Cryoneurolysis of the Subcostal Nerve: A Technical Description and Case Report

Cryoneurolysis has been utilized for numerous persistent and intractable painful conditions, including phantom limb pain and postsurgical pain. Although there are reports on the effectiveness of cryoneurolysis in various regions, including the intercostal nerves, the subcostal nerve remains a common culprit of chronic pain for which the literature is scarce. Different modalities are commonly utilized to address subcostal neuropathic pain, such as non-opioid pharmacotherapy, including nonsteroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants, site-specific regional anesthesia, and radiofrequency ablation.However, the analgesia provided by these modalities is often inadequate or short-lived. Cryoneurolysis of the subcostal nerve remains largely unexplored and may provide a promising solution.Here, we present the first technical description of ultrasound and fluoroscopic guided percutaneous cryoneurolysis of the subcostal nerve and the case of a patient with 14 years of lower thoracic rib pain who failed multiple interventions but achieved complete pain resolution at the three-month follow-up through this procedure.

Ultrasound-Guided Cryoneurolysis for the Treatment of Painful Diabetic Neuropathy of the Foot: A Case Series

Diabetic peripheral neuropathy is one of the most common causes of chronic neuropathic pain. Treatment of peripheral neuropathy has been limited to either treating the underlying cause or using medications, such as tricyclic antidepressants and anticonvulsants, to manage the symptoms. In this case series, we report the use of ultrasound-guided percutaneous cryoneurolysis of the superficial peroneal nerves to treat diabetic neuropathy of the feet. This demonstrates the potential effectiveness and safety of using cryoneurolysis for painful peripheral diabetic neuropathy.

Ultrasound-Guided Percutaneous Cryoneurolysis for Perioperative Analgesia Following Major Lower Extremity Amputation: A Randomized, Participant- and Observer-Masked, Sham-Controlled Pilot Study

BACKGROUND

Extremity amputations are associated with pain in both the residual limb and the phantom limb. This pain, which is often debilitating, may be prevented by excellent perioperative pain control. Ultrasound-guided percutaneous cryoneurolysis is an analgesic modality offering pain control for weeks or months following surgery. This treatment has not been compared to the sham procedure for large nerves (e.g., femoral and sciatic) to provide preoperative analgesia. We therefore conducted a randomized, controlled pilot study to evaluate the use of this modality for the treatment of pain following amputation to (1) determine the feasibility of and optimize the study protocol for a subsequent definitive clinical trial; and (2) estimate analgesia and opioid reduction within the first postoperative weeks.

METHODS

A convenience sample of seven patients undergoing lower extremity amputation were randomized to receive either active cryoneurolysis or a sham procedure targeting the sciatic and femoral nerves in a participant-masked fashion. This was a pilot study with a relatively small number of participants, and therefore the resulting data were not analyzed statistically.

RESULTS

Compared to the participants who received sham treatment (n=3), those who underwent active cryoneurolysis (n=4) reported lower pain scores and decreased opioid consumption at nearly all time points between days one and 21 following amputation.

CONCLUSIONS

Ultrasound-guided percutaneous cryoneurolysis of the femoral and sciatic nerves prior to lower extremity amputation appears feasible and potentially effective. The data from this pilot study may be used to power a definitive randomized clinical trial.

Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review

Osteoarthritis of the knee is a prevalent condition that causes pain, discomfort, and disability that can severely impact the quality of life. This literature review aims to review the various interventional pain management techniques available to treat knee osteoarthritis. It analyzes the efficacy of various interventions such as intra-articular corticosteroids, prolotherapy, viscosupplementation, platelet-rich plasma, and genicular nerve blocks with radiofrequency ablation or cryoneurolysis. We searched databases for studies published in the past 20 years. A total of 37 articles were included. The literature supports the idea that a comprehensive treatment plan consisting of the various aforementioned techniques can provide relief for patients while delaying or avoiding joint replacement surgery.

Cryoneurolysis of alveolar nerves for chronic dental pain: A new technique and a case series

BACKGROUND

Chronic neuropathic dental pain has a poor prognosis with a low chance of significant spontaneous improvement. Local or oral therapies may be efficient, however short in terms of duration with potential side effects. Cryoneurolysis has been described to prevent acute postoperative pain or to treat some chronic pain conditions; however, application to dental orofacial pain has not been reported so far.

CASE SERIES

Following a positive diagnostic block on the corresponding alveolar nerve, neuroablation was performed using a cryoprobe on three patients suffering from persistent pain after a dental extraction and 1 after multiple tooth surgeries. The effect of treatment was assessed using a Pain Numeric Rating Scale (NRS) and determined by changes in medication dosage and quality of life at day 7 and 3 months. Two patients experienced more than 50% of pain relief at 3 months, 2 by 50%. One patient was able to wean off pregabalin medication, one decreased amitriptyline by 50%, and one decreased tapentadol by 50%. No direct complications were reported. All of them mentioned improvement in sleep and quality of life.

