Pain Medicine Procedures: Intercostal Nerve Blocks (Steroid Injections)
A portion of patients at the chronic pain clinic present with complaints of chest pain and pain in the thoracic spine. Interventional procedures are a crucial component of treatment for such patients.
The choice of treatment method requires a thorough evaluation of clinical data to ensure the intervention is effective and provides maximum pain relief.
Interventional Pain Treatment Methods for Chest Pain
Among the procedures we perform to treat thoracic pain are:
- Trigger point injections for paravertebral (perispinal) muscles.
- Botulinum toxin injections.
- Erector spinae plane block.
- Procedures on facet joints of the spine, including radiofrequency denervation.
In this article, we will take a closer look at intercostal nerve blocks.
Clinical Case: Intercostal Nerve Block
Our patient had been experiencing pain in the left side of her chest for 30 years—these episodes periodically worsened and then subsided. The most recent exacerbation began in August, prompting her to seek medical assistance.
A diagnosis of intercostal neuralgia was established. Upon examination, applying pressure to the 7th and 8th ribs along the scapular line significantly increased the pain.
A block of the left 7th and 8th intercostal nerves was proposed. Following the procedure, the patient’s condition significantly improved.
Description of the Intercostal Nerve Block Procedure
Procedure Visualization (X-ray Guidance)
Step 1: Injection of Contrast Agent
- After positioning the needle under X-ray guidance into the subcostal groove of the 8th rib, an injection of iohexol (a contrast agent) was performed.
- The contrast clearly visualized the space between the internal and innermost intercostal muscles, where the 8th intercostal nerve runs.
Step 2: Injection of Therapeutic Solution
- After injecting a mixture of a local anesthetic and a glucocorticoid, the contrast in the 8th intercostal space began to “wash out.”
- The contrast also highlighted the space of the 7th intercostal nerve.
- Note: The contrast (and consequently, the medication) spreads into the intervertebral foramina, reaching the sensory ganglia of the spinal nerves.
Advantages of X-ray Navigation in the Block Procedure
For a long time, I attempted to perform intercostal nerve blocks under ultrasound guidance, as recommended in the literature. However, I later preferred X-ray navigation because it: ✔ Provides better visualization of the procedural steps. ✔ Allows precise control over needle placement and medication distribution.
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