# Combined Cryoanalgesia and Erector Spinae Plane Block for Postoperative Pain Management in the Nuss Procedure: A Case Report

## TL;DR

A combination of erector spinae plane block and cryoablation was used to manage postoperative pain in a patient undergoing a Nuss procedure, showing effective pain control and early recovery.

## Contribution

This case report introduces a combined cryoanalgesia and ESPB technique as a novel multimodal analgesic approach for postoperative pain management in the Nuss procedure.

## Key findings

- The combined approach provided effective immediate and sustained analgesia with minimal opioid use.
- The patient experienced early mobilization and recovery without complications.
- The technique may offer comparable efficacy to traditional methods with improved safety and simplicity.

## Abstract

Pectus excavatum, the most common congenital chest wall deformity, is conventionally corrected using the minimally invasive Nuss procedure; however, postoperative pain remains a significant clinical challenge. Thoracic epidural analgesia (TEA) has traditionally been considered the gold standard, but it carries potential complications and technical challenges, particularly in patients with thoracic deformities. Alternative strategies, including the erector spinae plane block (ESPB) and intercostal nerve cryoablation, are therefore being explored to optimize pain control, reduce opioid consumption, and facilitate recovery. Intercostal nerve cryoablation provides prolonged analgesia through temporary axonal degeneration, yet its delayed onset necessitates complementary techniques for effective immediate postoperative pain management.

We report the case of a 14-year-old female (American Society of Anesthesiologists Physical Status III (ASA III)) with significant thoracic deformity who underwent elective correction of pectus excavatum using the Nuss procedure. After induction of general anesthesia, bilateral single-shot pre-incision ESPB were performed at the T5 level with 0.375% ropivacaine. Thoracoscopic intercostal nerve cryoablation (T3-T7) was then performed under selective lung isolation using a CRYO-S Painless cryoprobe (Metrum Cryoflex, Łomianki, Poland) with high-pressure carbon dioxide, applied directly to the intercostal nerves bilaterally. Each nerve received a single 2-minute cycle reaching −70 °C, followed by bar placement. Postoperative multimodal analgesia included paracetamol, ketorolac, magnesium sulfate, ketamine, and tramadol. Upon arrival in the post-anesthesia care unit, the patient reported a Visual Analog Scale (VAS) score of 8/10, described as thoracic heaviness/pressure, although her clinical presentation did not clearly suggest pain of this intensity. For additional comfort, an intravenous tramadol-droperidol infusion was administered for approximately 3 hours, reducing pain to VAS 3/10. On postoperative day 1, VAS peaked at 2/10 and decreased to 0/10 thereafter. The patient was discharged on postoperative day 3 with well-controlled pain, and no complications were reported.

This combined approach appeared to provide effective immediate and sustained analgesia, minimize opioid use, and facilitate early mobilization and recovery. ESPB ensured rapid thoracic wall analgesia, while cryoablation offered prolonged pain control. Compared with TEA or paravertebral blocks, this strategy may offer comparable efficacy with potential advantages in safety and technical simplicity. The integration of ESPB with intercostal nerve cryoablation could represent a promising multimodal analgesic approach, supporting enhanced recovery and warranting further evaluation for broader application in perioperative pain management.