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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 176-178

Ultrasound-guided radiofrequency ablation in a patient with resistant intercostal neuralgia secondary to chronic osteomyelitis of anterior end of ribs


Department of Anaesthesiology and Pain Management, Sir. H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission19-Feb-2020
Date of Decision21-Feb-2020
Date of Acceptance25-Mar-2020
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Sheetal Shah
319, Vaishali Apt, 30/31 Parekh Street, Prarthana Samaj, Mumbai - 400 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_22_20

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  Abstract 


Intercostal neuralgia is a complex painful disorder characterized by intense, sharp shooting, or burning pain, along the distribution of intercostal nerve. It is difficult to treat condition in which pharmacological modalities of treatment often fail. We report a case of a 56-year-old female with postoperative sternal wound infection, following coronary artery bypass grafting, involving the left costochondral junction and left anterior ends of 7th, 8th, and 9th ribs. She presented with severe excruciating pain over left T7, T8, and T9 dermatomes for 3 months. Conservative management failed to provide significant improvement in pain relief. Hence, intercostal nerve block was performed and it provided good pain relief for 3 weeks. It was then followed by radiofrequency ablation (RFA) that provided good symptomatic pain relief at 9-month follow-up. Thus, ultrasound-guided RFA can be effectively and safely used in patients suffering from resistant intercostal neuralgia for providing quick and long-term pain relief.

Keywords: Deep sternal wound infections, intercostal neuralgia, osteomyelitis of rib, ultrasound-guided radiofrequency ablation


How to cite this article:
Kale N, Shah S, Mehta H. Ultrasound-guided radiofrequency ablation in a patient with resistant intercostal neuralgia secondary to chronic osteomyelitis of anterior end of ribs. Indian J Pain 2021;35:176-8

How to cite this URL:
Kale N, Shah S, Mehta H. Ultrasound-guided radiofrequency ablation in a patient with resistant intercostal neuralgia secondary to chronic osteomyelitis of anterior end of ribs. Indian J Pain [serial online] 2021 [cited 2021 Nov 30];35:176-8. Available from: https://www.indianjpain.org/text.asp?2021/35/2/176/325203




  Introduction Top


Deep sternal wound infections secondary to median sternotomy in cardiac surgery range from 0.5% to 6.8%.[1] Sternal wound osteomyelitis spreading along the costochondral junctions and ribs leads to excruciating chronic pain.[2] Neuropathic pain arises from inflammatory process resulting in bone destruction and sequestrum formation involving the intercostal nerves and is characterized by intense sharp and shooting or burning pain. Despite the several treatment options for intercostal neuralgia including medical management, nerve blocks, cryoablation, and radiofrequency ablation (RFA), it is challenging condition to treat.[3]

Ultrasound-guided RFA is a minimally invasive technique which involves heat generated from medium-frequency alternating current (250–500 kHz) and is used to induce cell death from coagulation necrosis. We report a successful management of intercostal neuralgia in a patient with chronic osteomyelitis of anterior ends of ribs, resistant to conservative treatment, using ultrasound-guided RFA.


  Case Report Top


A 56-year-old female, known case of diabetes mellitus and hypothyroidism, presented to our department with sharp stabbing pain (numeric rating scale [NRS] - 8/10), hyperalgesia, and severe allodynia over the left T7, T8, and T9 dermatomes extending from posterior axillary line to mid clavicular line for 3 months. She had a history of coronary artery bypass grafting done 7 months ago. Subsequently, she developed postoperative sternal wound infection, for which she underwent debridement twice followed by secondary suturing with pectoralis major muscle flap. Her computed tomography scan of the chest was suggestive of inflammatory changes around the sternotomy wound along with chronic osteomyelitis involving the left 7th, 8th, and 9th costochondral junction and anterior ends of the rib. Her pain was refractory to conservative measures including nonsteroidal anti-inflammatory drugs and antineuropathic medications. The patient underwent diagnostic left 7th, 8th, and 9th intercostal nerve blocks with significant resolution of pain (NRS - 2/10) for 3 weeks. She returned after 3 weeks with similar complaints with NRS 6/10. To provide prolonged pain relief, we performed ultrasound-guided RFA of the left 7th, 8th, and 9th intercostal nerves [Figure 1]. At her 1-month follow-up visit, the patient reported remarkable relief of pain (NRS - 6/10). The patient continued to report good pain relief for >9 months and did not need to seek any other modalities for pain management.
Figure 1: Ultrasound-guided intercostal nerve radiofrequency ablation. Probe positioned longitudinal over the T7 intercostal space

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Procedure

Procedure was duly explained to the patient with potential benefits and risks involved in her own language and the informed consent was taken. The patient was taken on the operation theater table with all resuscitation equipment kept ready for any complications (pneumothorax). Monitors were attached and a 22G intravenous cannula was secured. The procedure was done with the patient in the right lateral position with arms resting over a support. The lateral aspects of the left side of the chest was cleaned with antiseptic solution and draped. The site of injection was visualized with the high-frequency (6–13 Hz) linear ultrasonography (USG) probe.

