Ultrasound-controlled cryoneurolysis for peripheral mononeuropathies: a retrospective cohort study

A Review of Nonsurgical Neurolytic Procedures for Neuropathic Pain

Introduction

Ideally, a physical or chemical nonsurgical neurolytic procedure provides targeted neurolysis to relieve pain for a suitable length of time without causing complications. This narrative review focuses on five nonsurgical neurolytic procedures that are well-established and well-documented in the literature for the treatment of refractory neuropathic pain and peripheral neuropathies, in particular: two physical nonsurgical neurolytic techniques (cryoablation and radiofrequency ablation) and three chemoneurolytic agents (alcohol injection, phenol injection, and a high-concentration capsaicin 8% topical system).

Methods

Using the definition of nonsurgical physical and chemical neurolytic procedures for neuropathic pain, a focused literature search of the PubMed database for English-language, human studies published through July 2024 included, but was not limited to, the following search terms: "neuropathic pain" AND "cryoablation", "cryoneurolysis", "radiofrequency ablation", "alcohol neurolysis", "alcohol injection", "phenol neurolysis", "phenol injection", "chemoneurolysis", "topical capsaicin", and "TRPV1." While attempts were made to identify prospective clinical trials for each type of neurolytic procedure, information regarding the conduct and safety and efficacy of some of these nonsurgical neurolytic procedures was primarily limited to case studies and anecdotal evidence.

Results

The risk benefit basis of each technique is discussed, and recommendations for proper use based on the literature are summarized. Most techniques require ultrasound or fluoroscopy guidance. Pain relief typically ranges from 3 to 12 months, with repeat neurolytic procedures often required to maintain suitable levels of pain relief.

Conclusion

The authors provide their insights as to the best utilization of these identified nonsurgical physical and chemoneurolytic procedures for the treatment of refractory neuropathic pain in different patient populations based on neural targets. Together, these five nonsurgical neurolytic techniques provide patients and physicians with a variety of options for the treatment of refractory neuropathic pain.

Cryoneurolysis for management of post-mastectomy pain: a systematic review

AIMS

Post-mastectomy pain syndrome is a common postoperative complication that can impact patient quality of life and function. The aim of this systematic review is to evaluate the effectiveness of cryoneurolysis as an intervention for the management of post-mastectomy pain.

METHODS

A prospero-registered systematic review was performed following PRISMA 2020 guidelines. An initial screening consisted of 53 articles imported from the following databases: PubMed, Embase, Web of Science, Cochrane, and Scopus. Google Scholar and WorldCat were also searched to pull any further articles.

RESULTS

Three clinical trials, one case series, and one case report were included. Primary outcome measure of patient reported pain score (VAS or NRS) showed clinically significant reduction in pain in all five studies. Three of the studies also reported reduction in opioid use with cryoneurolysis intervention. A pooled effect size of Hedges g = -0.963, (95% CI [-1.55, -0.373]), with heterogeneity (I2 = 0.70).

CONCLUSION

Cryoneurolysis intervention shows promising and clinically significant relief in post-mastectomy pain in patients and further studies are encouraged.

A Narrative Review of Ultrasound-Guided and Landmark-based Percutaneous Cryoneurolysis for the Management of Acute and Chronic Pain

PURPOSE OF REVIEW

Cryoneurolysis refers to the process of reversibly ablating peripheral nerves with extremely cold temperatures to provide analgesia for weeks to months. With ultrasound-guidance or landmark-based techniques, it is an effective modality for managing both acute and chronic pain. In this review, we summarize the reported literature behind its potential applications and efficacy.

RECENT FINDINGS

Here, we summarize several studies (from case reports to clinical trials) describing the use of ultrasound-guided and landmark-based cryoneurolysis for acute and chronic pain. Acute pain indications included pain related to knee arthroplasty, limb amputations, mastectomies, shoulder surgery, rib fractures, and burn. Chronic pain indications included chronic knee pain (due to osteoarthritis), shoulder pain, painful neuropathies, postmastectomy pain syndrome, phantom limb pain, facial pain/headaches, foot/ankle pain, inguinal pain, and sacroiliac joint pain. For both acute and chronic pain indications, more high quality randomized controlled clinical trials are needed to definitively assess the efficacy of cryoneurolysis versus other standard therapies for a multitude of pain conditions.

Cryoneurolysis of Intercostal Nerves for Postherpetic Neuralgia: A Case Report

Cryoneurolysis is a procedure that has been shown to be efficacious in managing pain in various settings. Multiple studies have demonstrated the benefit of cryoneurolysis; however, the literature on managing postherpetic neuralgia with cryoneurolysis is scarce. The current treatment options available include transdermal lidocaine patches, capsaicin, non-steroidal anti-inflammatory drugs, nerve blocks, antidepressants, anticonvulsants, and opioids. Pain-relieving treatments such as opioids can have long-term detrimental effects on a patient or be ineffective for long-term pain relief, so there is cause to explore alternative treatment options. Here, we present a case of ultrasound-guided cryoneurolysis of the intercostal nerves for the management of postherpetic neuralgia after herpes zoster bilateralis symmetricus. After several treatment options were unsuccessful in alleviating this patient's pain, cryoneurolysis of the intercostal nerves proved to be a very effective pain management tool.

Cryoneurolysis of the Subcostal Nerve: A Technical Description and Case Report

Cryoneurolysis has been utilized for numerous persistent and intractable painful conditions, including phantom limb pain and postsurgical pain. Although there are reports on the effectiveness of cryoneurolysis in various regions, including the intercostal nerves, the subcostal nerve remains a common culprit of chronic pain for which the literature is scarce. Different modalities are commonly utilized to address subcostal neuropathic pain, such as non-opioid pharmacotherapy, including nonsteroidal anti-inflammatory drugs (NSAIDs) and anticonvulsants, site-specific regional anesthesia, and radiofrequency ablation.However, the analgesia provided by these modalities is often inadequate or short-lived. Cryoneurolysis of the subcostal nerve remains largely unexplored and may provide a promising solution.Here, we present the first technical description of ultrasound and fluoroscopic guided percutaneous cryoneurolysis of the subcostal nerve and the case of a patient with 14 years of lower thoracic rib pain who failed multiple interventions but achieved complete pain resolution at the three-month follow-up through this procedure.

Exploring new horizons in pain relief: introducing Volume 14 of Pain Management

To our readers, welcome to the first issue of Volume 14 of Pain Management. 2023 marked a significant year for the journal, as we received an impact factor of 1.7 and increased the number of issues from 8 to 12. This foreword presents some of our content highlights from 2023, covering our top articles from the year and providing you with an insight into what to expect in the forthcoming year.