Intercostal nerve cryoablation reduces opioid use and ICU stay compared to surgical stabilization alone in rib fracture patients

INTRODUCTION: Rib fractures are common in trauma patients and are associated with significant morbidity due to pain-related respiratory compromise. Surgical stabilization of rib fractures (SSRF) improves outcomes in select cases, but postoperative pain can persist despite surgery. Intercostal nerve cryoablation (INCA) has emerged as a potential adjunct to enhance analgesia and recovery. This systematic review and meta-analysis evaluated postoperative outcomes associated with the use of INCA in conjunction with SSRF in adult patients with rib fractures. METHODS: We conducted a systematic search of seven databases (PubMed, Embase, Scopus, Web of Science, Cochrane Library, Virtual Health Library, ClinicalTrials.gov) from inception to March 16, 2025. Comparative studies involving adult trauma patients undergoing SSRF with or without INCA were included. The primary outcomes were postoperative opioid consumption, intensive care unit (ICU) length of stay, and hospital length of stay. Secondary outcomes included pneumonia incidence, postoperative intubation rates, tracheostomy rates, and mortality. Meta-analyses were performed using random-effects models, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. RESULTS: Four retrospective cohort studies comprising 479 patients were included. Relative to SSRF alone, SSRF with adjunctive INCA was associated with lower postoperative opioid consumption (mean difference [MD] -140.14 morphine milligram equivalent; 95% confidence interval (CI), -266.79 to -13.49; P = 0.03), shorter ICU stay (MD -2.76 d; 95% CI, -3.78 to -1.73; P < 0.0001), and shorter hospital stay (MD -1.79 d; 95% CI, -2.79 to -0.80; P < 0.01). Adjunctive INCA was also associated with lower postoperative intubation rates (risk ratio 0.47; 95% CI, 0.28-0.80; P < 0.01) and showed a borderline association with lower pneumonia incidence (risk ratio 0.43; P = 0.0506). No significant differences were identified for tracheostomy or mortality. The certainty of evidence was very low overall owing to risk of bias, imprecision, and the observational design of the included studies. CONCLUSIONS: Adjunctive INCA during SSRF was associated with lower postoperative opioid requirements, shorter ICU and hospital stays, and more favorable pulmonary outcomes in patients with rib fractures. These findings are encouraging but derive from a small number of retrospective studies with important methodological limitations and should therefore be interpreted as associative rather than causal. Prospective randomized trials are needed to determine whether these associations persist and to better define the role of INCA in the management of rib fractures.