28 views 0 likes

Dr. Lurie Children's Hospital

GCMD Space · View profile →

Update Course Rewind: Part 2 Non-Pectus Uses of Cryoanalgesia 2024

Video Published 2025-06-30 Updated 2026-08-01

Timestops (10)

Global Cat MD along with Cincinnati Children's Hospital

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hel…

Presentations now fall into three categories green circles f…

Presentations now fall into three categories green circles for established practices, blue squares for promising newer p…

There are novel ways to use cryotherapy in a percutaneous ap…

There are novel ways to use cryotherapy in a percutaneous approach. Besides the standard cryoprobe, once you start using…

In some of these costochondral junctions and impingement on …

In some of these costochondral junctions and impingement on these intercostal nerves as the ribs slip and float and encr…

Slipping rib syndrome is more common in teenage girls than b…

Slipping rib syndrome is more common in teenage girls than boys. They often present with somatic tenderness of the abdom…

If they do get pain relief from the intercostal block with r…

If they do get pain relief from the intercostal block with ropivacaine and dexamethasone, the next step is to refer them…

This is an intraoperative X-ray of them doing their needle p…

This is an intraoperative X-ray of them doing their needle probe placements and freeze thaw cycles. This paper looked at…

Patients were able to resume normal activities much earlier.

Patients were able to resume normal activities much earlier. Let's review a case involving the use of cryoablation to tr…

There's multiple ways to apply this tool.

There's multiple ways to apply this tool. We're used to doing it with the standard probe from the intrathoracic approach…

Global Cat MD along with Cincinnati Children's Hospital

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

Topic Overview

This discussion covers the application of cryoablation techniques beyond traditional pectus repair, focusing on percutaneous approaches for slipping rib syndrome and rib fractures. Slipping rib syndrome, characterized by laxity in costochondral junctions causing intercostal nerve impingement, is more common in teenage girls and presents with somatic abdominal wall tenderness. The treatment pathway progresses from intercostal blocks to percutaneous cryoablation by interventional radiology, with outcomes showing reduced pain scores, decreased narcotic use, and shorter hospital stays. For rib fractures causing ventilator dependence, multi-level percutaneous intercostal nerve cryoablation can facilitate extubation.

Key Takeaways

Slipping rib syndrome presents as somatic abdominal wall pain, often in teenage girls, elicited by muscle flexion. (1:30)
Treatment pathway: intercostal block with ropivacaine/dexamethasone, then percutaneous cryoablation if responsive. (2:17)
Cryoablation for slipping rib syndrome reduces pain scores, narcotic use, hospital stay, and accelerates activity resumption. (3:13)
Multi-level percutaneous intercostal nerve cryoablation can facilitate extubation in ventilator-dependent rib fracture patients. (3:27)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Lizzie Lee — host
Speaker 3 — guest
Thomas Inge — guest

Chapters

0:00Introduction and Course Framework — Introduction to the video series recapping the 12th annual update course in pediatric surgery from August 2024, including the new classification system for practice-changing ideas.
0:56Percutaneous Cryotherapy Applications — Overview of cryoablation beyond thoracotomy, including percutaneous needle options and applications for rib fractures, slipping rib syndrome, and endochondromas.
1:21Slipping Rib Syndrome Pathophysiology and Presentation — Description of slipping rib syndrome as a condition involving cartilaginous union laxity causing intercostal nerve impingement, often misdiagnosed as other abdominal conditions.
2:12Treatment Pathway for Slipping Rib Syndrome — Stepwise approach from chronic pain evaluation and intercostal blocks to IR-guided cryotherapy and surgical intervention, with reported outcomes.
3:23Cryoablation for Rib Fractures — Case presentation and discussion of using multi-level percutaneous intercostal nerve cryoablation for ventilator-dependent patients with rib fractures.
4:04Summary and Closing — Recap of cryoanalgesia applications beyond thoracotomies using interventional radiology tools for rib fractures and slipping rib syndrome.

