Intercostal Nerve Block

  • Intercostal nerve block is among the oldest of the peripheral nerve blocks, having been described in as early as 1907
  • Injectate is usually local anesthetic, with or without steroid, just under the rib where intercostal nerve lies 
  • Neurolysis with Alcohol or Phenol

Relevant anatomy

  • There are 12 pairs of thoracic spinal nerves (T1-T12) that are divided into ventral and dorsal rami after they pass through the intervertebral foramina.
  • The ventral rami of T1-T11 form the intercostal nerves that enters the intercostal spaces
  • The ventral ramus of T12 forms the subcostal nerve that is located inferior to the 12th rib

Intercostal Nerves

  • The dorsal rami of T1-T12 passes posteriorly to supply sensation to skin, muscles and bones of the back.
  • Intercostal nerves are composed of dorsal horn sensory afferent fibers, ventral horn motor efferent fibers and post ganglionic sympathetic nerves
  • The major branches of intercostal nerve are anterior and lateral
  • CPT 64420 plus add on 64421 for additional levels

Intercostal Nerve


Intercostal Nerve Block


  • Have the patient’s arm raised with the hand behind the head
  • Confirm the rib by palpation or adequate landmarks
  • Identify mid axillary line
  • To avoid pneumothorax, the needle point should be in close proximity to the rib
  • The rib is held between 2nd and 3rd fingers
  • Insert the needle between 2nd and 3rd finger and advance to make contact with the rib
  • Direct the needle downward (caudally) and walk the needle until it slides off
  • Advance the needle not more than 5 mm to prevent pneumothorax
  • Finally, inject 2-3 ml of 0.5% bupivacaine at each level, after careful aspiration, as the intercostal artery and nerve are very close by

Intercostal Nerve Block

Intercostal Nerve Block


  • Use of real time, high resolution ultrasound improves the accuracy of intercostal nerve block, adequate analgesia can be provided with a single puncture
  • The advantage are:
    • Less expensive 
    • Avoid lung

Complications of Intercostal Nerve Block

  • Pneumothorax
  • Bruising or soreness at the injection site
  • Bleeding
  • Infection
  • Nerve injury
  • Allergic reaction to the medication

Intercostal Nerve Block

Articles on Ultrasound Guided Intercostal Nerve Block

“Ultrasound assisted approach is a simple, reproducible technique in most patients with an easy to understand ultrasound anatomy. Adequate analgesia could be provided through a single puncture and may be an alternative to neuroaxial blocks.”

  •     Dieguez Garcia P, et al. Ultrasound-assisted approach to blocking the intercostal nerves in the mid-axillary line for non-reconstructive breast and axilla surgery. [Article in spanish]. Rev Esp Anestesiol Reanim 2013 Aug-Sep;60(7):365-70.

In Percutaneous nephrolithotomy (PCNL) with nephrostomy tube placement US-guided intercostal nerve block (ICNB) performed at the 11th and 12th intercostal spaces provided effective analgesia.

  •     Ozkan D, et al. Effect of ultrasound-guided intercostal nerve block on postoperative pain after percutaneous nephrolithotomy : Prospective randomized controlled study. Anaesthetist 2013 Nov 1 [Epub anead of print]

“Utilization of continuous intercostal nerve block (CINB) significantly improves pulmonary function, pain control, and shortens length of stay (LOS) in patients with rib fractures.”

  •     Truitt MS, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma 2011 Dec;71(6):1548-52. 

“Concurrent combination therapy with proper medications and appropriate intercostal nerve blocks could offer satisfactory pain relief in the majority of elderly patients with Post Herpetic Neuragia (PHN).”

  •     Chau SW, et al. Clinical experience of pain treatment for postherpetic neuralgia in elderly patients. Acta Anesthesiol Taiwan. 2007 Jun;45(2):95-101


“Intrapleural intercostal nerve block (IINB) associated with mini-thoracotomy reduces postoperative pain and contributes to improve postoperative outcome after major pulmonary resections.”

  •     D’Andrilli A, Ibrahim M, Ciccone AM, Venuta F, De Giacomo T, Massullo D, Pinto G, Rendina EA. Intrapleural intercostal nerve block associated with mini-thoracotomy improves pain control after major lung resection. Eur J Cardiothorac Surg. 2006 May;29(5):790-4. 

“Additional intraoperative intercostal nerve blockade provides an additive benefit for postthoracotomy pain relief, especially early after operation.” 

  •     Takamori S, et al. Intraoperative intercostal nerve blockade for post thoracotomy pain. Ann Thorac Surg. 2002 Aug;74(2):338-41.

“An effective use of an intercostal nerve block using 5% tetracaine in three patients with postherpetic intercostal neuralgia or postoperative intercostal neuralgia.” 

  •     Doi K, et al. Intercostal nerve block with 5% tetracaine for chronic pain syndromes. J Clin Anesth 2002 Feb;14(1):39-41. 

“The incidence of pneumothorax (PTX) per individual intercostal nerve blocked is low. Intercostal nerve block (INB) is an effective form of analgesia, and for most patients with rib fractures one INBP is sufficient to allow adequate respiratory exercises and discharge from the hospital.” 

  •     Shanti CM, et al. Incidence of pneumothorax from intercostal nerve blockfor analgesia in rib fractures. J Trauma. 2001 Sep;51(3):536-9.

“Appropriate use of nerve block and establishment of practical guidelines for multidisciplinary management of pain are mandatory for improving the QOL of patients with cancer.”

  •     Moriwaki K, etal. Pain management for patients with cancer -current problems in a pain clinic. [Articles in Japanese]. Masui. 2000 Jun;49(6):680-5

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and more Interesting Articles!

  • Baxter CS, Singh A, Ajib FA, et al. Intercostal Nerve Block. [Updated 2022 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
  • Feng LJ. Painless abdominoplasty: the efficacy of combined intercostal and pararectus blocks in reducing postoperative pain and recovery time. Plast Reconstr Surg. 2010 Nov;126(5):1723-1732. doi: 10.1097/PRS.0b013e3181ef8fe5. PMID: 21042130.


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