When all else fails: a narrative review of surgical options for intercostal neuralgia from a plastic surgery perspective

Introduction

Background

Intercostal neuralgia (ICN) is a neuropathic pain syndrome characterized by pain along the distribution of the intercostal nerves which run between the ribs to innervate the chest wall and upper abdomen (1,2). It typically presents as persistent or paroxysmal pain described as shooting, burning or aching, localized to one or more intercostal spaces and often accompanied by sensory disturbances such as numbness or hyperesthesia. The etiology of ICN varies with most common causes being post-thoracotomy pain syndrome and post-herpetic neuralgia, but it has also been reported in the setting of traumatic or iatrogenic injury such as after chest tube placement or mastectomy or other breast surgery, anatomical compression, pregnancy, inflammatory/reactive, infectious, or neoplastic (1,3). Given the distinct etiology and pathophysiology of post-herpetic neuralgia, this review focuses specifically on post-traumatic and iatrogenic ICN.

Rationale and knowledge gap

The prevalence of ICN is difficult to ascertain due to its heterogenous etiologies but has been estimated to be approximately 15% in literature, predominantly in middle-aged and older adults (1). Estimates report that between 3 to 22% of pain clinic referrals are due to thoracic pain (4,5). Studies have shown that following thoracic procedures, including thoracotomy, internal mammary artery harvesting for coronary artery bypass grafting, and breast surgery, chronic post-surgical pain affects approximately 38% of patients at 12 months, with a neuropathic component present in 29–33% of cases (6). ICN has been reported in up to 80% of cases traumatic rib fractures (7,8), as well as older adults with osteoporotic thoracic vertebral compression fractures (9).

The functional burden of ICN is substantial, with patients seeing an average of 5 physicians before diagnosis (10). Among patients with chronic post-thoracotomy pain, 40–56% experience moderate-to-severe pain, and more than 80% report impaired daily activities, reduced ability to work, or sleep disturbance (6,11). Quality-of-life measures, including Short Form 36 Health Survey (SF-36) scores, demonstrate persistent deficits in both physical and mental health domains. Healthcare utilization is likewise considerable, and over 50% of patients require ongoing opioid therapy (6,7).

Multiple modalities have been utilized in the management of ICN. Traditional treatment options include pharmacologic agents and interventional procedures. In refractory cases, surgery may be considered (12). Contemporary techniques in peripheral nerve surgery such as targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), have been described to successfully treat ICN. Chronic pain associated with ICN often leads to physical deconditioning and psychosocial burden. As such, adjunctive therapy including physical therapy, psychotherapy, and complementary therapies such as acupuncture may provide synergistic benefit when combined with other modalities (1); however, such interventions are outside of the scope of this paper.

Objective

Despite growing interest in surgical management, the literature on operative interventions for ICN remains scarce. The aim of this study is to provide a narrative review of the current surgical techniques and their outcomes in treating ICN. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1171/rc).

Methods

A literature review was conducted from database inception through March 2026 on MEDLINE and Embase via Ovid, and PubMed. The search strategy incorporated combinations of medical subject headings and free-text terms including “intercostal neuralgia”, “intercostal nerve injury”, “post-thoracotomy pain syndrome”, “neuropathic chest wall pain”, “intercostal neuroma”, “nerve entrapment”, “surgical management”, “neurectomy”, “neurolysis”, “neuroma excision”, “targeted muscle reinnervation”, “TMR”, “regenerative peripheral nerve interface”, and “RPNI”, along with their synonyms. Table 1 summarizes the search strategy, and the full PubMed search strategy can be found in Appendix 1.

Eligible studies included primary research articles, systematic reviews, and meta-analyses published in English that investigated the surgical management of ICN, including operative techniques, perioperative considerations, and clinical outcomes. Studies evaluating peripheral nerve reconstructive strategies such as neuroma excision, nerve implantation, TMR, and RPNI in the context of thoracic or chest wall pain were also included.

