Neurolytic Intercostal Nerve Block

Thoracic paravertebral nerve at each level gives anterior and posterior branches. The anterior branch is the intercostal nerve which gives lateral and anterior cutaneous branches. They provide motor supply to abdominal wall muscles via T7-T11 and muscles of the forearm and hand via T1. They provide sensory innervation of the skin of the chest and abdomen anterolaterally. The intercostal nerves travel in the inferior part of the ribs posterior to the intercostal artery. Subcostal nerve comes from the ventral ramus of T12 and is equivalent to the intercostal nerve at the above levels.

Technique

Neurolytic intercostal nerve block is indicated for cancer pain involving the chest wall and/or the ribs. It is also indicated in cancer pain involving the upper abdominal wall. Table 28.10 describes the technique of neurolytic intercostal nerve block for cancer pain. For diagnostic block, 1-2 ml of bupivacaine 0.25-0.5% is injected. Calculating the total milligrams of local anesthesia per body weight is important because of the potential local anesthesia toxicity. For neurolytic block, phenol 10% 4-5 ml can be injected. Alcohol should be avoided because of the risk of intercostal neuritis after the block. Most clinicians now favor the use of radiofre-quency lesion of the intercostal nerves instead of injecting neurolytic medications because of the predictable lesion size of the radiofrequency probe. Radiofrequency lesion produces heat at the active tip of an insulated needle and causes destruction of the intercostal nerve.

Table 28.10 Technique of neurolytic intercostal nerve block.

Neurolytic intercostal nerve block

Position

Prone with patient ipsilateral arm hanging off the procedure table

Fluoroscopy use

Mandatory

Number of needles

One or more based on how many levels

Type of needle

22G 3.5 in. or insulated 21 G with 5 mm active tip if using radiofrequency lesion (see below)

Level of needle insertion

Posterior axillary line needle advanced perpendicular to the skin until the rib is contacted

Direction of the needle

Needle withdrawn, then the skin and subcutaneous tissues are retracted inferiorly and the needle advanced again perpendicular to the skin until the needle pass 2 mm deeper than the level of the ribs. Fluoroscopy confirmation is essential

Final position of the needle

Needle just passed the inferior border of the rib and the needle is perpendicular to the skin in the costal groove.

Complications

Possible complication of intercostal nerve block include pneumothorax and intercostal local anesthetic toxicity, which can occur during the diagnostic block and also during the infiltration of local anesthesia before radiofrequency lesioning. Post-procedure intercostal neuropathy may occur, which can be treated with transcutaneous electrical nerve stimulation (TENS) unit, transdermal lidocaine patch, or antiseizure medications.

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