Intercostal Nerve Blocks: Anybody use this technique?

[EruditeDoc]

http://omicsonline.org/omoigui-diffusion-technique-of-intercostal-nerve-block-2155-6148.1000344.pdf

---

Members don't see this ad.

 

[Ducttape]

yes.

wasn't overly impressed, but it sure feels a lot "safer" than going below the rib margin.

interesting that they the post procedure pain score hours after the injection never went above 4 . ? observer bias...

 

[DOctorJay]

I do them under ultrasound and watch the pleura

 

[pastafan]

I use the technique but I place the needle on the lower border of the rib. Low n but my results have been good.

 

[hyperalgesia]

Anybody doing cryo for these?

 

[SeniorWrangler]

It sounds a lot safer but I wonder about efficacy and would like to see an RCT done by someone not named Omoigui.

Also, I wonder if you could get in trouble if you try to bill this as intercostal nerve block, since an independent reviewer looking at your procedure note might say it was a trigger point injection or "rib block" instead.

 

[NJPAIN]

I do them under ultrasound and watch the pleura

Do you use a "hockey stick" probe? I have found it a difficult with a standard linear probe. Someone mentioned a "Sh-long"(out of plane to in plane vs oblique??) axis approach to me once but I cant quite figure it out.

 

[DOctorJay]

No I use the linear and if necessary build a gel bridge to angle the probe to get the needle under it.


Sent from my iPhone using SDN mobile

 

[pmrmd]

US or fluoro and get under the rib.

 

[Ducttape]

one problem i have with this approach that i forgot to mention is that it gives no real prognostic value to me as to whether pulsed RFA would be beneficial or not.... im not going to pulse the rib...

 

[oreosandsake]

Do you use a "hockey stick" probe? I have found it a difficult with a standard linear probe. Someone mentioned a "Sh-long"(out of plane to in plane vs oblique??) axis approach to me once but I cant quite figure it out.

I'll post pics later today

 

[Gauss]

Do you use a "hockey stick" probe? I have found it a difficult with a standard linear probe. Someone mentioned a "Sh-long"(out of plane to in plane vs oblique??) axis approach to me once but I cant quite figure it out.

in plane, linear or hockey stick. in any other plane you will not see the needle tip position which is really the whole point of doing this under imaging. Lots of gel, standoff if needed.

 

[oreosandsake]

In-plane is safe, and you get direct needle visualization. as previously mentioned gel standoff is helpful.

if you use the oblique aka "sh-long" approach, it is OOP. You need to be very slow and deliberate and visualize the tissues dissect on the way down. it allows you to get the tip past the edge of the rib compared to perpendicular OOP approach. be generous with your local to see where your needle tip is located. some folks will stop at the inner intercostal layer and deposit large volume and rely on diffusion of the LA. the inner-most intercostal layer is very thin, so you are on thin ice when your needle tip is near it. I would not recommend the oblique approach as your first US-guided injection. the benefit of this approach is that it is a little easier to get the needle into the intercostal space underneath the probe when you do not have a hockey stick ( I don't own one). also, I have had patients that could not tolerate laying prone and lateral recumbent was my only option. the gel standoff doesn't stay on.


I start off with the probe cranial-caudal. the intercostal space is in the middle of the probe. look at your depth from skin to rib to intercostal muscle layers to pleura. this will give you safety. I direct the needle towards the superior rib and start dissecting with LA. be careful not to cross the beam too shallow. once I get to the external rib layer if I like my trajectory I'll keep going. sometimes will intentionally touch the inferior border of the rib before re-directing caudad.

 

[nvrsumr]

What is the benefit of oop? If posterior block just do a ttfesi and keep needle more lateral. Usually see contrast tracking lower rib margin. I do not see alot of true intercostal neuralgia. See alot of costochondritis from mva searbelt injury and do midaxillary or anterior blocks plus a us guided tp. Have done a number left anterior at T4-6ish and see the heart beating... cool.

 

[EruditeDoc]

It sounds a lot safer but I wonder about efficacy and would like to see an RCT done by someone not named Omoigui.

Also, I wonder if you could get in trouble if you try to bill this as intercostal nerve block, since an independent reviewer looking at your procedure note might say it was a trigger point injection or "rib block" instead.

Interesting thought. I was actually wondering how you might bill this as well.

 

[EruditeDoc]

US or fluoro and get under the rib.

I need to get an Ultrasound machine!

 

[EruditeDoc]

I use the technique but I place the needle on the lower border of the rib. Low n but my results have been good.

I currently don't have access to an Ultrasound machine which honestly sounds like the most safe method. Therefor it's the idea of not dropping someone's lung with this technique that is appealing.

 

[dhcofc]

Are you guys doing conventional RFA if patients have an excellent response to intercostal nerve blocks? If so, how?