Diagnosis of ICN

ICN is primarily a clinical diagnosis based on a characteristic history of neuropathic pain localized to the distribution of one or more intercostal nerves (1). Patients typically describe sharp, burning, or shooting pain that may be constant or intermittent and often exacerbated by movements that engage the thoracic cage, such as deep inspiration, coughing, or trunk rotation (13). Associated sensory disturbances, including allodynia or hyperesthesia, are common. A history of precipitating factors, including thoracic surgery, trauma, herpes zoster infection, or iatrogenic injury such as chest tube placement, can further support the diagnosis.

A focused physical examination supports the diagnosis of ICN and may demonstrate focal tenderness along the affected intercostal spaces with reproduction of pain on palpation or percussion, consistent with a positive Tinel’s sign (14). Neuropathic sensory changes are common, including allodynia, hyperalgesia, numbness, or dysesthesia (15). In chronic cases, muscle atrophy or localized trigger points may be present (13). Provocative maneuvers can aid in diagnosis, as pain is often reproduced with thoracic movement or lateral bending. A positive Schepelmann’s sign, which is pain elicited with ipsilateral lateral flexion, supports intercostal nerve involvement, whereas contralateral pain may suggest pleuritic pathology (1). Inspection of the chest wall should assess prior surgical scars or trauma, with palpation of these areas to identify focal neuropathic pain or neuroma formation (16). In herpes zoster-related cases, vesicular eruptions or residual dermatomal scarring may be observed. Additional findings such as skin color changes or sensory loss further support underlying nerve injury (1).

Although no universally accepted diagnostic criteria exist for ICN, several adjunct tools can support the diagnosis and help localize the source of pain. A targeted intercostal nerve block is a key diagnostic modality, with temporary pain relief following injection confirming intercostal nerve involvement (13,17). Diagnosis is therefore based on clinical response rather than defined sensitivity or specificity metrics. Advanced imaging techniques, particularly magnetic resonance neurography (MRN), have emerged as useful tools for visualizing nerve pathology and guiding management. Chalian et al. demonstrated that MRN offers superior visualization of pathology and that treatment directed at MRN-identified neuropathy results in good outcomes while maintaining cost efficiency (10). Specifically, they showed that MRN identified intercostal nerve abnormality in 68% of cases (19 of 28 patients) with clinically suspected ICN. Electrodiagnostic studies, including nerve conduction studies and electromyography, may also aid in evaluation (8).

Treatment of ICN

The management of ICN is multimodal in a stepwise approach drawing on principles of treatment of neuropathic pain (1,18). Figure 1 summarizes the stepwise approach of the management of ICN.

Figure 1 Stepwise treatment algorithm for intercostal neuralgia. Escalation of care progresses from pharmacotherapy to interventional procedures and, in refractory cases, surgical management. BotNT/A, botulinum neurotoxin type A; RPNI, regenerative peripheral nerve interface; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; TMR, targeted muscle reinnervation.

Pharmacological treatment

Many pharmacologic agents have been proposed for the treatment of ICN, many of which are also used for neuropathic pain management (8). First-line pharmacologic therapy typically consists of one of α2δ-ligands (gabapentin/pregabalin), serotonin-norepinephrine reuptake inhibitors (duloxetine/venlafaxine), or tricyclic antidepressants (amitriptyline) (8). The chosen agent should be initiated at low doses and titrated slowly, and selection is based on patient comorbidities and tolerability.

Topical treatments are recommended as a helpful second line adjunct, although they may be first line in vulnerable patients (elderly, polypharmacy, comorbidities) due to their favorable safety profile and lack of systemic effects. These include lidocaine patches or capsaicin patches. Topical agents may also be combined with the oral drugs if monotherapy provides only partial relief (8). Subcutaneous injection of botulinum toxin A in the painful region also be considered (19). Alternatively, for refractory cases, opioids can be used (19).

