Kosin Medical Journal 2019;34:152-160. https://doi.org/10.7180/kmj.2019.34.2.152 &D VH 5HSRUWV

Treatment of Isolated with Ultrasound-Guided Paravertebral : a Case Report and Literature Review

Jun-Mo Park 1, Hyunjeong Kim 1

Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook Na - tional University Hospital, Daegu, Korea

In the case of isolated sternal fractures, conservative treatment with analgesics is common, but pain can persist for more than 10 weeks, which can significantly interfere with daily life. Ultrasound-guided paravertebral nerve block is reported to be a successful means of pain control in patients with chest wall injury or fracture. A 70-year-old female patient presented with anterior that had persisted for 2 weeks despite conservative treat - ment. Sagittal reconstruction chest computed tomography and lateral oblique x-ray revealed an isolated sternal fracture. An ultrasound-guided bilateral paravertebral nerve block was performed for pain control. After performing the procedure twice at a 1-week interval, the patient reported complete pain alleviation, and no other problems were observed over the 3-month follow-up period. Ultrasound-guided bilateral paravertebral nerve block can help patients with isolated sternal fractures to manage pain and return to normal activities sooner than with oral analgesics.

Key Words : Fracture, Nerve block, , Sternum, Ultrasonography

Sternal fractures are not uncommon and have to the internal thoracic organs, with isolated ster - been reported to occur in 3.7% of patients hos - nal fractures considered benign lesions in the ab - pitalized after a traffic accident. 1 Before the use sence of accompanying cardio-respiratory of seatbelts became mandatory, a sternal fracture damage. 1,2 More than 95% of sternal fractures was a marker for high-energy trauma. After the are treated conservatively. 2 The most important use of safety belts was legislated, the number of factor in the treatment of isolated sternal frac - patients surviving traffic collisions increased, tures is adequate pain control, usually managed accompanied by an increase in patients present - with oral analgesics. 3 ing with sternal fractures as a result of these ac - Few studies, however, have been published re - cidents. garding the functional effects of isolated sternal The morbidity and mortality rates of sternal fractures on daily activities. According to one fractures are determined by associated injuries study, although chest pain was the most fre -

Corresponding Author : Jun-Mo Park, Department of Anesthesiology and Pain Medicine, Kyungpook National Receive d: Aug. 26, 2019 University Chilgok Hospital, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea Revise d: Oct. 12, 2019 Tel: +82-53-200-2643 Fax: +82-53-200-2027 E-mail: [email protected] Accepted : Oct. 15, 2019

152 Treatment of isolated sternal fracture quently reported and persistent symptom, con - She was examined at a local clinic near her home tinuing for an average of 10.9 weeks, the dura - and was told that her sternum had cracked. That tion of pain was significantly prolonged in doctor recommended rest and prescribed an patients older than 50 years of age presenting NSAID . However, her symptoms had with an isolated sternal fracture. 4 This prolonged not improved, and she complained that the chest pain often necessitates the administration NSAID was causing facial swelling and - of oral analgesics for a relatively long period, but burn. In addition, the patient was planning an this long-term use can be limited by the side ef - overseas trip with her family in 2 weeks. She vis - fects of non-steroidal anti-inflammatory drugs ited our clinic to address her pain so she could (NSAIDs) and . 5 In particular, older pa - travel unencumbered. tients may have underlying medical conditions A sternal fracture was already suspected at the that contraindicate analgesic use. Other patients other facility, and the pain had persisted even may have to return to their daily lives before the after 2 weeks of adequate treatment. We thereby pain has subsided, which can be difficult to do performed chest computed tomography (CT) in - when undergoing conservative treatment alone. cluding sagittal reconstruction, x-rays of the We report a case of successful management of sternum lateral and lateral oblique aspects, elec - pain in a patient with an isolated sternal fracture trocardiography (ECG), and a cardiac enzyme using an ultrasound-guided bilateral paraverte - test to check for any accompanying injuries. A bral nerve block. thorough physical examination was also con - ducted on the patient, and no specific abnormal signs were found other than intense, localized CASE tenderness at the mid portion of the sternal body. A recent fracture was observed at the sternum be - A 70-year-old female patient presented with an - tween the third and fourth on the sagittal re - terior chest pain that had persisted for 2 weeks. construction chest CT and sternum lateral The patient had no pertinent medical history oblique x-ray (Fig. 1A, 1B). There was mild soft other than 10 years of anti-hypertensive drug tissue edema around the fractured area, but no medication. The patient reported a fall 2 weeks hemorrhage, and no soft tissue injury that would before visiting the pain clinic, hitting her chest indicate a . No abnormalities against a stone, followed by chest pain. The pain were found on the ECG or cardiac enzyme test. was less severe when she remained still but wors - As such, we decided to perform an ultrasound- ened when she coughed or spread her , and guided bilateral paravertebral nerve block at the she reported difficulty with bending her chest space between the third and fourth ribs to allow forward or turning over in bed. The patient's vi - the patient to return to normal daily life sooner, sual analog scale (VAS) score was 7 out of 10. particularly, to travel abroad with her family after

