Intercostal nerve blocks for Pain Relief
Nerves are present almost everywhere but are incredibly densely packed within our limbs and extremities and around major organs. In cases of acute, subacute, and chronic pain, a well-planned nerve block can do a lot to significantly reduce a patient’s discomfort as their body heals or give them the relief they need to continue working on their pain management in cases of chronic pain. Among many viable sites, intercostal nerves are common targets for nerve blocks due to various conditions involving immense and debilitating amounts of pain, from rib fractures to cervicothoracic angina, chronic chest wall pain, costochondritis, and more.
People who suffer from chronic pain or injuries that cause intense and constant pain need to schedule an appointment with PMIR for an intercostal nerve block at their earliest convenience.
Internal Cutaneous Branches of the Thoracic Nerves (T1-11)
The intercostal nerves, also known as the internal cutaneous branches of the thoracic nerves (T1-11), are a pair of nerves found within the rib cage of humans. They provide sensory innervation to the skin of the lateral chest wall and motor innervation to the muscles in between each rib.
An intercostal nerve block can help patients by numbing the pain they feel in their region of choice during specific medical procedures such as; fracture repair, tumor resection, rib fractures repair, and even delivery under local anesthesia, among many others.
Epidural Vs. Transverse Process Approach
An intercostal nerve block can be performed with both an epidural approach (penetrating the thoracic cavity) or a transverse process approach (from outside the rib cage), however; it’s important to note which technique is required as the epidural approach has a higher risk and cannot be used during pregnancy and in patients with bleeding disorders.
According to some reports, the transverse approach is ideal for providing analgesia through the T4 to T9 dermatomes (T4 – 9 specific nerves); however, it can extend down to at least T8. The technique is performed by using the pectoralis major muscle as a landmark for finding the T4 vertebrae, then puncturing at this location with an 18g pencil-point needle.
What Are Intercostal Nerves?
Alongside the phrenic, vagus, and subcostal nerves, intercostal nerves are a significant part of the nerve complex of the thorax. The intercostal nerves span from the spine to the chest, near the sternum. Intercostal nerves innervate the upper chest, connecting to the spinal cord and branching out from several vertebrae in the upper back through the ribs.
In practical terms, intercostal nerves are targeted to help manage chest pain, particularly pain within the walls of the chest, including pain caused by damage to the nerves or damage to the surrounding tissues, such as fractured or broken ribs and inflammation within the chest wall.
More than Just a Symptom
Pain relief in the thorax is not just a matter of comfort, although comfort is more important than many might realize. Pain relief and management through intercostal nerve blocks can prevent the onset of certain post-operative and post-traumatic complications, including atelectasis and pneumonia. Intercostal nerve blocks can also prevent the onset of chronic pain caused by the perception of extreme acute pain.
Pain is more than just a symptom; it can also become a causal factor. Several factors make the pain worse and are the product of pain. Patients may develop a series of physical and mental health conditions through untreated pain, and pain relief/management is essential to ensure a patient’s long-term health, pain relief, pain management, and prevent permanent damage to the nervous system.
Intercostal nerve injuries are relatively rare compared to other serious injuries but can occur during major surgeries or traumas to the chest, pelvis, ribs, spine, and upper arms. They are most commonly seen after accidents that result in fractures of the cervical vertebrae or lumbar spine.
Administered by Injections
An intercostal nerve block is a regional anesthesia technique. A local anesthetic injection is given to numb areas such as the lower dorsal side (including lumbar regions), groin, buttock, and lateral thigh. Intercostal nerve blocks are not confused with the intrapleural technique where a catheter is placed between two adjacent ribs or within the parietal pleura.
The Basic Step-by-Step Process for a Nerve Block
- A patient is diagnosed, and part of their treatment prescribes a nerve block, either for pain relief or to prepare for invasive surgery.
