Case study: Ultrasound-Guided Intercostal Nerve Block for Post-Herpetic Neuralgia
A 48-year-old male patient presented with severe pain localized to the left thoracic region, consistent with post-herpetic neuralgia following a recent episode of shingles involving the left T6 dermatome. The patient had no other significant medical history. The pain was described as sharp, burning, and significantly impacting the patient’s daily activities. Conventional analgesic medications provided limited relief, prompting the consideration of an ultrasound-guided intercostal nerve block for targeted pain management.
Nerve block technique
A high-frequency linear transducer was used to scan the left thoracic region, focusing on the intercostal spaces. Real-time ultrasound imaging provided identification of the targeted intercostal space, ribs, and underlying neurovascular structures.
Intercostal nerve block; transducer position and sonoanatomy. IMIM, innermost intercostal muscle; IIM, internal intercostal muscle; EIM, external intercostal muscle.
Next, a 25-gauge needle was inserted in-plane to penetrate the external and internal intercostal muscles. The optimal target needle endpoint is the location just below the internal intercostal muscle to ensure that the needle tip remains superficial to the parietal pleura. Then, 4 mL of bupivacaine 0.5% with 1:300,000 epinephrine was injected into the intercostal sulcus around the intercostal nerve. The procedure was repeated for additional intercostal spaces, depending on the extent of the patient’s pain and response.
Intercostal nerve block; Reverse Ultrasound Anatomy with needle insertion in-plane and local anesthetic spread (blue). IMIM, innermost intercostal muscle; IIM, internal intercostal muscle; EIM, external intercostal muscle.
Following the ultrasound-guided intercostal nerve block, the patient experienced significant pain relief within 30 minutes. The sharp, burning pain was reduced to a mild ache, allowing him to resume normal activities. Over the next few days, the pain continued to diminish, and the patient reported improved sleep and overall functionality. No adverse events or complications were observed.
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