Key claims

0:56Cryoablation is not limited to just thoracotomy or thoracoscopy — Lizzie Lee
1:00There are novel ways to use cryotherapy in a percutaneous approach — Lizzie Lee
1:12Cryoablation shows real benefits for rib fractures, slipping rib syndrome, and other endochondromas — Thomas Inge
1:21Slipping rib syndrome is a condition with cartilaginous union at the end of the ribs, for floating ribs in particular, but also for false ribs — Lizzie Lee
1:28Laxity in costochondral junctions causes impingement on intercostal nerves as the ribs slip and float — Thomas Inge
1:30Slipping rib syndrome can be the cause of chronic abdominal wall pain — Thomas Inge
1:44Patients with slipping rib syndrome may have already had their appendix or gallbladder removed without arriving at the right diagnosis — Thomas Inge
1:58Slipping rib syndrome is more common in teenage girls than boys — Lizzie Lee
2:01Patients with slipping rib syndrome often present with somatic tenderness of the abdominal wall that can be elicited by asking them to flex or crunch their abdominal muscles — Lizzie Lee
2:01Patients with slipping rib syndrome really won't have a visceral type tenderness — Lizzie Lee
2:12The usual approach for patients with slipping rib syndrome is to refer them to chronic pain — Thomas Inge
2:17Chronic pain can do an evaluation and do an intercostal block, usually a steroid as well as a long acting local — Thomas Inge
2:25If patients get pain relief from the intercostal block with ropivacaine and dexamethasone, the next step is to refer them to interventional radiology for ultrasound guided cryotherapy — Lizzie Lee
2:34If there's an actual response to intercostal block, the next step is to refer to surgery — Thomas Inge
2:44IR performs ablation at just the right level or more commonly multiple levels — Thomas Inge
3:01Cryoablation can be used intraoperatively in combination with surgery to remove the rib tips or to stabilize a slipping cartilaginous costal margin — Thomas Inge
3:13Outcomes from using cryoablation for slipping rib syndrome included reduced pain scores — Lizzie Lee
3:13Outcomes from using cryoablation for slipping rib syndrome included reduced narcotic use — Lizzie Lee
3:13Outcomes from using cryoablation for slipping rib syndrome included shorter length of stay in the hospital — Lizzie Lee
3:19Patients were able to resume normal activities much earlier after cryoablation for slipping rib syndrome — Lizzie Lee
3:27If you have someone come in with chest or fractures that gets stuck on a ventilator, you can do a world of good with cryoablation by anesthetizing just those intercostal spaces that are the problem — Thomas Inge
3:55IR colleagues use the same needles for cryoablating liver lesions and lung nodules that can be applied to intercostal nerve ablation — Speaker 3

Cases discussed

3:3916-year-old male with 5 rib fractures treated with multi-level percutaneous intercostal nerve cryoablation

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Percutaneous Cryoablation for Intercostal Nerve Pain Beyond Pectus Repair

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Recognize slipping rib syndrome as a surgical diagnosis

Slipping rib syndrome sits in the diagnostic blind spot between general surgery and chronic pain — patients accumulate negative workup and unnecessary procedures because the physical exam finding gets missed 1:44. The anatomy is straightforward: laxity at costochondral junctions allows floating or false ribs to impinge on intercostal nerves as they slip 1:28. What matters clinically is that this presents as chronic abdominal wall pain, not chest wall pain 1:30. The patient who has already lost an appendix or gallbladder to someone else's diagnostic uncertainty is the patient you need to recognize on exam 1:44.

The physical finding is somatic tenderness elicited by abdominal muscle flexion — have the patient crunch and watch where they guard 2:01. Visceral tenderness will be absent 2:01. The epidemiology skews toward teenage girls 1:58, but the exam is what matters. If you are seeing chronic abdominal pain in an adolescent with a negative visceral workup, put your hand on the costal margin and ask them to flex.

Use diagnostic block to guide treatment escalation

The treatment sequence is a stepwise test of the hypothesis. Refer to chronic pain for intercostal block with steroid and long-acting local anesthetic 2:17. If ropivacaine and dexamethasone produce relief, the diagnosis is confirmed and you have a roadmap 2:25. The block tells you which levels are involved and whether ablation will work.

The traditional next step is surgery 2:34, but percutaneous cryoablation now offers an intermediate option 2:25. Interventional radiology performs ultrasound-guided ablation at the affected levels — often multiple 2:44. The same needles used for liver lesions and lung nodules apply here 3:55. This is not a different technology; it is a different target.

For patients who proceed to surgery — rib tip resection or costal margin stabilization — cryoablation can be performed intraoperatively to address the nerve component while the structural problem is being corrected 3:01. The combination approach produced reduced pain scores, reduced narcotic use, shorter hospital stays, and faster return to normal activity in published series 3:13.

Apply the same technique to ventilator-dependent rib fracture patients

The logic that works for slipping rib syndrome applies to traumatic rib fractures. A patient with multiple fractures who cannot be liberated from the ventilator because of pain is a candidate for multi-level percutaneous intercostal nerve cryoablation 3:27. Anesthetize the affected intercostal spaces and the mechanical problem — inability to take a deep breath — often resolves 3:27. This is not analgesia for comfort; it is analgesia to enable extubation.

The technique is the same: IR-guided percutaneous needle placement at the levels corresponding to the fractures 2:44. The difference is the clinical context — you are not treating chronic pain, you are removing the barrier to weaning. The adolescent with multiple rib fractures who was extubated after cryoablation is the proof of concept 3:27.

