Analgesic outcomes following ultrasound-guided intercostal cryoneurolysis in oncologic thoracic surgery – A case series

Thoracic surgery remains a cornerstone in oncologic management of chest malignancies, yet despite advancements in surgical techniques and incorporation of enhanced recovery protocols, post-thoracotomy pain syndrome (PTPS) and prolonged post-surgical pain continue to be prevalent complications. Comprehensive multimodal management, including utilization of non-opioid analgesics and regional/neuraxial anesthesia, is essential for treatment of postoperative pain but even these strategies have limitations. Post-thoracotomy patients are at high risk of symptom progression to chronic pain, and often rely on prolonged opioid use to manage debilitating impacts on physical functioning and quality of life. More recently, the use of percutaneous cryoneurolysis has expanded to acute pain management, with the goal of extending analgesic effect. We describe a series of four cases in which patients presented with unrelenting pain following thoracic surgery, with limited relief from traditional analgesic modalities. Each patient was evaluated as a candidate for percutaneous ultrasound-guided intercostal cryoneurolysis (USG-IC), in conjunction with regional anesthesia techniques. Following cryoneurolysis, each patient reported significant pain relief, as was exhibited by a reduction in pain scores, as well as weaning from opioid consumption over the course of weeks to months, ultimately facilitating overall recovery. Given our experiences using percutaneous cryoneurolysis as an analgesic strategy in oncologic thoracic surgery, it could be beneficial to further explore optimizing patient selection, timing of intervention, as well as standardizing procedural technique. The benefits of cryoneurolysis include a relatively low-risk profile and the potential for extended analgesia, surpassing that of other modalities all while limiting the need for opioids. Perioperative analgesic goals aim to reduce postoperative acute pain, opioid requirements, and opioid-related adverse drug events (ORADES), while improving functional recovery and reducing the incidence of chronic pain syndromes. Percutaneous intercostal cryoneurolysis offers a promising opioid-sparing analgesic strategy in oncologic thoracic surgery to facilitate postoperative recovery and reduce post-surgical pain symptoms.