Interventional treatments

For patients refractory to pharmacologic therapy, interventional modalities are widely accepted as the next step in management. Beyond serving a diagnostic role, intercostal nerve blocks can also help treat ICN (20). In their case series of 17 pregnant women with ICN treated with ultrasound-guided intercostal blocks using ropivacaine, Tascón Padrón et al. showed that all patients reported immediate pain relief, with only 2 requiring a second infiltration due to pain recurrence and no serious adverse events reported (21). When repeated injections with local anesthetic, with or without corticosteroid, provide consistent but transient relief, more durable options such as neurolytic blockade using phenol or alcohol may be considered (22,23). Cryoneurolysis offers a reversible method of denervation by applying extreme cold to the affected nerve, resulting in a temporary conduction block lasting weeks to months (24,25). In a retrospective study of 43 patients, cryoneurolysis resulted in significant immediate pain relief in 60% of patients, with 50% maintaining benefit at 3 months and no reported cases of neuritis or neuroma formation (24).

Adjunctive non-invasive interventions may also be beneficial in select patients. Thoracic spine dysfunction, particularly involving the costovertebral joints, may contribute to intercostal nerve irritation. In such cases, manual physical therapies targeting the intervertebral and costovertebral joints can relieve mechanical impingement and improve symptoms (26).

Surgical treatment

Surgical treatment for ICN is reserved for refractory cases. The surgical treatment options for ICN include intercostal neurectomy with nerve implantation, surgical neurolysis, percutaneous endoscopic neurectomy, nerve decompression, and radiofrequency ablation (RFA). Table 2 summarizes current evidence on surgical interventions for ICN.

Intercostal neurectomy is the most widely explored surgical treatment for ICN. It involves confirmation of the affected nerves through an intercostal nerve block. The affected nerve is resected 3 cm proximal to the neuroma, and the proximal end is implanted into a muscle, typically the latissimus dorsi, to prevent neuroma reformation (27). A large series of 56 patients with trunk neurectomy (including intercostal nerves) showed average pain reduction from 9.0 to 3.5, with 80% achieving clinically meaningful pain relief at 2.8 years follow-up (28). Additionally, a study by Ducic and Larson examined 12 patients with chronic postoperative breast or abdominal pain who underwent intercostal neurectomy with muscle transposition, with 84% of patients achieving ≥50% pain relief at a mean follow-up of 8.7–12.5 months (29). Other studies have also confirmed such findings including reduced pain scores, sustained pain relief, and improvement in quality of life over longer periods of follow-up (27,30,31).

Surgical nerve decompression, or neurolysis, has been described for the treatment of ICN. It is a procedure where an incision is made over the cutaneous scar, with microscopic identification of the nerve being pale or hard upon inspection and palpation. It involves releasing the nerve from surrounding scar tissue or compressive pathology (14). A case series of 10 patients with postsurgical thoracic pain showed significant pain reduction from median score 8 to 3 at 2 months post-neurolysis (P<0.001), with decreased need for antiepileptic medications (14).

Percutaneous endoscopic neurectomy for refractory cases of ICN has also been described by Wei et al. This procedure is a minimally invasive, fluoroscopy-guided endoscopic intercostal neurectomy performed under local anesthesia, in which the symptomatic intercostal nerve is identified at the intervertebral foramen, confirmed via stimulation, and transected under direct visualization. A small incision and working cannula allow for targeted nerve access and resection, with closure performed after immediate symptom relief is verified (32). Thirteen patients were reviewed retrospectively, with pain relief in all patients, significantly lower Visual Analogue Scale (VAS) scores postoperatively and no recurrence during 12-month follow-up. Only one patient reported a burning sensation post-procedure (32).

Both conventional thermal RFA and pulsed radiofrequency (PRF) have been studied for ICN. Ultrasound-guided PRF for post-lung cancer surgery ICN showed significant improvements in pain scores and sleep quality compared to controls in an 80-patient retrospective observational study (33). A case series of 6 patients with blunt chest trauma treated with conventional thermal RFA showed four patients pain-free at their final visit (ranging from 3–9 months), with one requiring repeat treatment after 5.5 months (34). A systematic review found RFA for thoracic and abdominal pain syndromes had an average efficacy rate of 84% (range 55.8–100%) (35). PRF combined with pharmacotherapy for postherpetic neuralgia showed sustained pain reduction (VAS <30) until 22 weeks post-procedure (36).

