Rib Fracture pain and concurrent compression fx

[PinchandBurn]

Say a patient has compression fx..you've treated it (vert augmentation). However, the ribs are also fractured so they have pain over the ribs (T7-10).

What are the options?

Obviously a TLSO is out of the question right, as the rib fx's will be sensitive.

One option is IV opioids, but this pt wants to go home.

Another option is intercostal nerve blocks with steroids. But I cant imagine this is really going to last that long. I dont think her pain is as bad as needing a thoracic epidural as she's ambulatory.

My understanding is rib fx heal on their own, but it can tk 6-8 weeks. So in the meantime would any of you guys just treat this in an outpt manner. (percocets for break through pain, toradol or your other favorite NSAID). Could you consider weekly intercostal nerve blocks for breakthrough pain? I suppose after two intercostal nerve blocks one could try doing an RFA of these nerves.

Thoughts?

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[lobelsteve]

Millions of broken ribs out there.

99% heal without mucking around.
3-4 days of pain meds is fine.

How about flector or topical triple creams?

 

[mille125]

Say a patient has compression fx..you've treated it (vert augmentation). However, the ribs are also fractured so they have pain over the ribs (T7-10).

What are the options?

Obviously a TLSO is out of the question right, as the rib fx's will be sensitive.

One option is IV opioids, but this pt wants to go home.

Another option is intercostal nerve blocks with steroids. But I cant imagine this is really going to last that long. I dont think her pain is as bad as needing a thoracic epidural as she's ambulatory.

My understanding is rib fx heal on their own, but it can tk 6-8 weeks. So in the meantime would any of you guys just treat this in an outpt manner. (percocets for break through pain, toradol or your other favorite NSAID). Could you consider weekly intercostal nerve blocks for breakthrough pain? I suppose after two intercostal nerve blocks one could try doing an RFA of these nerves.

Thoughts?

I would not get interventional at this point. I would do a topical compound plus opioid. This is obviously acute pain and so I would guess that even the most anti-opioid folks in the forum would not object to use here............ Or would they?

 

[AirBubble]

Did you consider a paravertebral (LA + steroid)?

 

[mille125]

Did you consider a paravertebral (LA + steroid)?

good idea....it would be one of the things that I would consider if conservative treatments did not work....it would require as many 10-12 paravertebral injections.......

 

[PMR 4 MSK]

PO meds, sometimes a lidoderm patch.

 

[PinchandBurn]

good idea....it would be one of the things that I would consider if conservative treatments did not work....it would require as many 10-12 paravertebral injections.......

I definitely think opioids are indicated in this situation.

I will try lidoderm, but she's got some 'meat' I highly doubt it will penetrate deep enough.

I didnt think of paravertebral blocks, only because I dont usually do them. I'm wondering if that really has any better relief vs doing intercostal nerve blocks. In my anesthesia training we did a handful of paravertebral blocks with ultrasound. Again PTx is a complication (same wtih intercostal blocks).

But using fluro (not doing it blind), to do either one of these procedures, it seems doubtful that PTX can occur (knokcing on wood).

 

[mille125]

I definitely think opioids are indicated in this situation.

I will try lidoderm, but she's got some 'meat' I highly doubt it will penetrate deep enough.

I didnt think of paravertebral blocks, only because I dont usually do them. I'm wondering if that really has any better relief vs doing intercostal nerve blocks. In my anesthesia training we did a handful of paravertebral blocks with ultrasound. Again PTx is a complication (same wtih intercostal blocks).

But using fluro (not doing it blind), to do either one of these procedures, it seems doubtful that PTX can occur (knokcing on wood).

