2024 Update Course - New Uses for Cryoanalgesia - Timothy Lautz, John DiFiore, & Thomas Inge
With Dr. John DiFiore & Dr. Thomas Inge & Dr. Timothy Lautz · hosted by Dr. Todd Ponsky
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What the experts said
At Cleveland Clinic, the freeze point for cryoanalgesia is in the posterior axillary line about 4 centimeters from the vertebral column, using a 2-minute freeze cycle from T3 to T8.
The subclavian artery going over the top of the first rib serves as the landmark to count ribs during cryoablation.
Subpleural injection with 0.25% marcaine with epinephrine works immediately as opposed to the 8 to 10 hour delay with cryo nerve block.
The new cryoprobe saves almost 30 minutes when doing T3 to T8 bilaterally, reaching temperature about 20 seconds faster with a 90-second freeze cycle instead of 2 minutes.
The new probe has improved shaft insulation that only gets to room temperature, allowing it to safely touch the lung.
A new 10-millimeter probe with a 60-second freeze cycle that produces a larger ice ball is scheduled for release on October 1st.
Surgeons using single-lumen tubes who report ineffective blocks are invariably doing the block too far anteriorly because they cannot get posterior to the anterior axillary line.
If the cryoprobe is not placed posterior enough, blocks become ineffective due to missing the lateral cutaneous branch.
Cleveland Clinic anesthesiologists use zero opioid in the OR, running only anesthetic gas and propofol, and there is strong anesthesia literature showing that less opioid use in the OR correlates with less post-op use.
Cleveland Clinic's study shows a very short length of stay of 1.1 days with some of the least post-op opioid use available.
In approximately 20 patients treated with dual-level freezing, average peak pain scores dropped from about 5 to about 3.
The dual-level freezing technique has not affected length of stay at Cleveland Clinic because 98% of patients already go home the next day.
For cryoanalgesia, the goal is to stay 3 to 4 centimeters away from the sympathetic chains while staying far enough posterior.
Cryoablation causes axonal degeneration by freezing, but the epineurium stays intact, which allows for nerve regeneration.
For thoracotomy metastectomy cases, 60-second freeze cycles have been used in approximately 300 cases with great results.
For thoracotomy, cryoablation is performed 1 to 2 levels above and below the thoracotomy incision.
Cryoablation at T10 or lower can cause pseudo-hernias on the abdominal wall from affecting motor branches.
The standard cryoprobe is used down to about age 3, and has been used in children as young as 18 months.
A cardiac probe used for ablations can serve as a smaller probe for younger children.
In smaller children, a retractor must be used to hold the skin away during cryoablation because there is not much chest wall musculature and skin freeze could occur.
With the new cryoprobe, the shaft insulation only gets to room temperature, eliminating the risk of skin or lung freeze—only the probe tip gets cold.
Benefits of cryoanalgesia for thoracotomy include no epidural, no Foley catheter, immediate patient mobilization, and improved pulmonary toilet.
In a comparison study, cryoanalgesia showed a 2 to 3 fold reduction in narcotic use during hospitalization, with patients sent home without narcotic prescriptions.
In 23 thoracotomy patients, oral morphine equivalents during the hospital stay were 137 mg with cryoanalgesia versus 533 mg with regional blocks.
Cryoanalgesia is now routine for all thoracotomies except neonatal cases.
Slipping rib syndrome involves cartilaginous union laxity at the end of floating ribs and false ribs, causing impingement on intercostal nerves (inferior or superior) as ribs slip and float.
Slipping rib syndrome can be the cause of chronic abdominal wall pain, and patients often present after multiple negative workups including appendectomy, cholecystectomy, colonoscopies, CTs, and ultrasounds.
Slipping rib syndrome typically affects teenage girls more than boys.
Patients with slipping rib syndrome have somatic tenderness of the abdominal wall but not visceral tenderness, with more tenderness during abdominal wall flexion (crunch) than when relaxing.
For slipping rib syndrome, chronic pain specialists perform intercostal blocks with steroid and long-acting local anesthetic as a diagnostic test.
The diagnostic intercostal block for slipping rib syndrome may last for weeks, months, or only days, depending on the patient.
If there is a response to diagnostic block, the next step is referral to surgery or, as an intermediate option, IR-guided cryoablation using needle probes, often at multiple levels.
For flail chest or multiple rib fractures causing ventilator dependence, cryoablation of affected intercostal spaces can facilitate ventilator weaning and improve pulmonary toilet.
Cryoablation can be applied using the standard probe from an intrathoracic approach, external application in the OR during plating procedures, or via IR-guided percutaneous needles (the same needles used for liver lesions and lung nodules).
Repeat cryoablation has been successfully performed in at least 2 patients with osteochondromas who were initially treated with cryo and then re-treated during rib resection for osteochondroma, with good outcomes.
One patient who received IR-guided cryoablation for slipping rib syndrome obtained 8 months of relief from the original treatment.
Transcutaneous intercostal nerve blocks can be used as a diagnostic tool for unexplained chest wall pain before proceeding to cryoablation.
There is strong literature in adult trauma supporting cryoanalgesia for rib fractures, and the vast majority of cryoprobe company calls come from rib fracture cases with cryo and plating, with substantial data on cardiopulmonary recovery.
Cryoanalgesia works effectively for sternotomy pain.
Seth Goldstein's group in Chicago demonstrated that a 1-minute freeze cycle was just as effective as 2 minutes, though the study was limited because they didn't measure pain scores or directly compare to 2 minutes.
Dr. Kim from UCSF demonstrated in a cadaver study that 18% of lateral cutaneous nerve branches are posterior to the mid-axillary line.
Dr. Kim's cadaver study showed a large collateral branch of the intercostal nerve running along the top of the nerve, separate from the main intercostal branch on the bottom.
Dr. Kim cryoablated both the main intercostal nerve on the bottom and the top of the nerve below it in a small patient series.
In Dr. Kim's study using dual-level freezing, patients went home in 1 day instead of 2, and 9 out of 22 patients reported pain scores of 0.
A Phoenix group study found that surgery for slipping rib syndrome combined with intraoperative cryoablation resulted in shorter length of stay and lesser narcotic use.