More recently, surgical techniques adopted by plastics and reconstructive surgeons for treatment of peripheral nerve pain and neuromas have been implemented in ICN. Techniques such as RPNI and TMR have been applied to trunk neuromas, including intercostal nerve-related pain, though the evidence remains limited to small case series. A recent study of 76 TMR operations in 74 non-amputee patients included 15 trunk surgeries (19.8%), with 88.9% of trunk cases reporting improvement on the Patient Global Impression of Change (PGIC) scale at a mean follow-up of 2 years (37). RPNI has also been explored in the context of post-breast surgery pain, which involves intercostal nerve injury and neuroma formation. A recent systematic review and meta-analysis by Nag et al. found that RPNI demonstrated promising pain relief with median pain score reductions from 9 to 1 (P=0.02) in a small cohort (38).

Despite these early results, the theoretical advantages of TMR and RPNI may extend beyond those observed in current clinical series. While existing surgical approaches, such as neurectomy and cryoneurolysis, aim to interrupt nociceptive signaling, they do not address the underlying pathophysiology of neuroma formation, potentially perpetuating aberrant nerve regeneration (39). TMR is a surgical technique that transfers severed peripheral nerves to motor nerves of nearby denervated muscles, preventing painful neuroma formation and creating a physiologic pathway for nerve regeneration. RPNIs offer a distinct and potentially more durable solution by providing a physiologic target for regenerating axons. In this technique, the proximal end of a transected affected intercostal nerve is implanted into a free denervated muscle graft, which serves as a biologic scaffold. This reduces ectopic firing associated with neuroma formation (40). By redirecting axonal growth into a functional end organ rather than allowing disorganized sprouting within scar tissue, both RPNI and TMR have the potential to mitigate both spontaneous and evoked neuropathic pain. Given that ICN frequently arises from nerve injury or iatrogenic neuroma, the application of these techniques is compelling as it directly targets maladaptive regenerative processes driving chronic pain. Furthermore, early success of RPNI in the management of post-amputation neuromas and other peripheral nerve pain syndromes suggests strong translational potential to the intercostal nerve territory, where similar mechanisms of neuropathic pain predominate (31,41).

Discussion

The heterogeneity of ICN

ICN is a poorly defined entity in the literature, with substantial variability in its classification and description. Broadly, it is a neuropathic pain syndrome involving the intercostal nerves; however, its etiology is heterogenous, encompassing post-thoracotomy pain, post-herpetic neuralgia, and post-breast surgery (1). This heterogeneity complicates efforts to study ICN systematically, as the difference in patient populations, clinical context, and etiology limits the ability to accurately assess its incidence on a large scale. Hence, it is important to recognize that ICN is a spectrum of related conditions sharing that same anatomical distribution and underlying pathology of the intercostal nerves resulting in characteristic neuropathic pain. Similarly, the cost of ICN on the U.S healthcare system, including cost and loss of workforce productivity remains unquantified. Cost studies investigating the impact of ICN can be valuable to guide comparative analysis on the different management modalities. Furthermore, with much of the management of ICN is informed by neuropathic pain guidelines. There remains a need to have ICN-specific management guidelines that recognize its variability and heterogeneity.

Failures of treatment

The etiology and morbidity of ICN make it a candidate for early diagnosis and intervention. However, prognosis is variable with some patients achieving resolution of symptoms over time and others developing chronic pain, a significant source of morbidity on physical and psychological health.