- Then, through an x-ray machine and a blunt needle, a contrast liquid is introduced into the area in the body with the nerve that is being targeted. In this case, a patient is typically injected in the upper back. The patient is asked to lean forward in a seated position, sometimes holding onto something.
- The patient is asked to relax, letting the scapulae (shoulder blades) pull towards the chest. Then, using a marker, a doctor marks the various points along the patient’s back and ribs where the needle may be injected.
- A local anesthetic is applied to numb the injection, and through the contrast liquid and the x-ray, a doctor can have a much clearer image to help guide the next needle through the tissue to the proper location for the nerve block.
- The medication injected into the nerve region is typically an anesthetic, a minor opioid, or asteroid. Both the amount and frequency of the injections depend on the purpose of the injection and the intensity of the pain, and the patient’s reaction to the first injection. A single-shot intercostal nerve block, for example, may include “bupivacaine 0.25–0.5 percent, lidocaine 1–2 percent with epinephrine 1/200,000–1/400,000, and ropivacaine 0.5 percent,” although some injections will vary.
Temporary Soreness After Nerve Blocks
An intercostal nerve block may cause temporary soreness, and hospitals often recommend that patients ice the injection site. However, the effects should ideally be analgesic and last anywhere from 6 to 18 hours for the first injection, depending on the dosage and the patient’s physiology.
There are a few risks surrounding intercostal nerve blocks. While intercostal nerve blocks are not as risky as more invasive treatments, they are not to be taken very lightly either. A few side effects may occur, such as temporary spinal headaches (if the fluid sac around the spinal cord is accidentally punctured). If not cared for properly, an infection may develop.
The main concern – although still rare – is a pneumothorax (collapsed lung); occurring in roughly 1 percent of cases, a pneumothorax may occur after an intercostal nerve block. It’s usually recommended for patients to lie back and rest after an intercostal nerve block and refrain from any strenuous physical effort within the next few days.
Nerve Blocks Treatment Candidates
Symptoms of intercostal nerve injury may be mild, moderate, or severe. They may include tingling; pain; numbness; loss of sensation in the skin and underlying tissues; muscle weakness; decreased strength in the arms or legs; partial paralysis (in more severe cases); burning pain around the chest area, including between the shoulder blades; decreased motion of the affected side of the body; and chest pain.
Intercostal nerve injury is diagnosed using medical history, physical exam, electromyography (EMG), imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, and blood tests. Intercostal nerve injuries are not often diagnosed early, and the exact mechanisms of injury are not always identified, though it is usually possible to determine the likely cause. Intercostal nerve injuries can be mild or severe and may result in permanent disability if not correctly diagnosed and treated. Intercostal nerve blocks are primarily used in the management of onset chest pain after a surgical incision, injury, or shingles. In some cases, before a procedure. However, there are contraindications preventing certain people from utilizing an intercostal nerve block.
Who Should Not Have Nerve Block Treatment?
It is generally recommended to postpone an intercostal nerve block until your condition improves/explore alternatives if:
- You are allergic to any drugs typically injected in an intercostal nerve block.
- You’re currently fighting a severe infection.
- You are on blood-thinning medication or struggle with severe and acute symptoms of heart disease or diabetes.
A collapsed lung is rare, but some individuals with respiratory problems may opt not to have an intercostal nerve block injection to reduce risk.
It’s crucial to encourage a patient to catalog their thoughts and feelings. A pain diary can help a medical professional properly assess the efficacy of any given treatment, including a nerve block. Follow-up is expected after any medical intervention and in the case of pain relief and management.
If no complications arise, you’re good to continue living your life normally within a few days. As long as work isn’t strenuous, you can typically get back to work within a day.
People with chronic pain should consider an intercostal nerve block as a solution, but they need to talk to their doctor first about what treatment options are best for them. If a collapsed lung is a risk, then that person needs to consider their options, but if not, then an intercostal nerve block can be a very effective solution for pain management for acute pain.