Chilling the nerve, easing the pain?: A randomized clinical trial evaluating surgeon-administered bedside percutaneous cryoneurolysis for rib fracture pain.

Abstract

A cornerstone of rib fracture management is multimodal pain control, which includes scheduled nonopioid analgesics, as-needed opioids, regional or neuraxial blockade, and surgical stabilization of rib fractures. However, adverse effect profiles and individual factors limit their use in all patients. Surgeon-administered, ultrasound-guided percutaneous cryoneurolysis performed at the patient bedside is a promising analgesic adjunct. We performed a prospective, randomized clinical trial assessing benefit and safety of surgeon-administered percutaneous cryoneurolysis to our existing multimodal rib fracture pain control bundle (standard of care [SoC]) for injured adults aged 18 to 64 years. Patients with fractured ribs 3 to 9 were randomized within 72 hours of admission to receive either surgeon-administered, ultrasound-guided percutaneous cryoneurolysis at the bedside and our multimodal pain control bundle, or SoC alone. Patients undergoing surgical stabilization of rib fractures were excluded. The primary outcome was pain score at discharge. Secondary outcomes included hospital length of stay, intervention-associated adverse events, morphine milligram equivalent (MME) use, Short Form (SF)-12, and McGill Pain Score (Patient Reported Outcomes), which were assessed at discharge and 1-, 3-, and 12-month intervals after discharge. Forty-three patients were randomized: 24 in the intervention arm and 19 in the SoC arm, with 3 screen failures. The median age was 53 years (interquartile range [IQR], 45-60 years), 9 patients (23%) were female, the median Injury Severity Score was 13 (IQR, 10-17), and the median number of rib fractures was 6 (IQR, 4-8). Patients were well matched with no differences between groups. No intervention-associated adverse events were identified. Pain scores, MME use, and Patient Reported Outcomes were not different between groups at discharge, 1 month, 3 months, or 12 months. Application of surgeon-administered, ultrasound-guided percutaneous cryoneurolysis at the bedside is safe but was not associated with reduced pain or MME use when compared with SoC. Therapeutic/Care Management; Level II.