Intercostal Nerve Block for Pain Relief

Patient Leaflets Team

  • Reference Number: HEY1122/2020
  • Departments: Pain Medicine

Introduction

This leaflet has been produced to give you general information about your treatment.  This leaflet should have answered most of your questions.  It is not intended to replace the discussion between you and the healthcare team but may act as a starting point for discussion.  If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is an intercostal nerve block?

An intercostal nerve block is an injection around an intercostal nerve. All the ribs have nerves that closely travel underneath them from the spine at the back to the sternum breast bone at the front. These are called intercostal nerves. An intercostal nerve block is usually given if someone has chest wall pain over a localised area of the chest wall. This can occur after an attack of shingles or when there is a scar after an operation on the chest.

Why do I need an intercostal nerve block?

An intercostal nerve block may be a test to determine the source of your pain and/or to relieve your pain.  If you get a period of sustained pain relief from the injection, it will help the doctor decide which procedure to do next.

Can there be any complications or risks?

As with any procedure, side-effects may occur. However, these are usually minor and there is little risk of serious harm.

Side-effects may include;

  • Mild local tenderness and/or bruising at the site of the injection, that usually settles over the first few days.
  • Pneumothorax. There is a small chance of puncturing the lung (pneumothorax). This can lead to pain and breathlessness. The pain is often a severe pain, which is sharp and worse on taking a large breath in. If this symptom were to occur or you were to feel breathless then you must seek immediate medical help since this may require treatment and a stay in hospital.
  • During the injection, you may experience signs of local anaesthetic toxicity if the injection is passing into a blood vessel. You should inform your doctor immediately if you develop tingling around your mouth or a metallic taste, ringing in your ears, feeling drunk, dizzy, blurred vision, muscle twitches or difficulty in breathing
  • The local anaesthetic may rarely spread causing some numbness. Should this occur, the effect is temporary and will rapidly resolve over minutes or rarely hours
  • Infection. This is rare. You should seek medical help if there is local warmth or redness over the site of injection with tenderness and/or you feel hot and unwell. This may require antibiotic treatment
  • Nerve injury is extremely rare (less than 1 in 10,000 cases)
  • Injection treatments are not always effective and may not help your pain

I have heard that steroids are being used  unlicensed/off-label, what does this mean?

Steroid medications (corticosteroids) are licensed for use through specific routes of administration only. However, for managing chronic pain they are in use through variety of routes for number of years and some routes of administration to treat pain are not on license. This is referred to as off-label use. The manufacturer of the medicine may not have applied for a specific licence to extend its usage.

Many medicines used in pain medicine are used off-label. You can discuss this further with your doctor.

Advice to be read before having a pain relief procedure

The following information has been produced to ensure that you are able to have your pain relief procedure.  It is essential that you read and follow the advice given below before you come to the hospital. If you do not follow the advice you may not be able to have your treatment.

Please contact the Pain Service if any of the following apply to you:

  • You are diabetic and take medication to control your diabetes. (Please see below for further advice)
  • You have recently had an admission to hospital.
  • You have tested positive for MRSA.
  • You have an infection and are currently taking antibiotics.
  • If there is any possibility you may be pregnant.

Continue your other regular medications including your pain relief.  However, If you take any anticoagulants or blood thinning medications (examples are listed below but may not include some of the newest drugs introduced since the publication of this leaflet), please notify the Pain Service at least 10 days before your appointment.  You may need to stop taking these drugs at least 1 week prior to the procedure unless your doctor has advised against this.

  • Warfarin (Marevan)
  • Clopidogrel (Plavix)
  • Dabigatran (Pradaxa)
  • Rivaroxaban (Xarelto)
  • Apixaban (Eliquis)
  • Edoxaban(Lixiana)
  • Prasugrel (Effient)
  • Ticagrelor (Brilique)
  • Dalteparin (Fragmin) injections
  • Enoxaparin (Clexane) injections
  • Tinzaparin (Innohep) injections
  • Dipyridamole (Persantin Retard)
  • Phenindione
  • Acenocoumerol (Sinthrome)
  • Asasantin Retard

You may have to wait a while before your procedure, so please bring something to read or do to keep yourself occupied. Please bring a dressing gown and slippers to wear.

Please leave any valuables or jewellery at home.  It is essential that after the procedure you arrange for an adult friend or relative to collect you by car or taxi. You will not be able to use the bus or train to travel home.

Hospital transport may be available if there is a medical need. If you think you may be eligible, please contact the doctor.

Advice for diabetic patients only

Your blood sugar level may raise and remain raised for few days after the procedure due to steroid medications that might be used during the injection. It is advisable to monitor your sugar level regularly for one week following the procedure.  Any concerns please contact your doctor.

What happens before the procedure?

You will be admitted by the nursing staff who will ask for and record some information about you.  Your blood pressure will be checked and you will be given a gown to put on. The doctor will explain the procedure and ask you to sign a consent form.  Please make sure you have understood what has been said and feel free to ask any questions.

What to expect during the procedure

As a precautionary measure, a thin plastic tube (cannula) may be inserted into a vein in your arm/hand before the procedure itself.  This allows us to give medication if there are any issues during the procedure.

Regarding the procedure itself, after cleaning your skin with antiseptic solution, local anaesthetic will be injected into your skin to numb it first.  Under X-ray screening or ultrasound guidance, a fine needle is introduced towards the area to be treated.  A small dose of contrast (X-ray dye) may be used to confirm the exact location of the needle.  Once the optimal position is obtained, local anaesthetic with or without steroid will be injected close to the nerve.

What happens after the procedure?

You will be taken on the trolley to the recovery area where the nurse will check your blood pressure and pulse.  You will be asked to rest for about an hour.  After that you will be able to get up, but please check with the nurse before you do so.

Once you are comfortable, you will able to go home accompanied by an adult friend or relative.

Please ensure that you have arranged for someone to drive you home after this procedure.  Failure to do so will result in your procedure being cancelled. You should not drive for 24 hours after the procedure.

What to expect when you return home

Take it gently for a few days but gradually build up your activities. You should continue to take all your usual medication/pain relief as the pain may be slightly worse until the nerve block starts to work.

Some people find that they get relief from their pain but, after a couple of months this wears off.  Others may experience complete relief; however, there is a chance that the pain will not improve, not change or will get worse.

During the reduced pain period you should try to gently increase your exercise.

Try not to overdo things on a good day as this may result in you experiencing more pain the following day.

Follow-up appointment

A letter will be sent to your doctor and you will be reviewed either by telephone or seen at the Pain Service in due course.

At this review you will be asked to discuss the Pain Diary you were given at your injection appointment, please have this completed diary to hand at the time of the phone call.

Points to remember

  • You will need to have arranged for someone to drive you home after this procedure.
  • Please bring your glasses if you need them for reading.
  • Always bring a list of all current medication.
  • Continue taking all your usual medication on treatment day (please see above advice if you are a diabetic patient)
  • If there is any possibility you may be pregnant please inform the doctor or nurse.
  • If you are planning to travel abroad or fly within two weeks after the injections, please let your doctor know as it may be best to change the date of the injections.

Additional information

If you experience unusual symptoms such as a marked increase in pain around an injection site, fever, severe headache, new symptoms of pins and needles, new muscle weakness in your arms and legs, or you are very concerned about how you feel after the procedure, please contact your doctor.

Pain Service Outpatient Department East Riding Community Hospital, Beverley (01482) 478868 / 624179

In the event of an emergency and outside normal working hours of the Pain Service (9.00am – 4.00pm, Monday to Friday) please contact your local doctor, Local Walk in Clinic / Minor Injuries Unit.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.

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