Image-guided nerve cryoablation for post-thoracotomy pain syndrome

Abstract

Chronic post-thoracotomy pain syndrome (PTPS) can cause significant patient distress and is frequently difficult to manage. Percutaneous intercostal nerve (ICN) cryoablation by palpation of surface landmarks can be risky, as inaccurate probe placement can lead to hemo- or pneumothorax. Experience with image-guided ICN cryoablation with treatment planning and device navigation is limited. A patient with intractable PTPS was treated with ICN cryoablation under cone-beam computed tomography guidance with software-assisted needle trajectory planning and ablation zone simulation. This procedure provided the patient ~8 weeks of relief. This case demonstrated that ICN cryoablation is feasible under image guidance with device navigation and ablation simulation and may result in a few months of pain relief in cases of intractable PTPS.

Figure 1

Axial image of procedural cone-beam CT scan showing the actual needle with superimposed planned virtual trajectory (green line) and superimposed treatment zone (shaded pink sphere). Skin entry point (pink ellipse, A), planned target (green ellipse, B), and planned needle position as it traverses through this axial slice (green ellipse, C) are also displayed.

Figure 2

Oblique multiplanar reconstruction cone-beam CT shows “progress view” of the needle along the superimposed planned trajectory (green line with markings). The planned trajectory displays the skin entry site (A), the planned needle tip target (B), and the distance along the planned trajectory via millimeter demarcations. Ablation zone (pink shaded ellipse) for planned -40°C isotherm (13 mm diameter, 15 mm length) is superimposed.

Figure 3

Procedural reconstructed cone-beam CT shows “entry point view,” which is the view down the needle shaft toward the nerve target. Expected ablation zone (arrow) for -40°C isotherm (13 mm diameter) is superimposed over the needle.