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The patient with intercostal neuralgia suffers with intractable rib pain that is
difficult to treat with any long acting therapies. The intercostal nerve itself may be
subjected to cryoneurolysis, but the position is variable. One study shows 85%
of the time the nerve lies in the soft tissues between the inferior border of the
superior rib and the superior border of the inferior rib. Therefore, a field
cryoneurolysis would often be necessary which would entail multiple lesions. The
placement of these lesions is somewhat problematic in that there is no backstop
for the cryoprobe in the intercostal space. DRG RF is possible but suffers from
the technical difficulties of inability to place the active RF needle tip parallel to the
DRG.
Cryoneurolysis of the DRG is possible at the lower intercostal segments since
the DRG is unshielded by rib or transverse process. Figure 1 depicts localization
of the DRG which may often be seen in the thoracic spine as an enlargement of
the spinal nerve located just outside the lateral pedicular line in the thoracic spine.
Note this is different than the infrapedicular foraminal location of DRGs in the
cervical and lumbar spine. By performing a transforaminal neurogram as in
figure 1, the DRG is initially localized. Figure 2 depicts advancement of an
angiocath to the DRG using a straight AP approach. The angiocath is used as
an insulator to prevent freezing of undesired tissues including the skin. Figure 3
demonstrates the final positioning of the cryoneurolysis probe after advancement
through the angiocath to the DRG. Note the tip of the probe appears to be in the
posterior neuroforamen but in reality it is located lateral to the neuroforamen.
Cryoneurolysis is performed for 3 min at a temperature of minus 60 degrees C.
Anecdotally results have been excellent with an almost immediate reduction of
pain.

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Fig 3- Cryoneurolysis
Probe on DRG

Algos Techniques

Thoracic DRG Cryoneurolysis

Fig 1-DRG Localization

Fig 2-Angiocath
on DRG