Treatment is also not without risks. All pharmacological treatments have potential side effects and possible reactions with other medications including somnolence, dizziness, and constipation (19). Regional interventional techniques have many risks, including, but not limited to, damage to nerves or surrounding structures and local anesthetic toxicity. Electrodiagnostic studies, including nerve conduction studies and electromyography, were associated with an 8.8% incidence of pneumothorax in one study (42). This is in addition to the complications of the condition itself which can affect the mechanics of breathing, leading to splinting post surgically, and in turn respiratory complication particularly in elderly and immunocompromised patients (14). Surgical treatment also carries the risk of rare but serious complications. Neurectomy is associated with loss of intercostal muscle function, recurrence of neuroma residual ectopic hyperexcitability and postoperative burning sensation (27,43). Neurolysis carries the risk of pneumothorax and postoperative hyperesthesia, though it is generally associated with fewer complications than neurectomy given its nerve-sparing nature (14). RFA complications include infection, bleeding, lung puncture/pneumothorax, headache, and neuroma formation (44).

Beyond the disease itself, treatment is difficult and between 20 and 40% of patients may not achieve satisfactory pain relief with initial interventions, and success rates improve with escalation to more advanced therapies. For instance, among patients undergoing diagnostic intercostal nerve blocks with local anesthetic and steroid, 21% did not report improved pain relief in one oncologic population study (45). Of those who did respond to diagnostic blocks, only 22% experienced prolonged relief (average 21.5 days), while the majority required additional interventions (45). Moreover, among patients who underwent successful diagnostic blocks and elected to proceed to neurolysis, the success rate was 62% of pain control. In another study using MRN-guided perineural injections, 33% (3/9) of MRN-positive patients failed to improve after their first injection round (10).

Given that approximately one-third of patients may require escalation from initial nerve blocks to more definitive treatments like RFA or surgical neurectomy to achieve satisfactory pain control, surgical intervention arises as an attractive choice to consider early on in a patient’s management plan. Notably, surgical options appear to offer more durable pain relief. While no randomized controlled trials have directly compared surgical to non-surgical management for ICN, smaller case series and retrospective reviews elucidate some considerations. Pharmacotherapy provides modest efficacy but requires continuous use to maintain benefit (18). Interventional procedures offer intermediate duration of relief, with nerve blocks providing a benefit for an average of 41 days (10). Other interventional techniques like RFA/PRF provide longer relief of 4–6 months but also often require repeat procedures (46). Surgical options appear to offer the most durable and definitive pain relief on average for 8–12 months or longer, with higher success rates (27,29,32). However, surgical techniques are more invasive and may result in sensory loss.

Prophylactic surgical nerve management

Prophylactic surgical nerve management at the time of thoracic surgery to prevent post-surgical ICN has mixed evidence, with some techniques showing benefit while others have failed to demonstrate superiority over standard approaches. A retrospective study of 410 patients found that intercostal nerve preservation for patients undergoing thoracotomies resulted in significantly less opiate use, earlier mobilization, and reduced chronic post-thoracotomy pain compared to nerve sacrifice (47). The “edge closure technique”, which preserves the caudal intercostal neurovascular bundle by suturing the thin space between the inferior edge of the caudal rib and the neurovascular bundle, demonstrated significantly lower pain scores throughout the first postoperative year compared to conventional closure (48). However, a randomized controlled trial of 90 patients comparing modified nerve-sparing thoracotomy to standard posterolateral thoracotomy found no significant differences in acute or chronic post-thoracotomy pain, with chronic pain incidence at 6 months being 37.8% vs. 40% (49). This suggests that simply preserving nerves during retraction and closure may not be sufficient to prevent ICN.

Prophylactic cryoablation of intercostal nerves at the time of minimally invasive thoracic surgery was evaluated in a randomized trial of 103 patients. Surprisingly, cryoanalgesia did not decrease postoperative pain or narcotic requirements and instead increased neuropathy scores at 2 weeks (23). Similarly, a randomized trial of paravertebral intercostal neurectomy performed at the beginning of thoracotomy showed no difference in neuropathic pain at day 120: 26.6% in neurectomy patients vs. 28.8% in controls (50).