153 Kosin Medical Journal 2019;34:152-160.

Fig. 1. (A) Sternum lateral oblique x-ray. (B) Sagittal reconstruction chest CT. Arrows indicate fracture site.

2 weeks. The patient was placed in the prone po - direction using an in-plane technique. After it sition, the third and fourth ribs were visualized was confirmed that the needle was placed in the with C- guidance (Fig. 2A), and the skin was region under the transverse process and that no marked along the running direction of each rib blood or air was withdrawn during negative as - (Fig. 2B). After sterilization of the skin, a curved piration, a mixture of 10 mL of 0.5% lidocaine transducer (1.5–4.6 MHz) for a GE Logiq7 ul - and 20mg of methylprednisolone acetate was trasound machine (Tokyo, Japan) was placed slowly injected. During the injection, concomi - parallel to the direction indicated on the skin and tant anterior movement of the parietal pleura was moved medially to check the spinous and trans - checked by ultrasound to confirm that the drug verse processes of the third thoracic . was injected into the correct location (Fig. 3B). The transducer was then moved laterally along After completing this procedure on one side, it the skin markings to locate the thoracic paraver - was repeated on the other side. tebral space for injection (Fig. 2C). The trans - Thirty minutes after the procedure, the patient’s ducer was moved slightly in the cephalad and VAS score of the pain caused by coughing or caudal directions perpendicular to the direction spreading her arms was reduced to 2 out of 10, of the rib indicated on the skin to confirm that without any complications. Since the patient the rib was excluded from the path of the needle complained of side effects from the NSAID, tra - (Fig. 3A). A 10-cm, 22-gauge SonoPlex cannula madol and a skeletal muscle relaxant were pre - with facet grinding (Pajunk GmbH, Geisingen, scribed, and the patient was asked to return for a Germany) was inserted in the lateral to medial follow-up in 1 week. After 1 week, the patient

154 Treatment of isolated sternal fracture

Fig. 2. (A) C-arm view showing the direction of the third and fourth ribs. (B) Skin was marked along the running direction of the third and fourth ribs. (C) Curved transducer was placed parallel to the di- rection indicated on the skin and moved medially and laterally along the skin markings and cepha- lad and caudally to locate the thoracic paravertebral space for injection.

Fig. 3. (A) Ultrasound view showing the ribs were excluded from the path of the needle. (B) Ultrasound view showing anterior movement of the parietal pleura (small arrow). T: target region, TP: trans- verse process, needle (arrow head), tip of needle (large arrow).

