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

Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Lizzie Lay 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 Dr. Thomas Inge from Lurie Children's Hospital. This is video number two of this topic. If you'd like to watch video number one first, 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 indromas, 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 their appendy 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 ropivicane and dexamethazone, 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 they are these needle probes for the cryo, our IR folks are doing 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 saw 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 cartilagenous 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 flail chest or fractures that get 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 five rib fractures, doing multi-level percutaneous intercostal nerve cryoablation helped to reduce his pain and he was able to be excavated. 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 cryoblading, 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 Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.