Paravertebrals are as safe as it comes. Use a 22 G tuohy so that you can see the exact mark on the skin when you contact the transverse process. Do not advance more the 1 cm past this point (you can see exactly how far that is when looking at the tuohy)

 

[Ducttape]

diagnostic ICNB, then RFA if successful.

i use paravertebral blocks only if there are more than 1 rib fracture, like the 3 you are talking about, but i dont do RFA of paravertebrals. i might consider phenol if it is a palliative situation.

i use US from ICNB, and seems technically much less likely to have a PTX. i do cheat a little, and instead of counting all the ribs under US, i might get 1 or 2 scout films to count the ribs, and see the rib fractures (dont bill for it). i used to do ICNB all under fluoro for this reason, but the safety factor is just so appealing...

 

[ultm8frisbee]

diagnostic ICNB, then RFA if successful.

i use paravertebral blocks only if there are more than 1 rib fracture, like the 3 you are talking about, but i dont do RFA of paravertebrals. i might consider phenol if it is a palliative situation.

i use US from ICNB, and seems technically much less likely to have a PTX. i do cheat a little, and instead of counting all the ribs under US, i might get 1 or 2 scout films to count the ribs, and see the rib fractures (dont bill for it). i used to do ICNB all under fluoro for this reason, but the safety factor is just so appealing...

RFA for a rib fracture? I can see for cancer pain, but don't know if I would go that route in pain that eventually go away on its own. Have you had any issues with this?

 

[mille125]

RFA for a rib fracture? I can see for cancer pain, but don't know if I would go that route in pain that eventually go away on its own. Have you had any issues with this?

I agree as well...it is going to heal...

 

[Ducttape]

i guess it depends on whether you think kypho works for long term pain relief. so would the compression fractures that you put in a permanent cement. depending on who you read, long term data show no difference in pain relief from kyphoplasty.

if you are willing to using kypho to reduce the acute pain and the need for opioids, then why not do the same for the rib fractures?

i do often use steroids in ICNB, but for acute fractures, i have not found that much benefit. hence, the RFA.

 

[PinchandBurn]

I agree as well...it is going to heal...

I have a lady in her 70s. She had fallen 3mo ago. I did a kypho on here for her back pain 2 mo ago. Back pain is somewhat controlled. However, at the time of her fall she had rib fx's that are 'non displaced'. I told the family that it will 'heal' on it's own and so for the interim gave NSAIDS and opioids.

It's 3 mo out now.

She's still in pain. That's why I think some sort of injection therapy is necssary. I havent had much success in the whole, 'wait 6-8weeks for teh rib fxs to heal' dogma.........

 

[lobelsteve]

i guess it depends on whether you think kypho works for long term pain relief. so would the compression fractures that you put in a permanent cement. depending on who you read, long term data show no difference in pain relief from kyphoplasty.

if you are willing to using kypho to reduce the acute pain and the need for opioids, then why not do the same for the rib fractures?

i do often use steroids in ICNB, but for acute fractures, i have not found that much benefit. hence, the RFA.

A single fracture can permanently reduce TLC by 9%.
A rib fracture will not reduce lung capacity once it heals.

 

[Ducttape]

A single fracture can permanently reduce TLC by 9%.
A rib fracture will not reduce lung capacity once it heals.

im hard pressed finding studies that show that kyphoplasty or vertebroplasty corrects the changes in TLC long term.

the best article i did find, which did support the use of kyphoplasty, was this one: http://www.ncbi.nlm.nih.gov/pubmed/17473642

but even this article stated that the only thing that improved pulmonary function wise 3 months out was MVV.

"After kyphoplasty was performed on these women, thoracic kyphotic angle, local kyphotic angle, pain scores, and pulmonary function parameters-vital capacity, inspiratory capacity, residual volume, functional residual capacity, total lung capacity, forced vital capacity (FVC), and maximum voluntary ventilation (MVV) were measured. All measurements were taken before, 3 days after, and 1 month after the kyphoplasty. The height of the vertebral body was restored, the local kyphotic angle was improved, and pain scores were significantly decreased after kyphoplasty. FVC and MVV were significantly increased 3 days after the procedures; whereas only MVV had gone on to improve 1 month later."