While RPNI and TMR have demonstrated substantial efficacy for preventing and treating neuroma pain in amputation settings, there is no published evidence of their application specifically for prophylactic intercostal nerve management during thoracic surgery. In amputation literature, both techniques show impressive results. Prophylactic RPNI in pediatric lower limb amputation significantly reduced chronic postamputation pain from 79% in controls to 21% in treated patients, with no cases of neuroma pain compared to 20% in controls (47). Both TMR and RPNI improve established neuroma pain (75–100%) and phantom limb pain (45–80%), with greater prevention when performed prophylactically, where up to 100% report no neuroma pain and 45–87% report no phantom limb pain (40).

Overall, prophylactic surgical nerve management for ICN remains controversial and is not currently supported for routine use. While some nerve-preserving techniques during thoracotomy have demonstrated improvements in postoperative pain and functional outcomes, randomized evidence suggests that these approaches may not reliably reduce the incidence of chronic neuropathic pain. Similarly, prophylactic interventions such as intercostal nerve cryoablation and neurectomy have failed to show meaningful benefit and, in some cases, may worsen early neuropathic symptoms. Although emerging strategies like TMR and RPNI have shown substantial efficacy in preventing neuroma-related pain in amputation populations, their application in thoracic surgery and ICN prophylaxis remains unexplored.

Alternative therapies

Other surgical therapy modalities have recently emerged for ICN to include neuromodulation techniques offering distinct mechanisms and durations of pain relief beyond traditional pharmacotherapy and nerve blocks.

Neuromodulation techniques, including spinal cord stimulation (SCS) and dorsal root ganglion stimulation (DRG-S), represent emerging treatment options that have demonstrated promising results for thoracic neuropathic pain conditions, including post-thoracotomy pain syndrome and ICN (49-51). SCS, especially high-frequency (10 kHz) modalities, has demonstrated high success and response rates in thoracic neuropathic pain, with advantages over traditional tonic SCS due to paresthesia-free analgesia and improved targeting (51,52). DRG-S offers more anatomically precise, dermatomal targeting and may be particularly suited for ICN (53). Small studies show substantial and sustained pain reduction, with theoretical advantages including lower energy requirements and posture-independent, focused stimulation (54). Mechanistically, SCS modulates pain through dorsal column activation and inhibitory pathways, while DRG-S acts more directly on primary sensory neurons within the dorsal root ganglia (55,56). However, both techniques carry risks, including lead migration, infection, and rare but serious complications such as nerve injury or lung damage. DRG-S may have a slightly higher complication rate, and thoracic placement requires technical expertise due to anatomical constraints (53,57). However, both techniques are overall minimally invasive, reversible approaches that are well tolerated.

Alternative approaches such as peripheral nerve stimulation and peripheral nerve field stimulation have also shown meaningful pain reduction in thoracic neuropathic conditions (58-60). Overall, neuromodulation should be considered in carefully selected patients after failure of conservative management, with current evidence limited to small studies, underscoring the need for larger trials.

These emerging therapies offer advantages over traditional treatments, including longer duration of action, reduced systemic side effects, and potential disease-modifying effects. However, several challenges remain: lack of standardized protocols, limited head-to-head comparative trials, variable patient selection criteria, and most importantly they don’t necessarily target ICN but extrapolate to ICN from diverse neuropathic conditions. Most evidence comes from small studies, case series, or single-center trials, highlighting the need for larger multicenter randomized controlled trials with extended follow-up to establish definitive clinical guidelines and optimal treatment algorithms.

Conclusions

ICN remains a challenging and heterogeneous neuropathic pain condition with significant functional and quality of life burden. While traditional pharmacologic and interventional therapies provide variable and often temporary relief, surgical management offers a promising avenue for more durable outcomes in refractory cases. Established procedures such as intercostal neurectomy and neurolysis demonstrate consistent pain reduction but may not address the underlying pathophysiology of aberrant nerve regeneration. Emerging neuromodulation techniques are also an option for carefully selected patients with refractory ICN, particularly in the context of postherpetic neuralgia and post-thoracotomy pain.