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reported that her VAS score was about 1 or 2 out total of 32,746 cases of injuries including sternal of 10 for most of the day. She also did not com - fracture between 2007 and 2010 using the Na - plain of any particular side effects of the pre - tional Trauma Data Bank, Yeh et al. reported that scribed drugs. Since the patient was concerned 84% of sternal fractures were associated with car that the pain would recur during the planned accidents, with sternal fracture confirmed in overseas trip with her family 1 week later, the 3.7% of all patients hospitalized due to a colli - procedure was repeated, and the same drugs were sion. 1 According to Oyetunji et al., the most com - prescribed. The patient followed up with us 2 mon cause of sternal fracture is car accidents, weeks after the trip and reported that she had not and the second most common cause is falls. 6 felt any pain during the trip and that she had Other common causes are motorcycle injuries, since stopped taking the pain medication because pedestrian injuries from cars, and cyclist injuries. the pain had completely subsided. At her 3- They also reported that most traumatic sternal month follow-up, the patient reported a return to fractures occur as one of multiple traumatic in - normal activities without pain, and no abnormal - juries rather than in isolation. Sternal fracture is ities were found on lateral and lateral oblique x- often associated with severe and rays of the sternum; thus, her treatment was frequently associated with severe intrathoracic terminated. and vertebral injuries. The injuries most com - Approval of this study was waived from the monly associated with sternal fracture are rib Ethics Committee of Kyungpook National Uni - fracture (57.8%), contusion, closed pneu - versity Chilgok Hospital based upon their policy mothorax or , closed thoracic or lum - on case reports. The authors obtained written bar vertebra fracture, concussion, and blunt consent from the patient to publish this case re - cardiac injury. The morbidity and mortality rates port. associated with sternal fracture are determined by the level of internal thoracic damage ac - companying the injury, with a mortality rate DISCUSSION ranging from 4 to 45%. 2 For this reason, it is im - portant to check for the presence of accompany - In the present case report, after ultrasound- ing injuries in all patients presenting with sternal guided bilateral paravertebral nerve block was fracture, and current protocols call for cardiac performed twice, the patient’s pain was success - monitoring, serial ECG, and hospitalization for fully relieved and she was able to return to daily further examination as needed. 7 However, iso - life early. This is the first report on pain manage - lated sternal fractures without other thoracic in - ment of an isolated sternal fracture with an ultra - jury do not necessarily require this level of care. sound-guided bilateral paravertebral nerve block. In the absence of accompanying cardio-pul - In 2014, through a retrospective analysis of a monary complications, an isolated sternal frac -

156 Treatment of isolated sternal fracture ture is considered a benign injury. 2,3 visualize such fractures. In addition, the lateral Previously, before the use of routine CT for di - view of the sternum is an unattractive option for agnosis and evaluation in blunt trauma patients, critically injured patients, especially those with lateral chest x-ray was considered the most use - multiple injuries. As such, ultrasound-based di - ful method for diagnosing sternal fractures, and agnosis is increasingly relied upon in emergency sternal fractures were considered clinically sig - departments for sternal fracture patients and nificant injuries associated with high morbidity other types of trauma patients. 10 The use of ultra - and mortality rates. 8 According to Perez et al., sound to detect sternal fractures can be as sensi - most sternal fractures can only be observed on tive or even twice as sensitive as conventional CT, are clinically insignificant, require no change radiography. Ultrasonography allows physicians in treatment protocol, and are accompanied by a to quickly and easily identify the presence or ab - low mortality incidence. 8 Terry et al. noted that sence of sternal fracture in trauma patients. CT remains the best diagnostic imaging method Sternal fracture can cause short- and long-term for trauma patients for the rapid identification of sequelae. De Oliveria et al. reported that persist - multiple injuries. 9 However, due to the curvature ing chest pain was the most common short-term of the anterior chest wall, an axial image may sequelae and the duration of chest pain after ster - miss a sternal injury, as the sternum may be ex - nal fracture was between 2 and 28 weeks, with cluded from the image. They suggested including an average of 8 to 12 weeks (mean period of 10.9 a sagittal reconstruction image to increase agree - weeks) for all age groups, and noted that pain du - ment among imaging physicians and confidence rations were significantly prolonged in patients in the diagnosis and recommended adding sagit - over 50 years of age. 4 Chest pain can worsen in tal reconstruction to the standard chest trauma cold weather or while performing certain maneu - CT protocol. The sagittal reconstruction image vers such as lifting, walking, or lying down. can be appended to the exam with little or no ad - They also reported that the mean length of time ditional cost to the patient or the institution and that had to be taken off work was 5.1 weeks. De - without exposing the patient to additional radia - layed complications from sternal fractures are tion. In the present case, the sagittal reconstruc - uncommon; however, some do present with de - tion image (Fig. 1B) was used to diagnose the layed complications and poor functional out - isolated sternal fracture and check for the pres - comes. Racine et al. reported that delayed ence of accompanying injuries with a high level hemothorax occurred in 12.5% of patients with of accuracy. sternal fracture. 11 However, the clinical signifi - Sternal fracture or dislocation usually occurs in cance of delayed hemothorax remains uncertain. the sagittal plane, rendering the lateral view of They reported that the proportion of patients with the sternum best suited to accurate diagnosis. 8 moderate to severe disability was significantly Conventional radiography can sometimes fail to higher for sternal fracture than other types of

