty young patient.
More levels than makes sense or that I have ever heard treated at once.


What could go wrong?

 

[willabeast]

Suggest avoiding anything neurolytic. IC nerves have a rep for doing really badly after neurolytic interventions. If you want to do pulsed you should be OK in terms of making patient worse although chances of succeeding i think are really low. Make sure patient understands that pneumothorax is a risk in the best of hands. . BTW this is different problem but you might find it entertaining.
Pulsed radiofrequency of the dorsal root ganglia is superior to pharmacotherapy or pulsed radiofrequency of the intercostal nerves in the treatment... - PubMed - NCBI
regarding other things to try. neuropathic meds, psych consult/MMPI, lidoderm patch, TENS, bentyl?, and best of all,*referral to a tertiary center*. FYI in 1999 the PCP would have put this guy on long acting morphine.

 

[Bsb2015]

We have done cryoablation for this in fellowship. Also would not recommend thermal but pulsed RFA. I agree-Would be a lot of levels to do at once

 

[Ronin1]

I would repeat selective IC blocks first. Try and narrow down your potential neurolytoc targets. That is if you really want to do it. Personally I would not

 

[painfree23]

Why not do thermal? There are a lot of case reports of successful interventions. I’ve personally done a few with good results

 

[Bsb2015]

Why not do thermal? There are a lot of case reports of successful interventions. I’ve personally done a few with good results

I was taught it could cause deafferentation pain

 

[painfree23]

I was taught it could cause deafferentation pain

Vs their already existing neuropathic pain sometimes (intercostal or PHN neuralgia sometimes)

 

[Tapspatellas]

Vs their already existing neuropathic pain sometimes (intercostal or PHN neuralgia sometimes)

Can make that bothersome burning feel like the fire of hades. I only recommend thermal for palliative cancer. 1% chance per level burned for anesthesia dolorosa is what I’ve learned. Try the pulsed. I’d agree with the DRG, but I’ve had decent results with IC PRF too. I would not include 6th or 7th unlikely they are involved, too low for costosternal.

 

[nvrsumr]

I’d repeat steroid intercostal/sternocostal block a couple times

 

[painfree23]

Landmarks for sternocostal blocks? Fluoro?

 

[likeaboss]

What is the likelihood that a pulsed radiofrequency ablation reduces nociceptive pain?

 

[likeaboss]

I’d repeat steroid intercostal/sternocostal block a couple times

If this fails, I will recommend a series of sternocostal joint injections and PT...

 

[Bsb2015]

What about Stimwave (intercostal) if the patient got good relief

 

[nvrsumr]

I poke where it hurts make a circle and do “intercostal blocks” at three levels. Right at the lateral border of stenum with US. Sometimes see heart beating

Rinse and repeat a week later. If 50% improvement could be convinced to do one more time.

I think u can’t bill for a nerve block using Fluoro anymore...

 

[Orin]

I agree with not ablating at this age. I am okay with pulsed RFA, as that's safer if nothing else. The putative mechanism of action is independent of the neuropathic/nociceptive nature of pain.

Have you tried TENS?
Is he skinny enough for topical Flector patches?
Have you tried magic beans? Sorry, stem cells.

I would also consider stimulation with a good trial. I would prefer peripheral but I would prefer you narrow down the number of nerves if possible.

Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial. - PubMed - NCBI

This might be a good thing to try. You can actually hook it up to a Bioness external unit to verify their sensory stimulation patterns can block the pain pattern, and the Stimucath is rather cheap. They tell me it technically meets criteria for a PNS trial, but you can judge for yourself. The good thing though is that you can push on the chest, assess the pain in the joint, etc, prior to implanting.

The initial reports on PNS involved people poking themselves in the region of stimulation with a needle, showing reduced pain with pinprick, so I would give it a try regardless of your thoughts on the neuropathic/nociceptive nature of it, assuming you can get it approved. It beats a resection/surgery on the joints.

