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Intercostal Nerve Block
Rafael Vazquez, MD; Nicole Z. Spence, MD; James Taylor Lloyd, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • Intercostal nerve block (ICNB)
              • Intercostal nerve (ICN)
            • Synonyms

              • Rib block
              • ICNB
            • Definitions

              • Nerve block of ICN that results in somatic analgesia to anterolateral chest wall and upper midabdomen
                • Useful for acute &/or chronic pain of chest wall and abdomen
                • Can be performed under ultrasound guidance (USG) (most common) or fluoroscopic guidance (FSG)
                • ICNB lasts ~ 4 hours due to high vascularity of region
              • ICN originates as ventral ramus of spinal nerve as it emerges from vertebral foramen
                • Upon emerging from vertebral foramen, ventral ramus (ICN) travels between endothoracic fascia and superior costotransverse ligament/internal intercostal membrane
                • More distal at angle of rib, ICN travels between innermost intercostal muscle and internal intercostal muscle
                • It gives off 2 main branches
                  • Lateral cutaneous branch: Provides sensory innervation to lateral chest wall
                    • Emerges anterior to midaxillary line and divides into anterior and posterior branch
                  • Anterior cutaneous branch: Provides sensory innervation to anterior chest wall, including sternum
                    • Emerges lateral to sternum and divides into lateral and medial branch

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Findings and Reporting

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Expected Outcome

                              • Things to Do

                                • Things to Avoid

                                  OUTCOMES

                                  • Problems

                                    • Complications

                                      Selected References

                                      1. Baxter CS et al: Intercostal nerve block 2019
                                      2. Kang CM et al: Postoperative pain control by intercostal nerve block after augmentation mammoplasty. Aesthetic Plast Surg. 41(5):1031-6, 2017
                                      3. Hsieh MJ et al: Management of acute postoperative pain with continuous intercostal nerve block after single port video-assisted thoracoscopic anatomic resection. J Thorac Dis. 8(12):3563-71, 2016
                                      4. Gulati A et al: A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population. Pain Med. 16(4):802-10, 2015
                                      5. Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
                                      6. Hwang EG et al: Effectiveness of intercostal nerve block for management of pain in rib fracture patients. J Exerc Rehabil. 10(4):241-4, 2014
                                      7. Bhatia A et al: Review article: is ultrasound guidance advantageous for interventional pain management? A systematic review of chronic pain outcomes. Anesth Analg. 117(1):236-51, 2013
                                      8. Bhatia A et al: Comparison of anatomic landmarks and ultrasound guidance for intercostal nerve injections in cadavers. Reg Anesth Pain Med. 38(6):503-7, 2013
                                      9. Connelly NR et al: Use of ultrasound-guided cryotherapy for the management of chronic pain states. J Clin Anesth. 25(8):634-6, 2013
                                      10. Shankar H et al: Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections. Pain Pract. 10(4):312-7, 2010
                                      11. Akkaya T et al: Chronic post-surgical pain. Agri. 21(1):1-9, 2009
                                      12. Byas-Smith MG et al: Ultrasound-guided intercostal nerve cryoablation. Anesth Analg. 103(4):1033-5, 2006
                                      13. Doi K et al: Intercostal nerve block with 5% tetracaine for chronic pain syndromes. J Clin Anesth. 14(1):39-41, 2002
                                      14. Green CR et al: The role of cryoanalgesia for chronic thoracic pain: results of a long-term follow up. J Natl Med Assoc. 94(8):716-20, 2002
                                      15. Science Direct: Intercostal blocks for thoracic and abdominal surgery. https://doi.org/10.1016/S1084-208X(98)80007-4. Published January 1998. Reviewed November 2019. Accessed November 2019.
                                      16. Huang TT et al: Outpatient breast surgery under intercostal block anesthesia. Plast Reconstr Surg. 63(3):299-303, 1979
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Preprocedure

                                          • Procedure

                                            • Post Procedure

                                              • Outcomes

                                                TERMINOLOGY

                                                • Abbreviations

                                                  • Intercostal nerve block (ICNB)
                                                  • Intercostal nerve (ICN)
                                                • Synonyms

                                                  • Rib block
                                                  • ICNB
                                                • Definitions

