Intercostal nerve cryoablation for postoperative analgesia in open thoracic surgical procedures: a GRADE-assessed systematic review and meta-analysis

Abstract Background Major open thoracic surgery is associated with severe postoperative pain and substantial opioid requirements, contributing to pulmonary complications and delayed recovery. Thoracic epidural analgesia (TEA) remains the standard regional technique but is frequently contraindicated or associated with complications in high-risk cardiothoracic patients. Intraoperative intercostal nerve cryoablation (CRYO) has emerged as a potential opioid-sparing alternative; however, its effectiveness across diverse thoracic surgical indications remains uncertain. Methods A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Scopus, and Cochrane Library were searched from inception to January 5, 2026 for randomized and observational studies evaluating intraoperative CRYO in adult patients undergoing major open thoracic surgery. Comparators included standard multimodal analgesia and TEA. Random-effects models were applied, and certainty of evidence was assessed using GRADE. Results Eight studies comprising nine independent cohorts ( n = 825) were included. CRYO significantly reduced cumulative inpatient opioid consumption compared with control strategies (SMD − 0.86; 95% CI − 1.57 to − 0.15) and improved early postoperative pain scores (MD − 0.74; 95% CI − 1.45 to − 0.03). Pulmonary function recovery was significantly enhanced (SMD 0.61; 95% CI 0.20 to 1.01), with consistent effects across surgical indications. Conclusions Intraoperative intercostal nerve cryoablation is associated with no significant increase in reported complications and is an effective opioid-sparing adjunct that improves early pain control and pulmonary recovery following major open thoracic surgery. Its clinical benefits are procedure-dependent, with greatest impact observed outside the lung transplantation population. CRYO represents a viable alternative to neuraxial analgesia, particularly in patients at elevated risk for epidural-related complications.