 

[lobelsteve]

im hard pressed finding studies that show that kyphoplasty or vertebroplasty corrects the changes in TLC long term.

the best article i did find, which did support the use of kyphoplasty, was this one: http://www.ncbi.nlm.nih.gov/pubmed/17473642

but even this article stated that the only thing that improved pulmonary function wise 3 months out was MVV.

"After kyphoplasty was performed on these women, thoracic kyphotic angle, local kyphotic angle, pain scores, and pulmonary function parameters-vital capacity, inspiratory capacity, residual volume, functional residual capacity, total lung capacity, forced vital capacity (FVC), and maximum voluntary ventilation (MVV) were measured. All measurements were taken before, 3 days after, and 1 month after the kyphoplasty. The height of the vertebral body was restored, the local kyphotic angle was improved, and pain scores were significantly decreased after kyphoplasty. FVC and MVV were significantly increased 3 days after the procedures; whereas only MVV had gone on to improve 1 month later."

I never said it would fix this. But if there is a Fx that has not yet crumped, fixing it before hand can prevent that loss.

I thought as long as we are arguing hypothetical nonsense.....

Let the ribs heal up with some Aleve and topicals, then at 8 weeks if there is still pain treat as you wish.

 

[Tenesma]

1) get an Intra-Osseous IV kit (usually ER or pedi ER has those)
2) Under fluoro enter the rib with the IO needle...
3) Under fluoro advance a thick wire (get this from IR) along the marrow and cross the fracture line
4) Remove the IO needle and then thread over that wire (Seldinger technique) a large central line.
5) Remove the wire
6) Inject Methylmethacrylate (MMA) slowly as you slowly pull the line out - thus creating an intra-osseous line of cement
7) tell the patient not to breathe for about 6-7 minutes while the MMA hardens

OR

tell them that rib fractures hurt, they will recover... just takes time... I usually tell my patients it takes 2-3 months to feel better, and then when i see them in follow-up 2-3 weeks after injury, I am always "amazed at their amazing recovery under my care" 🙂

ps: please do not do steps 1-7 unless you are a CRNA/PA fully trained in interventional pain at a weekend course.

 

[ultm8frisbee]

1) get an Intra-Osseous IV kit (usually ER or pedi ER has those)
2) Under fluoro enter the rib with the IO needle...
3) Under fluoro advance a thick wire (get this from IR) along the marrow and cross the fracture line
4) Remove the IO needle and then thread over that wire (Seldinger technique) a large central line.
5) Remove the wire
6) Inject Methylmethacrylate (MMA) slowly as you slowly pull the line out - thus creating an intra-osseous line of cement
7) tell the patient not to breathe for about 6-7 minutes while the MMA hardens

OR

tell them that rib fractures hurt, they will recover... just takes time... I usually tell my patients it takes 2-3 months to feel better, and then when i see them in follow-up 2-3 weeks after injury, I am always "amazed at their amazing recovery under my care" 🙂

ps: please do not do steps 1-7 unless you are a CRNA/PA fully trained in interventional pain at a weekend course.

Bravo

 

[Ducttape]

so my point is this...

some are being very aggressive injecting cement into a compression fracture, under the auspice that "it will reduce the pain and it will reduce opioid use", keeping in mind that some good studies have shown it to be no better than a sham procedure.

yet i also hear that "you have a rib fracture, deal with it, it will (probably) get better in 8 weeks, its okay to have those opioids you avoided by having a kyphoplasty,"



if that is not hypocrisy, please explain what im missing.

(and you dont have to RFA...)

 

[sweetalkr]

for what it is worth.

there was a colonel that came in, 75 years old, inpatient, with broken ribs from a fall. he was extremely stubborn and refused any pain meds and said he wanted his "nerves blocked". so i performed the blocks with steroid. he had extended relief with 2 of the ribs, but the other two ribs still hurt. he admitted himself (he had some pull) and wouldn't leave until I performed these again. I ended up just RFA'ing the intercostal nerves, and he didn't come back for 5 months.

so i was forced to do something aggressive because of his rank and my new job status, but i explained to him the risks and he said just burn those suckers and we did it. i wouldn't recommend it in civilian world, but keep that in ur back pocket. we used cryo in fellowship but we still don't have a cryo machine.