CONCLUSION

Cryoneurolysis on alveolar nerves is a safe and easy-to-use technique allowing prolonged neuropathic pain relief after dental surgery.

Ultrasound-controlled cryoneurolysis for peripheral mononeuropathies: a retrospective cohort study

Aim: Cryoneurolysis is a potential therapy for peripheral mononeuropathies, but randomized studies of its effects on the duration of pain reduction are lacking. Methods: This retrospective cohort study evaluated the analgesic effects of cryoneurolysis on patients with refractory peripheral mononeuropathy. We included 24 patients who underwent ultrasound-guided cryoneurolysis between June 2018 and July 2022. The daily maximum pain level was recorded using a numerical rating scale before and 1, 3 and 6 months after the procedure. Results: At 1 month, 54.2% of patients reported pain reduction of at least 30%. This percentage was significantly lower at 3 and 6 months (13.8 and 9.1%, respectively). Conclusion: Our results suggest that repeated cryoneurolysis may be a viable treatment for refractory mononeuropathy. Further investigations are needed.

Introduction to interventional radiology's role in palliative care for children with cancer: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

As palliative care continues to be an area of increasing emphasis in pediatric oncology programs, it is important to raise awareness about minimally invasive, image-guided procedures that can supplement more conventional palliative interventions, such as systemic analgesics, external beam radiation, and locoregional anesthesia. These procedures, when performed for appropriately selected patients, can often facilitate discharge from an inpatient facility, and help patients meet their end-of-life goals. This article specifically discusses three palliative procedures performed by interventional radiologists that can assist pediatric palliative care teams in: (a) percutaneous thermal ablation of painful bone metastases, (b) cryoneurolysis, and (c) tunneled drainage catheter placement for malignant pleural effusions and ascites.

Preoperative Cryoneurolysis for Total Knee Arthroplasty: A Case Series

PURPOSE

The purpose of this pilot project case series is to describe the use of preoperative cryoneurolysis for 10 patients presenting for total knee arthroplasty (TKA).

DESIGN

Descriptive research design.

METHODS

Billing codes were used to identify 10 patients who had previously undergone TKA, preoperative cryoneurolysis and physical therapy (PT) at a Midwestern community hospital. Data collected included anesthetic management strategies, multimodal analgesic therapies, postanesthesia care unit pain scores (PACU), pain scores during physical therapy, and achievement of a range of motion during physical therapy.

FINDINGS

Nine of 10 patients who received preoperative cryoneurolysis had PACU pain scores of 0 (0-10 scale) up to 90 minutes postoperatively. Pain scores immediately following cryoneurolysis therapy were reduced in all patients reporting pain greater than 0 (1-10 pain scale) before their treatment. Increased active range of motion trends were noted with reports of decreased pain scores during postoperative physical therapy sessions.

CONCLUSIONS

This pilot project case series demonstrates potential benefits of using preoperative cryoneurolysis to provide postoperative pain control and aid with physical therapy recovery following TKA.

The applications of cryoneurolysis for acute and chronic pain management

BACKGROUND

Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting.

APPLICATION

Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain.

CONCLUSION

The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.

Ultrasound-Guided Percutaneous Intercostal Cryoneurolysis for Acute-on-Chronic Pain in CLOVES Syndrome

Cryoneurolysis is an analgesic method that has been shown to provide extended pain relief in postoperative patients. However, to date, this method has not been described in nonsurgical inpatients with chronic pain experiencing an acute exacerbation. This analgesic modality has the potential to provide pain relief for patients whose expected duration of severe acute pain would outlast that of other regional anesthetic techniques while avoiding opioid escalation and facilitating discharge. We present a patient with acute exacerbation of chronic pain from breast ulcerations caused by congenital lipomatous overgrowth, vascular malformations, epidermal nevis, spinal/skeletal anomalies/scoliosis (CLOVES) syndrome that was successfully treated as an inpatient with a portable cryoneurolysis device.  This is the first reported use of cryoneurolysis in an inpatient setting to treat acute-on-chronic pain in a nonsurgical patient. The authors recommend regional anesthesiologists and acute pain specialists to utilize this technique to provide analgesia in patients with complex pain to facilitate hospital throughput.

Ultrasound-Guided Percutaneous Cryoneurolysis for Post-Thoracotomy Pain Syndrome: A Case Report

Post-thoracotomy pain syndrome (PTPS) is a post-operative thoracotomy complication that is difficult to treat. We describe the first-time use of ultrasound-guided percutaneous cryoneurolysis of the intercostal nerves to successfully treat PTPS refractory to conventional medications and interventions. We report a case of a 40-year-old male with two years of severe PTPS sustained after undergoing a thoracotomy. Treatment with intercostal cryoneurolysis resulted in an immediate 75% improvement in pain for six weeks followed by sustained 50% pain relief for eight weeks. This highlights the potential of this intervention as a radiation-free, safe, and efficacious therapy for chronic PTPS.

