Nerve blocks have been invaluable in pain management for many years, drastically reducing potentially traumatic pain by intercepting it at its origin point: the nerves throughout our body that connect back to the brain. A nerve block is, in its simplest form, a very precise and small injection of medication, applied in the surrounding area of a nerve.
Nerves are present almost everywhere but are especially 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 greatly 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 a variety of different conditions involving immense and debilitating amounts of pain, from rib fractures to cervicothoracic angina, chronic chest wall pain, costochondritis, and more.
What Are Intercostal Nerves?
Intercostal nerves innervate the upper chest, connecting to the spinal cord and branching out from several vertebrae in the upper back through the ribs. The intercostal nerves span from the spine to the chest, near the sternum. Alongside the phrenic, vagus, and subcostal nerves, intercostal nerves are a major part of the nerve complex of the thorax.
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.
The Role of Intercostal Nerve Blocks in Pain Management
Pain management in the thorax is not just a matter of comfort, although comfort is more important than many might realize. Pain 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, which can be caused by the perception of extreme acute pain.
Pain itself is more than just a symptom, it can also become a causal factor. Several factors not only make pain worse but are the product of pain. Through untreated pain, patients may develop a series of both physical and mental health conditions, and pain management is important to ensure a patient’s long-term health and prevent permanent damage to the nervous system.
Administered by Injections
The basic step-by-step process for any nerve block is the same. A patient is diagnosed, and part of their treatment prescribes a nerve block, either for pain management or to prepare for an 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) get pulled 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 either an anesthetic, a minor opioid, or a steroid. 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. Both the amount and frequency of the injections depends on the purpose of the injection and the intensity of the pain, as well as the patient’s reaction to the first injection.
A 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 as well as the patient’s physiology.
There are a few risks surrounding intercostal nerve blocks. While nerve blocks are not as risky as more invasive treatments, they are not to be taken very lightly either. While there are no common side effects, there are a few side effects that may occur such as temporary spinal headaches (if the fluid sac around the spinal cord is accidentally punctured) and, if not cared for properly, and infection at the injection site.
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 to refrain from any physical labor or strenuous physical effort within the next few days.
Non-Ideal Treatment Candidates
Intercostal nerve blocks are primarily used in the management of onset chest pain, often after a surgical incision, injury, or shingles, or in some cases, before a procedure. However, there are contraindications preventing certain people from utilizing an intercostal nerve block.
If you are allergic to any of the drugs typically injected in an intercostal nerve block, if you’re currently fighting a serious infection, if you are on blood thinning medication or struggle with severe and acute symptoms of heart disease and/or diabetes, it is generally recommended to postpone an intercostal nerve block until your condition improves/explore alternatives. While a collapsed lung is rare, some individuals with respiratory problems and poor lung function may opt not to have an intercostal nerve block injection to avoid the possibility of a collapsed lung.
Follow up is normal after any medical intervention, and in the case of pain management, it’s crucial to encourage a patient to catalogue their thoughts and feelings. A pain diary can help a medical professional properly assess the efficacy of any given treatment, including a nerve block.
If no complications arise, you’re good to continue living your life normally within a few days, and as long as work isn’t strenuous, you can typically get back to work within a day.