After infiltrating the skin with 2% lignocaine 1 mL, 5 cm long straight RF cannula with 5 mm active tip was advanced under USG guidance into the intercostal space between the ribs. This position was confirmed by instilling small amounts of normal saline which was seen pushing the pleura downward. Then, final position was identified by eliciting paresthesia at the site of pain by stimulating at 50 Hz current of 0.5 mV. After negative aspiration of blood or air, lidocaine (1 mL of 2%) was injected through the RF cannula before activation of the RF generator. The RF electrode was then inserted through the RF cannula, and the conventional RF treatment was done for 70 s at 60 and 70 temperatures at 7th, 8th, and 9th intercostal nerves by Cosman RFG-1B RF generator (Cosman Medical, Inc., Burlington, Massachusetts, USA). The patient was observed for about 2 h for any immediate complications.


  Discussion Top


Sternal wound osteomyelitis secondary to cardiac surgery is a serious complication and severely affects the quality of life of the patient. Risk factors for deep sternal wound infections involves diabetes causing microcirculation dysfunction and tissue hypoxia, internal mammary artery transplantation which reduces more than 90% of the blood supply to the ipsilateral sternum, long surgery time, inadequate drainage of postoperative blood, leading to accumulation behind sternum, loose sternal fixation, and poor health and nutrition.[4]

Chronic sternal pain after cardiac surgery most often arises from traumatic or inflammatory nerve injury which results in neuropathic pain.[5] Chronic pain in osteomyelitis of the ribs is secondary to the inflammation and destruction of bone causing periosteum distortion, pressure on endosteum, intercostal neuritis, or nerve root compression.[6]

In our case report, RFA has been effective in management of intercostal neuralgia secondary to osteomyelitis of the ribs. Radiofrequency had been found to be useful for pain arising out of cervical and lumbar facet joints, sacroiliac joint, and trigeminal neuralgia. The literature on RF of intercostal nerve is very limited.

Ahmed et al.[7] performed ultrasound-guided radiofrequency treatment of intercostal nerves for the prevention of incidental pain arising due to rib metastasis. They concluded that after the RF treatment, there was more than 50% decrease in both intensity and frequency of breakthrough pain in more than 50% of patients for 3 months, and there was more than 50% decrease in BTP opioid dose in more than 50% of patients throughout the study period. There was also significant improvement in background pain, functional status, and the quality of life after the RF.

Abd-Elsayed et al.[8] performed thermal RFA for treating resistant intercostal neuralgia in two patients. They concluded that the first patient with intercostal neuralgia secondary to lumpectomy for breast cancer surgery had excellent improvement in pain for more than 1 year and second patient with lung cancer and post thoracotomy pain, had complete resolution of pain at 2-month follow-up after RFA.

Thermal RFA is a minimally invasive procedure performed in outpatient settings under local or conscious sedation anesthesia and is well tolerated by most patients. Thermal RFA has the advantage to relieve pain for longer duration and avoid the innumerable side effects associated with polypharmacy to treat intercostal neuralgia. It also prevents the disability associated with socioeconomic and psychological outcomes due to chronic pain. Although we did not encounter any adverse effects, thermal RFA is associated with risk of infections, bleeding, and lung puncture, resulting in pneumothorax. RFA under USG guidance provides increased safety during intercostal nerve block by correct needle placement, decreased rate of complications, and decreased time of the procedure.[9]

Further research and large-scale studies are warranted to understand the indications and implications of using thermal RFA in the intercostal neuralgia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015;4:265-73.  Back to cited text no. 1
    
2.
Ucak A, Onan B, Sen H, Selcuk I, Turan A, Yilmaz AT. The effects of gabapentin on acute and chronic postoperative pain after coronary artery bypass graft surgery. J. Cardiothorac Vasc Anesth 2011;25:824-9.  Back to cited text no. 2
    
3.
Dureja GP. Intercostal neuralgia: A review. J Neurol Transl Neurosci 2017;5:1076  Back to cited text no. 3
    
4.
Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: A prospective, multicenter study. J Thorac Cardiovasc Surg 1996;111:1200-7.  Back to cited text no. 4
    
5.
Moon MH, Kang JK, Kim HW, Jo KH, Choi SH, Song H. Pain after median sternotomy: Collateral damage or mitigatable byproduct? Thorac Cardiovasc Surg 2013;61:194-201.  Back to cited text no. 5
    
6.
Panteli M, Giannoudis PV. Chronic osteomyelitis: What the surgeon needs to know. EFORT Open Rev 2016;1:128-35.  Back to cited text no. 6
    
7.
Ahmed A, Bhatnagar S, Khurana D, Joshi S, Thulkar S. Ultrasound-guided radiofrequency treatment of intercostal nerves for the prevention of incidental pain arising due to rib metastasis. Am J Hosp Palliat Care 2017;34:115-24.  Back to cited text no. 7
    
8.
Abd-Elsayed A, Lee S, Jackson M. Radiofrequency Ablation for treating resistant intercostal neuralgia. Ochsner J 2018;18:91-3.  Back to cited text no. 8
    
9.
Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence-based medicine: Ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010;35:S36-42.  Back to cited text no. 9
    


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