                                                  • Nerve block of ICN that results in somatic analgesia to anterolateral chest wall and upper midabdomen
                                                    • Useful for acute &/or chronic pain of chest wall and abdomen
                                                    • Can be performed under ultrasound guidance (USG) (most common) or fluoroscopic guidance (FSG)
                                                    • ICNB lasts ~ 4 hours due to high vascularity of region
                                                  • ICN originates as ventral ramus of spinal nerve as it emerges from vertebral foramen
                                                    • Upon emerging from vertebral foramen, ventral ramus (ICN) travels between endothoracic fascia and superior costotransverse ligament/internal intercostal membrane
                                                    • More distal at angle of rib, ICN travels between innermost intercostal muscle and internal intercostal muscle
                                                    • It gives off 2 main branches
                                                      • Lateral cutaneous branch: Provides sensory innervation to lateral chest wall
                                                        • Emerges anterior to midaxillary line and divides into anterior and posterior branch
                                                      • Anterior cutaneous branch: Provides sensory innervation to anterior chest wall, including sternum
                                                        • Emerges lateral to sternum and divides into lateral and medial branch

                                                PREPROCEDURE

                                                • Indications

                                                  • Contraindications

                                                    • Getting Started

                                                      PROCEDURE

                                                      • Patient Position/Location

                                                        • Equipment Preparation

                                                          • Procedure Steps

                                                            • Findings and Reporting

                                                              • Alternative Procedures/Therapies

                                                                POST PROCEDURE

                                                                • Expected Outcome

                                                                  • Things to Do

                                                                    • Things to Avoid

                                                                      OUTCOMES

                                                                      • Problems

                                                                        • Complications

                                                                          Selected References

                                                                          1. Baxter CS et al: Intercostal nerve block 2019
                                                                          2. Kang CM et al: Postoperative pain control by intercostal nerve block after augmentation mammoplasty. Aesthetic Plast Surg. 41(5):1031-6, 2017
                                                                          3. Hsieh MJ et al: Management of acute postoperative pain with continuous intercostal nerve block after single port video-assisted thoracoscopic anatomic resection. J Thorac Dis. 8(12):3563-71, 2016
                                                                          4. Gulati A et al: A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population. Pain Med. 16(4):802-10, 2015
                                                                          5. Krediet AC et al: Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology. 123(2):459-74, 2015
                                                                          6. Hwang EG et al: Effectiveness of intercostal nerve block for management of pain in rib fracture patients. J Exerc Rehabil. 10(4):241-4, 2014
                                                                          7. Bhatia A et al: Review article: is ultrasound guidance advantageous for interventional pain management? A systematic review of chronic pain outcomes. Anesth Analg. 117(1):236-51, 2013
                                                                          8. Bhatia A et al: Comparison of anatomic landmarks and ultrasound guidance for intercostal nerve injections in cadavers. Reg Anesth Pain Med. 38(6):503-7, 2013
                                                                          9. Connelly NR et al: Use of ultrasound-guided cryotherapy for the management of chronic pain states. J Clin Anesth. 25(8):634-6, 2013
                                                                          10. Shankar H et al: Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections. Pain Pract. 10(4):312-7, 2010
                                                                          11. Akkaya T et al: Chronic post-surgical pain. Agri. 21(1):1-9, 2009
                                                                          12. Byas-Smith MG et al: Ultrasound-guided intercostal nerve cryoablation. Anesth Analg. 103(4):1033-5, 2006
                                                                          13. Doi K et al: Intercostal nerve block with 5% tetracaine for chronic pain syndromes. J Clin Anesth. 14(1):39-41, 2002
                                                                          14. Green CR et al: The role of cryoanalgesia for chronic thoracic pain: results of a long-term follow up. J Natl Med Assoc. 94(8):716-20, 2002
                                                                          15. Science Direct: Intercostal blocks for thoracic and abdominal surgery. https://doi.org/10.1016/S1084-208X(98)80007-4. Published January 1998. Reviewed November 2019. Accessed November 2019.
                                                                          16. Huang TT et al: Outpatient breast surgery under intercostal block anesthesia. Plast Reconstr Surg. 63(3):299-303, 1979