Intercostal nerve block is the injection of local anesthetic into the costal groove or its vicinity to block the intercostal nerves running there for the purpose of analgesia in the chest and abdominal wall. Evidence-based medicine evidence recommendation level A1a.
Case introduction and outcome:
patients, Female, 55 years old, hospital number 454973, diagnosed with intercostal neuralgia, after lung cancer surgery. The patient suffered from left pulmonary nodular left lobectomy 2 years ago. After the operation, the patient developed pain at the incision. The pain channel was located in the left anterior axillary line, between the 5th and 6th intercostal space. The pain was acupuncture, accompanied by a burning sensation on the skin. VAS 4-5 points, the symptoms of oral Sanlitong have not been relieved significantly, and “closed treatment” has been performed, but the symptoms have not been significantly relieved. Physical examination: There is a 1.5cm long scar on the left 5th and 6th intercostal space and anterior axillary line. There is no redness and swelling, no elevated skin temperature, and no tenderness (-). 2019-8-27 The right 5th intercostal nerve radiofrequency treatment + serratus anterior muscle block was performed. The patient’s pain symptoms were relieved after the operation, and the VAS score was 2-3 points. There was no recurrence of symptoms after 2 weeks of follow-up.
1. Anatomy
Intercostal nerves are 12 Anterior branch of the thoracic nerve, mainly distributed in the chest wall and abdominal wall. The upper 2 pairs of thoracic nerves distribute to the upper extremities in addition to the chest wall, 3-6 pairs of intercostal nerves distribute only to the chest wall, 7-11 pairs of intercostal nerves distribute to the chest wall and abdominal wall, and subcostal nerves distribute to the skin of the abdominal wall and buttocks. The intercostal nerve emerges from the paravertebral body and then travels in the corresponding costal groove and travels with the intercostal blood vessels. During the whole process, most of the intercostal nerve is located between the intercostal muscles and the innermost intercostal muscles. The intercostal nerve gives off a lateral cutaneous branch just before the rib cage, which transitions into an anterior cutaneous branch near the sternum or the rectus abdominis. The lateral cutaneous branch of the intercostal nerve has passed through the intercostal muscle and serratus anterior muscle at the midaxillary line, and the distal block of the intercostal nerve at this location can only block the anterior intercostal cutaneous branch.
2. Ultrasound-guided intercostal nerve block technique
First positioning Detach the intercostal nerve to be blocked. Body surface localization or ultrasound localization can be used. First locate the 12 ribs, and count from bottom to top to the stage of the desired block. Place the probe at the rib level of the desired block, perpendicular to the rib, approximately 4-6 cm from the posterior midline of the spine. The ultrasound image of the rib, pleura, and intercostal muscles can be clearly displayed under the ultrasound of the block adjustment probe. The lower border of the target rib is the course of the intercostal nerve. The in-plane needle insertion technique is mostly used. The 22G puncture needle is inserted vertically into the skin from the caudal end of the probe, and the needle insertion angle is adjusted. The needle tip passes through the back muscle, intercostal muscle, intercostal muscle, etc. to the lower edge of the target rib, and the injection can be done without blood. Anesthesia 3-5ml, ultrasound can see the drug spread in the lower edge of the ribs, the pleura showed varying degrees of subsidence. Out-of-plane needle insertion techniques are not recommended to avoid pneumothorax caused by a deep needle tip.