Early Percutaneous Cryoneurolysis for Pain Control After Rib Fracture for Older Patients: A Prospective Randomized Clinical Trial.

Abstract

Rib fractures are common and multimodal pain control bundles are essential to optimal care. Minimizing therapeutic side effects is important among older adults. The purpose of this study is to determine whether the addition of CT-guided percutaneous cryoneurolysis (CT-PCN) to existing multimodal pain control bundles reduces pain associated with rib fractures in older adults. A prospective, randomized clinical trial assessed the addition of CT-PCN to a multimodal rib fracture pain control bundle (standard of care [SoC]) for injured adults aged 65 years or older. Bluntly injured patients with fractured ribs 3 to 9 were randomized 72 hours or less from admission to CT-PCN and SoC, or SoC alone. The primary outcome was the highest pain score within 24 hours of discharge with deep inspiration. Secondary outcomes included hospital length of stay, rib-specific readmissions, intervention-associated adverse events, morphine milligram equivalent use, 12-item short form, and McGill pain scores, assessed at discharge and at 1-, 3-, and 12-month intervals postdischarge. 110 patients were included (56 in the intervention group, 54 in the SoC group). No difference in highest pain score with deep inspiration (intervention mean 5.6 [SD 2.4] vs SoC mean 5.9 [SD 2.4]; p = 0.49) was within 24 hours of discharge between groups and there was no difference in milligram equivalent use on day of discharge (intervention median 24 [IQR 6 to 45] vs SoC median 15 [IQR 4 to 34]; p = 0.29). Among 77 participants completing a 1-month follow-up (39 in the intervention group, 38 in the SoC group), the mean numeric pain score was 1 point worse among intervention patients (intervention mean 2.7 [SD 2.4] vs SoC mean 1.7 [SD 1.8]; p = 0.04), and the mean sensory pain score was 3.1 points higher (95% CI 1.4 to 4.9; p < 0.001). CT-PCN did not decrease pain associated with rib fractures and may be associated with worse physical quality and emotional response to pain within 1 month after hospital discharge.