Percutaneous ultrasound-guided cryoanalgesia has been previously described for a few acute pain indications, both perioperative and unrelated to surgery. Apparent related benefits of the cryoanalgesia may be found in the increased quality of sleep, with these three patients reporting no insomnia due to pain, compared with 30%, 27%, 33%, and 20% for historic controls the nights of postoperative days 0, 3, 7, and 28, respectively. However, as it happens, the cryoneurolysis appears to have provided significant benefit even during the ropivacaine infusion since these three patients reported almost no pain at all, while published controls from our own institution and receiving a similar continuous paravertebral ropivacaine infusion reported a median (interquartile) NRS of 3.6 (2.0–4.0) the day following mastectomy. In addition, our primary aim was to provide potent analgesia following perineural catheter withdrawal prior to discharge on postoperative day 2, and not replace the single-injection and/or continuous nerve blocks. We provided a continuous paravertebral nerve block to the three patients described in this report since there were no similar previously-published cases (that we are aware of) to suggest the degree of cryo-induced analgesia that might be expected, and we wanted to provide our current standard-of-care analgesics. Patient #3 was a 47-year-old woman with hormone receptor negative breast cancer who underwent bilateral mastectomy with left-sided axillary node biopsy and received bilateral T3 paravertebral catheters. Patient #2 was a 45-year-old woman with hormone receptor positive, Her2-negative invasive ductal carcinoma who underwent left-sided mastectomy with axillary sentinel node biopsy who received a T3 paravetebral catheter. Patient #1 was a 46-year-old woman with hormone receptor positive, Her2-negative breast cancer who underwent left-sided mastectomy and received a T4 paravertebral catheter. All patients were called by telephone on postoperative days 1–4, 7, 14, 21, and 28. Catheters were removed the morning of postoperative day 2 prior to home discharge, and patients given a prescription for oxycodone (5 mg tablets) to be taken if needed. Within the recovery room the perineural catheter(s) were attached to portable pump(s) which infused ropivacaine 0.2% 8 ml/h basal with an optional patient-controlled 4 ml bolus available every 30 min (every 60 min for bilateral catheters). We now report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy.Īll patients received a general anesthetic without complications. Given its analgesic duration roughly corresponds to that of post-mastectomy pain, cryoanalgesia is a possible analgesic option. While described extensively in the chronic pain literature, recently published case reports support the use of ultrasound-guided percutaneous cryoneurolysis for the treatment of acute postoperative pain. The result is a temporary sensory and motor nerve block with a duration measured in weeks and occasionally months without any delivery device to manage or infusion pump to remove. Ultrasound-guided percutaneous cryoneurolysis is an alternative regional analgesic modality that reversibly induces peripheral nerve Wallerian degeneration using extremely cold temperatures, yet spares the endo-, peri-, and epineurium along which the nerve regenerates at approximately 1–2 mm/d. Due to its typical duration of multiple weeks, post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques which provide multiple hours or days of analgesia (e.g., single injection nerve blocks or continuous nerve blocks, respectively). Poorly controlled post-mastectomy pain remains a challenge often leading to persistent postsurgical pain lasting months to years.
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