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minor thoracic trauma. able to safely travel abroad, it was necessary to According to the systematic review of the liter - return to daily life early. The ultrasound-guided ature published between 1990 and 2017 by Klei bilateral paravertebral nerve block was chosen et al., the majority of patients with sternal frac - after taking the patient’s medical background and tures (more than 95%) received conservative personal circumstances into account and per - treatments such as bed rest, oral analgesics, and formed to help the patient return to normal activ - orthotics. 2 They found that proper pain control ities sooner. was critical, because sternal fractures can cause The ultrasound-guided paravertebral nerve pain during breathing that results in respiratory block is used during surgeries for breast cancer, complications due to respiratory insufficiency. inguinal hernia repair, lithotripsy, and video-as - Although it is often necessary to take oral anal - sisted thoracic surgery; however, it is most com - gesics for an extended period of time in the con - monly used for perioperative pain management servative treatment of sternal fractures due to and pain management in patients with multiple prolonged pain, long-term treatment may not be rib fractures. 14 Thoracic paravertebral block is a possible due to the side effects of NSAIDs or method of injecting drugs into the thoracic ver - opioids. 5 In particular, older patients or patients tebrae close to the spinal nerve from the interver - with underlying diseases may not be good can - tebral foramen. This procedure allows for the didates for the NSAIDs or opioids used in con - ipsilateral somatic and sympathetic nerve block, servative treatment. 7 Because of these issues, and characteristically, the injected drug spreads several new treatments have been introduced to up and down the injection site to enable blockade treat these patients, including infiltration of local in multiple dermatomes. The intercostal nerves anesthetics directly into the fracture site with a innervate the costotransverse joints, the ribs (1– subcutaneous cannula, periosteally positioned 12), the costosternal joints, and the sternum. catheter, or sternal catheter. 7 Recent develop - Since the intercostal nerve originates from the ments of new procedures using ultrasound are thoracic spinal nerve, it was able to block the cor - also being applied to the treatment of patients responding intercostal nerve that innervated the with sternal fracture. 12,13 fractured sternal region. Unlike the intercostal Recently, ultrasound has been used not only for nerve block, one procedure on one side was suf - the diagnosis of sternal fracture but also for the ficient because the drug spread to the level below treatment in more and more cases. 12,13 In the pres - or above the injection site. This procedure has ent case, only 2 weeks after sternal fracture, con - the advantage of being easier and more familiar servative management with oral analgesics was because it has been used by more and more anes - needed. However, the pain was not controlled by thesiologists as well as pain medicine doctors in NSAIDs, and NSAIDs could no longer be taken recent years. due to their side effects. Moreover, in order to be In most cases, conservative treatment is all that

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