Expand your concept of what cryoablation treats

Cryoablation is not a pectus technique that occasionally gets used elsewhere 0:56. It is an intercostal nerve ablation technique that happens to have been popularized in pectus repair. Once you recognize that the tool is the needle and the target is the nerve, the indications expand 1:00. Slipping rib syndrome, rib fractures, and other endochondromas all involve intercostal nerve pain that can be addressed percutaneously 1:12.

The discussants emphasized that this requires collaboration with interventional radiology, who already possess the equipment and imaging expertise 3:55. The surgical judgment — which patients to offer this to, when to combine it with operative intervention — remains yours. But the technical execution can be shared, and the outcomes justify the referral pattern.

Takeaways from this story

Slipping rib syndrome presents as chronic abdominal wall pain with somatic tenderness on flexion, not visceral tenderness.
Diagnostic intercostal block with steroid and long-acting local guides treatment escalation to percutaneous cryoablation or surgery.
Multi-level percutaneous cryoablation can enable extubation in ventilator-dependent patients with multiple rib fractures.
IR uses the same percutaneous needles for intercostal nerve ablation that they use for liver and lung lesions.

Keywords

slipping rib syndrome rib fractures endochondromas chronic abdominal wall pain cryoablation cryotherapy intercostal block percutaneous intercostal nerve cryoablation ultrasound guided cryotherapy appendectomy cholecystectomy colonoscopy ropivacaine dexamethasone steroid

Hashtags

#cryoanalgesia #pediatric surgery #cryoablation #slipping rib syndrome #rib fractures #interventional radiology #pediatric pain management #SlippingRibSyndrome #PediatricSurgery #PainManagement

Transcript

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Lizzie Lee from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories green circles for established practices, blue squares for promising newer practices, and black diamonds for early adopter practices only. Today we are talking about cryoanalgesia uses outside of pectus repair with pediatric surgeon Doctor Thomas Inge from Laurie Children's Hospital. This is video number 2 of this topic. If you'd like to watch video number 1 1st, it's linked below. Cryoablation is not limited to just thoracotomy or thoracoscopy. There are novel ways to use cryotherapy in a percutaneous approach. Besides the standard cryoprobe, once you start using the tools that the IR folks have available, which includes percutaneous needle options, what else you can do? We've seen some real benefits of cryo treatment, cryoablation for rib fractures, slipping rib syndrome, and other endochondromas, as you see here. Slipping rib syndrome is a condition with cartilaginous union at the end of the ribs, for floating ribs in particular, but also for false ribs. We see laxity. In some of these costochondral junctions and impingement on these intercostal nerves as the ribs slip and float and encroach upon these nerves, slipping rib syndrome can be the cause of chronic abdominal wall pain. We've all seen patients that come to us with it, they're already out, maybe even their gallbladder out, and nobody has arrived at the right diagnosis. A lot of colonoscopies and CTs and ultrasounds, they can end up. In your clinic, so always assess for it. Slipping rib syndrome is more common in teenage girls than boys. They often present with somatic tenderness of the abdominal wall that can be elicited by asking them to flex or crunch their abdominal muscles, but they really won't have a visceral type tenderness. So what is the usual approach for patients with slipping rib syndrome? Refer them to chronic pain. Chronic pain can do an evaluation and do an Intercostal block, usually a steroid as well as a long acting local. If they do get pain relief from the intercostal block with ropivacaine and dexamethasone, the next step is to refer them to interventional radiology for ultrasound guided cryotherapy. If there's an actual response, the next step is to refer to surgery. Sometimes patients want to know is there an in between now that there are these needle probes for the cryo. Our IR folks are doing. An ablation, they may do an ablation at just the right level or more commonly multiple levels. This is an intraoperative X-ray of them doing their needle probe placements and freeze thaw cycles. This paper looked at outcomes from using cryoablation for slipping rib syndrome. They've used cryoablation intraoperatively, so the marriage of the surgery to remove the rib tips or to stabilize a slipping cartilaginous costal margin. And then use cryoablation at the same time. Outcomes included reduced pain scores, reduced narcotic use, and shorter length of stay in the hospital. Patients were able to resume normal activities much earlier. Let's review a case involving the use of cryoablation to treat rib fractures. If you have someone come in with chest or fractures that gets stuck on a ventilator, you can do a world of good with this technique by anesthetizing just those intercostal spaces that are the problem. In this 16-year-old male with 5 rib fractures, doing multi-level percutaneous intercostal nerve cryoablation helped to reduce his pain, and he was able to be extubated. There's multiple ways to apply this tool. We're used to doing it with the standard probe from the intrathoracic approach. You can refer to the IR colleagues who are using these same needles for cryoablaating liver lesions and lung nodules. It's just a different application of the tools that they have. In summary, cryoanalgesia is being adapted for various conditions beyond thoracotomies, leveraging tools from interventional radiology to treat patients with rib fractures and slipping rib syndrome. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

Comments

Loading comments…