What comes after intercostal blocks?

[Baron Samedi]

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I have a gentleman I'm seeing with post-lobectomy chest wall pain. He had intercostals with steroids done a while back but unfortunately wore off. I repeated them today, ribs 8-9-10 with 100% pain relief immediately post proc. It just got me thinking -- what comes after this if this if it's short lived? I wouldn't have an issue repeating these about every 3mo or so but I'm curious what others are doing. I thought pulsed RF might be an option but unsure of the efficacy, and traditional RFA seems like a setup for disaster. I'm also a bit reluctant to go the stim route with him since he's a pretty unhealthy guy with some cognitive impairment.

What other sorts of things have others tried for chest wall pain?

 

[lobelsteve]

Traditional RF.

 

[BobBarker]

I have done traditional rf a couple times with no issues.

 

[Baron Samedi]

How have those patients done long term? I've heard horror stories of bad deafferent pain afterwards. Any suggestions for settings?

 

[soccrwz]

cryo is an option

 

[Espn123]

Drg

 

[painfree23]

Has anyone tried stim? Where did u put the leads if so

 

[cowboydoc]

I've done both traditional RFA and cryo. No issues with either. I ride out intercostal blocks as long as I can before considering either.

 

[deleted993114]

I have a gentleman I'm seeing with post-lobectomy chest wall pain. He had intercostals with steroids done a while back but unfortunately wore off. I repeated them today, ribs 8-9-10 with 100% pain relief immediately post proc. It just got me thinking -- what comes after this if this if it's short lived? I wouldn't have an issue repeating these about every 3mo or so but I'm curious what others are doing. I thought pulsed RF might be an option but unsure of the efficacy, and traditional RFA seems like a setup for disaster. I'm also a bit reluctant to go the stim route with him since he's a pretty unhealthy guy with some cognitive impairment.

What other sorts of things have others tried for chest wall pain?

A. Cryo first. If you don't have a cryo machine, that spiffy "Iovera" device comes with longer single probes you could use for intercostals. I have only done intercostals using the old massive cryo probe, but am going to use the Iovera device for intercostals to see how it works. It is a spiffy hand held device that is nice if the old cryo machine is not available. It additionally has a warming element for skin to reduce chances of thermal injury to the skin.

B. While rf of myelinated nerves may lead to a painful neuritis, it does not always happen. If cryo is not an option, an rf could be done, informing the patient about neuritis. Pulsed rf, in my experience, is of limited value. I visited Sluyter in the 90s in Amsterdam when he revealed to me a "radical and novel" treatment he had come up with called "pulsed rf". Being an idiot, I got Radionics to convert my box back in the US to do pulsed, being the first in the US to use it. I tried it for two years and was very disappointed. Initially, like alka-selzer fizzing, I thought it must be doing something, as you had all these nice multifidies twitching while it was being done. It seems that is all we got- twitching, but very poor results. If rf, I'd use thermal.

Plan C- stim. If you do not want to implant a conventional device, you could use stimwave. However, unless they are VERY thin, just put a conventional stim with the tip of the lead at T4. If conventional stim does not work, I have put stim leads in the "gutters" segmentally for thoracic radicular pain. Not a big stimwave fan myself, but I know a few guys who like them.

Plan D- phenol. I have done intercostal phenol on patients I thought were going to be dead in six months, only to be surprised that they just wouldn't die. I had a few of those patients I would repeat in every 6-12 months for several years before they died. Certainly not conventional by any means, but an option. I certainly never planned repeat neurolytics on those folks, but sometimes patients surprise you.

 

[BobBarker]

Old fellar won’t be able to keep up with the stim wave pads. I would probably do abt drg and instruct the rep to handle
all programming if I went down that path. The conventional RFA worked fine though on my two patients.

 

[mazinger]

I would do a pRF of the DRG. I had around 60% success rate with this and definitely worth trying before burning or freezing the nerves.

 

[Baron Samedi]

Any good resources for DRG pulsed RF technique?

