Percutaneous Cryoneurolysis for Pain Control after Rib Fractures in Older Adults

Introduction: Older adults who sustain rib fractures have increased morbidity and mortality compared with younger counterparts. Early and adequate pain control is the cornerstone of management. Percutaneous cryoneurolysis of intercostal nerves (PCNIN) is an opioid-sparing, minimally invasive procedure that may improve outcomes in this population.

Methods: Older patients (≥≥ 65 years) who sustained fractures on ribs 3-9 inclusive, were ineligible for surgical stabilization, and had pre-procedure numeric pain scores ≥≥ 5 were selected and underwent CT-guided PCNIN within 72 hours of admission. Wilcoxon signed-rank tests were used to assess the differences in numeric pain scores before the intervention, at discharge, and at 30-day follow-up, as well as change in opioid use (morphine milligram equivalent, MME) during admission. Additional outcomes evaluated included procedure-related adverse events, hospital length of stay, and rib-specific readmission.  

Results: Thirty-eight patients underwent CT-guided PCNIN. The median (IQR) patient age was 74.5 (70, 83) years. The median (IQR) number of rib fractures was 4 (3,6). The median (IQR) hospital length of stay was 4 (3, 5) days. There were no reported procedure-related adverse events or rib-specific readmissions. Patients had significantly decreased numeric pain scores from pre-intervention to discharge (median (IQR) from 8 (7,9) to 5.5 (4,7), P<0.001) and additionally to 30-day follow-up (median (IQR) 2 (0,4), P<0.001) (Figure). There was no significant change in opioid use during admission: pre-intervention to discharge median (IQR) MME were 21.13 (11.25,39) to 26.36 (7.5,45), P=0.6663. 

Conclusion: PCNIN is a safe intervention for older patients with rib fractures resulting in effective pain control.