What's your closest academic center?

 

[likeaboss]

I agree with not ablating at this age. I am okay with pulsed RFA, as that's safer if nothing else. The putative mechanism of action is independent of the neuropathic/nociceptive nature of pain.

Have you tried TENS?
Is he skinny enough for topical Flector patches?
Have you tried magic beans? Sorry, stem cells.

I would also consider stimulation with a good trial. I would prefer peripheral but I would prefer you narrow down the number of nerves if possible.

Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial. - PubMed - NCBI

This might be a good thing to try. You can actually hook it up to a Bioness external unit to verify their sensory stimulation patterns can block the pain pattern, and the Stimucath is rather cheap. They tell me it technically meets criteria for a PNS trial, but you can judge for yourself. The good thing though is that you can push on the chest, assess the pain in the joint, etc, prior to implanting.

The initial reports on PNS involved people poking themselves in the region of stimulation with a needle, showing reduced pain with pinprick, so I would give it a try regardless of your thoughts on the neuropathic/nociceptive nature of it, assuming you can get it approved. It beats a resection/surgery on the joints.

What's your closest academic center?

Closest academic center is UCLA. That's where he was before he came to me.

 

[clubdeac]

I've done phenol on the intercostals which caused pretty significant deafferentaiton pain. I've also done a number of intercostal RFs resulting in one PTX. These procedures are not without risk. I don't think I'd do either now. My pucker factor gets higher the older I get.

 

[painfree23]

Why r the intercostal nerves more susceptible to this neuritis vs genicular nerves, suprascapular nerves or even TON?

 

[likeaboss]

I just did pulsed rfa. No need to set this guy's chest wall on fire... ‍

 

[Sadder]

I just did pulsed rfa. No need to set this guy's chest wall on fire... ‍

What result? May be picture?

 

[likeaboss]

Will let you know in a couple weeks...

 

[painfree23]

Why r the intercostal nerves more susceptible to this neuritis vs genicular nerves, suprascapular nerves or even TON?

Bump

 

[DrSpine]

Glad I saw this. I have a patient as well, post-lobectomy, horrible pain under the breast and radiating toward the back. Don't feel comfortable with RF at any point. Will do block with steroid and see if that relieves them posteriorly laying prone. If it does, great, could repeat in the future. Still don't think I'll move forward with RF though.

 

[Bsb2015]

Glad I saw this. I have a patient as well, post-lobectomy, horrible pain under the breast and radiating toward the back. Don't feel comfortable with RF at any point. Will do block with steroid and see if that relieves them posteriorly laying prone. If it does, great, could repeat in the future. Still don't think I'll move forward with RF though.

For this patient what about erector spinae plane block?

 

[painfree23]

No one has explained why we r so scared of intercostal rf but ok with rf of other peripheral nerves

 

[dhcofc]

No one has explained why we r so scared of intercostal rf but ok with rf of other peripheral nerves

It’s a nerve with a long course that hurts a lot if it develops a new post-RF neuralgia.

 

[likeaboss]

No one has explained why we r so scared of intercostal rf but ok with rf of other peripheral nerves

I was not afraid of RF of one intercostal, I was afraid of RF of 6 of them. Odds seem very very high that at least one of those nerves would get a partial burn/ neuritis resulting in worse pain...

 

[Ducttape]

No one has explained why we r so scared of intercostal rf but ok with rf of other peripheral nerves

No reason. And no logic behind it.

Just don’t do chemical neurolysis.

 

[cowboydoc]

I will do several local blocks (1 or 2 level, not 4!) before considering RF, but will RF an intercostal on occasion. Despite the handle, I'm generally quite conservative. I would consider pulsed first if you can get it paid for. Personally, I haven't seen a problematic neuritis from RF of these, but treated a nasty neuritis the IR folks caused with phenol. (lyrica and a U/S guided block backed her off the cliff)