 

[SommeRiver]

Any good resources for DRG pulsed RF technique?

Do a transforaminal with an RF needle and pulse it for 3 min. That's what we did in fellowship. Make sure you 2% the DRG first...Wait 3 min before pulsing.

I thought the general belief was that the pRF wasn't very effective and no longer covered by insurance.

I would pulse laterally at the intercostal nerve before I pulse the DRG.

 

[deleted993114]

Old fellar won’t be able to keep up with the stim wave pads. I would probably do abt drg and instruct the rep to handle
all programming if I went down that path. The conventional RFA worked fine though on my two patients.

good point about the stim wave

 

[soccrwz]

How are you doing the thoracic RF, temperature times, and approach?

 

[PainMD23]

Here is my algorithm, fwiw:
1. ICNB
2. ICNB with Pulsed RFA (works fairly well; patient with post-thoracotomy last week had 11 months relief, repeated the procedure for him; not a covered service-- you cannot bill insurance for pulsed rfa, requries ABN).
3. Thoracic SNRB/Trans esi (I have a few patients who have had rib resections, difficult to visualize the Rib to do ICNB safely-- I typically perform SNRB on these)
4. Thoracic tfesi with drg pulsed RFA (As above; I have been doing left t7-9 tfesi with drg pulsed rfa for 10 years on one patient, gets approximately 15 months of releif with each).
5. SCS

I personally have shied away from thermal RF of the intercostals, and from neurolytic blocks of intercostals in patients who are non-cancer patients. Far too often when I inject contrast in intercostal space, I see tracking medially into the foraminal entry zone and into epidural space, often with only 0.5mL contrast. You have to be extremely careful with phenol or alcohol to prevent serious complications.
I would favor Cryo, but I don't do it in my practice because of difficulty with coverage, and I don't have a cryo machine.

I agree with DRG stimulation as a possibility; however, I have not placed drg leads above T12 in my patients. The technique required in placing Abbott's DRG leads requires too much flipping/ turning of the introducer, needle, and lead in the epidural space to make me feel comfortable in the higher thoracic areas.

 

[deleted993114]

Here is my algorithm, fwiw:
1. ICNB
2. ICNB with Pulsed RFA (works fairly well; patient with post-thoracotomy last week had 11 months relief, repeated the procedure for him; not a covered service-- you cannot bill insurance for pulsed rfa, requries ABN).
3. Thoracic SNRB/Trans esi (I have a few patients who have had rib resections, difficult to visualize the Rib to do ICNB safely-- I typically perform SNRB on these)
4. Thoracic tfesi with drg pulsed RFA (As above; I have been doing left t7-9 tfesi with drg pulsed rfa for 10 years on one patient, gets approximately 15 months of releif with each).
5. SCS

I personally have shied away from thermal RF of the intercostals, and from neurolytic blocks of intercostals in patients who are non-cancer patients. Far too often when I inject contrast in intercostal space, I see tracking medially into the foraminal entry zone and into epidural space, often with only 0.5mL contrast. You have to be extremely careful with phenol or alcohol to prevent serious complications.
I would favor Cryo, but I don't do it in my practice because of difficulty with coverage, and I don't have a cryo machine.

I agree with DRG stimulation as a possibility; however, I have not placed drg leads above T12 in my patients. The technique required in placing Abbott's DRG leads requires too much flipping/ turning of the introducer, needle, and lead in the epidural space to make me feel comfortable in the higher thoracic areas.

We have put leads in the "gutters" in the thoracic area for decades. Unlike DRG stimulation (which is just root stimulation anyway), you can cover 3 segments. I would not want to put that Abbot DRG introducer weapon anywhere near the cord. You can get away with it below the cord.

 

[clubdeac]

I agree with what’s been mentioned above. Pulsing the drg works pretty well in some cases. Cohen from Hopkins showed that it worked for intercostal neuralgia from post thoracotomy pain better than intercostal RF

 

[PittsburghPain]

Have done PNS stim for refractory ICN. Still doing well 1 year out as of last week.