 

[lobelsteve]

so my point is this...

some are being very aggressive injecting cement into a compression fracture, under the auspice that "it will reduce the pain and it will reduce opioid use", keeping in mind that some good studies have shown it to be no better than a sham procedure.

yet i also hear that "you have a rib fracture, deal with it, it will (probably) get better in 8 weeks, its okay to have those opioids you avoided by having a kyphoplasty,"



if that is not hypocrisy, please explain what im missing.

(and you dont have to RFA...)

It's societal and cultural. I've broken several ribs and it hurt to breath deep, laugh, cough, sneeze. It was gone in 2 weeks without meds. I've never fractured my spine but was in the boat when my dad suffered an L1 burst Fx and needed a Jewitt for 3 months. He went on to RFA and did not need kypho (dont think kypho existed at that time). Equating the pain from a rib Fx to a vertebral body fracture is like equating a tension headache to a brain bleed headache. I'm sure we could do a lot of plexus blocks for all of the Colles Fx folks out there as well- but nobody does this.


And what studies are out saying kypho doesn't work? That crap in the NEJM form Kalmes et al? They preselected failed patients to include and never got to half their enrollment despite this. Those studies were turds

 

[Ducttape]

So do you must think both the Kallmes data and the Buchbinder data are flawed...

i agree about your statement "Equating the pain from a rib Fx to a vertebral body fracture is like equating a tension headache to a brain bleed headache" being cultural and specific.

playing devils advocate, i would not hesitate to guess that more patients get admitted to an ICU for rib fractures, especially multiple rib fractures, than compression fractures. its my cultural experience, having been in ED for 12+ years, seeing patients with rib fractures have pain, splinting, significant V/Q shunts related to rib fractures, pneumothorax, pulmonary contusions, etc.


Other studies that have caught my eye, particularly with long term followup.



1. Therapeutic Efficacy of Vertebroplasty in Osteoporotic Vertebral Compression Fractures With Avascular Osteonecrosis: A Minimum 2-Year Follow-up Study
Heo, Dong Hwa MD, PhD*;

Spine Issue: Volume 37(7), 01 April 2012, p E423–E429
"According to our results, in cases of osteoporotic vertebral compression fractures with osteonecrosis that manifests as an intravertebral vacuum phenomenon, pseudoarthrosis, or intravertebral fluid collection, percutaneous vertebroplasty may not effectively provide enough stability or maintain stabilization for an extended period of time. After vertebroplasty, the compression and kyphosis of avascular necrotic vertebral bodies progressed continuously during the 2 years or longer of patient follow-up."


2.Cost-Effectiveness of Balloon Kyphoplasty Versus Standard Medical Treatment in Patients With Osteoporotic Vertebral Compression Fracture: A Swedish Multicenter Randomized Controlled Trial With 2-Year Follow-up
Spine
Issue: Volume 36(26), 15 December 2011, p 2243–2251
"In this health-economic evaluation conducted as an RCT including patients with an acute/subacute (<3 months) vertebral compression fracture due to osteoporosis, it was not possible to demonstrate that BKP was cost-effective compared with standard medical treatment in Sweden."

 

[pmrmd]

I've never fractured my spine but was in the boat when my dad suffered an L1 burst Fx. Equating the pain from a rib Fx to a vertebral body fracture is like equating a tension headache to a brain bleed headache.

True dat. I fractured L1 and it hurt like a mofo. Ankle, not so much.

 

[Ligament]

Intercostal blocks work really well for rib fracture pain, with surprisingly long lasting results. I would do a few of these if needed. I've had a number of these patients and they have all done suprisingly well with ICNBs for rib fxs...