Cryoneurolysis of Intercostal Nerve for Rib Trauma and Intercostal Neuralgia in the Emergency Department: A Multidisciplinary Approach

BACKGROUND

Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae.

CASE REPORT

We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

Safety and Efficacy of Genicular Nerve Radiofrequency Ablation for Management of Painful Total Knee Replacement: A Systematic Review

Painful total knee replacement (TKR) without an obvious underlying identifiable pathology is not uncommon. Dissatisfaction after TKR can be up to 20%. Different treatment modalities, including non-operative and operative procedures, have been described in the literature. Radiofrequency ablation of genicular nerves (GNRFA) is emerging as a newer treatment modality for painful TKR without an obvious underlying identifiable pathology. Despite a modest number of publications demonstrating the usefulness of GNRFA in managing pain in knee osteoarthritis, the efficacy of GNRFA has not been completely established in the management of residual pain after TKR. This systematic review aimed to analyze all published studies (nine studies) on GNRFA as an option to manage residual pain after TKR. Based on this current systematic review, we noted that GNRFA is a modality to treat post residual pain and patients can anticipate improvement in pain up to three months with minimal complications. This article provides an overview of the currently available knowledge and techniques employed for this procedure, as well as the expected outcome and safety profile of GNRFA in painful TKR.

Successful treatment of complex regional pain syndrome type 1 of upper limb with cryoneurolysis of the stellate ganglion: A rare case report

Complex regional pain syndrome type I (CRPS I) is a multifactorial condition that is related to neural damage, and leads to chronic neuropathic pain. Due to its multifactorial nature, there are many methods that have been recruited for its management. Most of them limit the symptoms to some degree, but the most effective of them so far seems to be blockade of the sympathetic innervation of the region. We present the case of a 71-year-old woman, with an upper limb fracture which was treated conservatively, and later on developed CRPS type I. Analgesic medications and pregabalin were ineffective in controlling her symptoms. Blockade of the stellate ganglion was performed with local anesthetic and dexamethasone. After the stellate ganglion blockade was marked as successful in relieving her symptoms, cryoneurolysis was performed which was very effective. There are not many cases that have been treated with cryoneurolysis, and this is what makes this case interesting.

Percutaneous cryoneurolysis for acute pain management: current status and future prospects

Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.

Cryoneurolysis for cervicogenic headache - a double blinded randomized controlled study

Background and aims Cervicogenic headache (CEH) is a debilitating condition and analgesics have limited effect. Percutaneous cryoneurolysis is thus still in use although the clinical evidence is lacking. We present a randomized, controlled study to assess the clinical efficacy of cryoneurolysis compared with a corticosteroid combined with a local anaesthetic. Methods In a university-based outpatient pain clinic we performed a randomized, double blinded, comparative study with an 18-week follow-up. After positive diagnostic test blocks 52 eligible patients were randomly allocated in a ratio of 3:2, 31 participants to occipital cryoneurolysis and 21 participants to injections of 1 mL methylprednisolone 40 mg/mL (Depo-Medrol®) combined with 1 mL bupivacaine 5 mg/mL. Results We observed a significant pain reduction of more than 50% in both treatment groups, slightly improved neck function and reduced number of opioid consumers. After 6-7-weeks, however, pain intensity increased gradually, but did not reach baseline within 18 weeks. Although cryoneurolysis provided a more prolonged effect, the group differences did not reach statistical significance. Health related quality of life and psychological distress improved minimally. A large number reported minor and transient side effects, but we found no significant group differences. After 18 weeks, 29% rated the headache as much improved, and 12 (24%) somewhat improved, but a large proportion (78%) reported need for further intervention/treatment. Conclusions Cryoneurolysis provided substantial, but temporary pain relief, and the effect was not significantly different from injections of a corticosteroid combined with a local anaesthetic. Participants were selected by a single test block, and the neurolytic procedure was guided by anatomical landmarks and nerve stimulation. A stricter patient selection and an ultrasound-guided technique might have improved the results. Cryoneurolysis provides temporary pain relief not significantly superior to corticosteroid injection, and the results question the value of occipital cryoneurolysis for a chronic pain condition like CEH. Implications Occipital cryoneurolysis may be considered when non-invasive treatments appear insufficient, but only for patients who have responded substantially to test blocks. A risk of local scar and neuroma formation by repeated cryoneurolysis, leading to neuropathic pain has been discussed by other researchers.

Interventional Cryoneurolysis: What Is the Same, What Is Different, What Is New?

