1. 2026;29;45-54Thoracic Intervertebral Foramen Blocks Compared to Midpoint-to-Pleura Transverse Process Blocks for the Management of Acute Rib Fracture Pain
   Randomized Controlled Trial
   Barbara Pizzi, MD, Vincenza Cofini, MD, Emiliano Petrucci, MD, Stefano Necozione, MD, and Franco Marinangeli, MD,PhD.

BACKGROUND: Rib fractures can lead to intense acute pain, chest wall instability, and pulmonary complications in trauma patients, necessitating their admission to critical care units. Furthermore, these lesions represent a source of neuropathic disturbances. 

OBJECTIVES: The goal was to compare continuous thoracic intervertebral foramen blocks (CTIFBs) to continuous midpoint-to-pleura transverse process blocks (CMTPBs), both guided by ultrasound, for their efficacy in managing acute pain caused by rib fractures.

STUDY DESIGN: A double-blind, randomized controlled trial.

SETTING: This research was conducted in the Intensive Care Unit (ICU) of San Salvatore Academic Hospital (L’Aquila, Italy) from December 2022 to November 2024.

METHODS: Ninety-six adult trauma patients with rib fractures were randomized to receive either the CTIFB (experimental group; n = 48) or the CMPTB (control group; n = 48). The former block was performed by placing the tip of the needle over and behind the transverse process of the vertebra. In the latter block, the needle tip involved the midpoint between the pleura and transverse process. All patients received an initial bolus of 5 mL of levobupivacaine 0.25% with 4 mg of dexamethasone at each fracture level, followed by a continuous infusion (5 mL/h of levobupivacaine 0.25% with 16 mg of dexamethasone). The primary outcome was the proportion of patients who achieved pain control (Numeric Rating Scale [NRS] score <= 3) by 2 hours after the block. The secondary outcomes included neuropathic disturbances (assessed by von Frey hair and Lindblom tests), respiratory parameters (P/F ratio, spirometry, and diaphragmatic motion), and daily morphine consumption.

RESULTS: Success (NRS score <= 3) was achieved in 21/48 patients (44%) in the experimental group and 3/48 patients (6%) in the control group (P < 0.001). Patients in the experimental group showed significant reductions in neuropathic disturbances (F(5,470) = 18.5, P < 0.001) and required less daily morphine (10.1 ± 3.9 mg versus 20.8 ± 4.5 mg, P < 0.001). Both groups demonstrated improved respiratory parameters, but patients in the experimental group showed superior airflow rates by 48 hours (P = 0.004) after the block.

LIMITATIONS: The anesthetic procedures were performed under ultrasound rather than fluoroscopic guidance. These techniques may have utility in chronic pain management, requiring fluoroscopy rather than ultrasound. This aspect of our research is not generalizable to chronic pain practice. Additionally, this study had a single-center design, and patients undergoing anticoagulation therapy, an important subgroup of trauma care, were excluded. Those factors might have limited generalizability to other clinical settings. Third, the follow-up period was relatively short, precluding the assessment of long-term outcomes such as chronic pain development or functional recovery. Finally, although improved respiratory parameters were observed, the study was not equipped to detect differences in clinical outcomes such as pneumonia rates or mortality.

CONCLUSION: For patients with rib fractures, the CTIFB offered superior pain management, fewer requests for opioids, and better respiratory function than did the CMTPB. 

KEY WORDS: Rib fractures, acute pain, neuropathic disturbances, paravertebral catheters, midpoint transverse process to the pleura, intervertebral foramen, respiratory function, opioid-sparing techniques