Cryoneurolysis is the deliberate application of cold temperatures to nerves for therapeutic purposes. The idea of treating pain with this technique is thousands of years old and has evolved over time through the application of surgical techniques, nerve stimulation and/or landmark guidance, and through device development. Recent integration of the interventional radiology skill set to this space has unlocked a myriad of opportunities-primarily through a unique ability to percutaneously access deep structures in the body with accuracy and precision, and the capacity to monitor ablation zones. Understanding of the specific neurohistological process that follows targeted cryoneurolysis leads to new options for treating patients in pain without drugs and opens doors for the potential modification of a wide array of disease states.

Case Report Of Cryoneurolysis For The Treatment Of Refractory Intercostobrachial Neuralgia With Postherpetic Neuralgia

Postherpetic neuralgia is a common and potentially debilitating neuropathic pain condition. Current pharmacologic therapy can be inadequate and intolerable for patients. We present a case of a gentleman with refractory postherpetic neuralgia in the intercostobrachial nerve distribution that was successfully treated with cryoneurolysis/cryoanalgesia therapy.

Cryoneurolysis for the Treatment of Sensory Nerve Pain

Acute and chronic pain account for high costs both societally and economically, estimated in the United States to be $635 billion. Untreated or undertreated acute pain is associated with substantial morbidity and may become chronic pain. Surgical patients are at an increased risk of long-term opioid use or addiction. Overdose from drugs of abuse, including opioids, is the leading cause of death due to injury in the United States. Traditional pain management strategies for acute and chronic pain have focused on opioid medications, which are often associated with severe side effects. Cryoneurolysis is a minimally invasive, nonsurgical, nonpharmacologic pain management technique that uses cold temperatures to ablate the sensory nerves that cause pain. Because of its safe and reversible nature, cryoneurolysis should be considered as part of a multimodal pain management plan in patients experiencing pain originating from sensory nerves.

Cryoneurolysis for the treatment of cervical facet joint syndrome: a technical note

Objective

Neck pain has an annual prevalence of 30%. A frequent cause of neck pain is cervical facet joint pain. In cases of refractory cervical facet joint pain, radiofrequency can be employed, but the grade of evidence attested in systematic reviews is fair. Cryoneurolysis has been reported to induce favorable outcomes in lumbar facet joint pain. We sought to examine the feasibility of cervical facet joint cryoneurolysis.

Setting

Tertiary academic pain center.

Patients and methods

We report here the operative technique of cervical facet joint cryoneurolysis for patients with cervical facet joint pain. The procedure is performed under CT-guidance. The lesion points are defined with the help of sensory stimulation.

Results

Six cervical facet joint denervations were carried out in five patients. All patients had an uneventful course with adequate pain relief. Apart from soreness of the paravertebral muscles no severe side effects were encountered.

Conclusion

This is the first report of cryoneurolysis for the treatment of cervical facet joint pain. The technique is feasible and warrants further studies.

What is new in pain modification in osteoarthritis?

There is a big need for the development of novel therapies for the safe management of chronic pain associated with OA. Here we reviewed PubMed (2015 onward) and ClinicalTrials.gov for ongoing and recently completed trials where pain in OA is the primary outcome measure. Three broad categories were identified: biological therapies, small molecules and cryoneurolysis. The most promising new strategy is blockade of nerve growth factor with antibodies. Two anti-nerve growth factor antibodies, tanuzemab and fasinumab, are in active development after the 2010 hold on trials was lifted in 2015. In addition, several active clinical trials are testing distinct mechanism-based interventions, including cytokine inhibition, selective μ, δ or κ opioid receptor agonists, zoledronate and intra-articular capsaicin. In addition to pharmacological approaches, cryoneurolytic strategies that directly target peripheral nerves may play a role in OA pain management, but efficacy profiles and long-term effects of such treatments need more study. Clearly, the therapeutic landscape for OA pain is rapidly expanding. Since symptomatic OA is a heterogeneous disease, the challenge will be to identify patients that will benefit the most from specific approaches.

Percutaneous cryoanalgesia in pain management: a case-series

BACKGROUND

Cryoanalgesia, also known as cryoneuroablation or cryoneurolysis, is a specialized technique for providing long-term pain relief.

METHOD

We present here retrospective data on pain relief and changes in function after cryoanalgesia techniques: we describe the effect of this procedure on articular facet syndromes, sacroiliac pain and knee pain.

RESULTS

We reviewed the records of 18 patients with articular lumbar facet pain, knee pain and sacroiliac pain. The Visual Analog Scale and Patient's Global Impression of Change scale show satisfaction at 1 month after cryoablation, with the best scores after three months. Only three patients showed a worse condition than the first month.

CONCLUSION

The majority of patients experienced a clinically relevant degree of pain relief and improved function following percutaneous cryoanalgesia.