Emerging plastic surgery driven techniques, particularly TMR and RPNI, represent a paradigm shift in the management of ICN. By providing physiologic targets for regenerating axons, these approaches aim to prevent neuroma formation and reduce neuropathic pain, offering both therapeutic and potentially preventive benefits. Early evidence, although limited, demonstrates meaningful and sustained pain improvement in select patients.

As interest in peripheral nerve reconstruction grows, further high-quality studies are needed to define optimal patient selection, timing, and comparative effectiveness of these techniques in ICN.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Roman V. Petrov and Andrei I. Gritsiuta) for the series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” published in Journal of Thoracic Disease. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1171/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1171/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1171/coif). The series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Fazekas D, Doroshenko M, Horn DB. Intercostal Neuralgia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
2. Elkhashab Y, Wang D. A Review of Techniques of Intercostal Nerve Blocks. Curr Pain Headache Rep 2021;25:67. [Crossref] [PubMed]
3. Gruver C, Guthmiller KB. Postherpetic Neuralgia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
4. Singh V, Manchikanti L, Shah RV, et al. Systematic review of thoracic discography as a diagnostic test for chronic spinal pain. Pain Physician 2008;11:631-42.
5. van Kleef M, Stolker RJ, Lataster A, et al. 10. Thoracic pain. Pain Pract 2010;10:327-38.
6. Wang L, Yang M, Meng W. Prevalence and Characteristics of Persistent Postoperative Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis. Anesth Analg 2023;137:48-57. [Crossref] [PubMed]
7. Kim KH, Lee CK, Kim SH, et al. Prevalence of chronic post-thoracotomy pain in patients with traumatic multiple rib fractures in South Korea: a cross-sectional study. Sci Rep 2021;11:2615. [Crossref] [PubMed]
8. Gambardella K, Ashy C, Daley D, et al. Intercostal nerve electrodiagnostic testing in rib fractures. Muscle Nerve 2024;70:831-6. [Crossref] [PubMed]
9. Liu ZG, Yang F, Li PF, et al. Analysis of factors associated with intercostal neuralgia after osteoporotic thoracic spine fracture and construction of a prediction model. BMC Musculoskelet Disord 2025;26:110. [Crossref] [PubMed]
10. Chalian M, Hoang D, Rozen S, et al. Role of magnetic resonance neurography in intercostal neuralgia; diagnostic utility and efficacy. Br J Radiol 2021;94:20200603. [Crossref] [PubMed]
11. Yaman F, Çetinkaya D, Uğurlu İ, et al. Investigation of the Frequency of the Development of Chronic Pain After Thoracotomy. J Clin Med 2026;15:2035. [Crossref] [PubMed]
12. Pirvulescu I, Biskis A, Candido KD, et al. Overcoming clinical challenges of refractory neuropathic pain. Expert Rev Neurother 2022;22:595-622. [Crossref] [PubMed]
13. Dellon AL. Intercostal neuroma pain after laparoscopic cholecystectomy: diagnosis and treatment. Plast Reconstr Surg 2014;133:718-21. [Crossref] [PubMed]
14. Cappellari AM, Tiberio F, Alicandro G, et al. Intercostal Neurolysis for The Treatment of Postsurgical Thoracic Pain: a Case Series. Muscle Nerve 2018;58:671-5. [Crossref] [PubMed]
15. Kato J, Gokan D, Hirose N, et al. Clinical course of pain in a patient with neuropathic pain induced by ligation of an intercostal nerve. J Clin Anesth 2010;22:50-1. [Crossref] [PubMed]
16. Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin 2008;26:355-67. vii. [Crossref] [PubMed]
17. Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis. Anesth Analg 2011;112:1487-93. [Crossref] [PubMed]
18. Soliman N, Moisset X, Ferraro MC, et al. Pharmacotherapy and non-invasive neuromodulation for neuropathic pain: a systematic review and meta-analysis. Lancet Neurol 2025;24:413-28. [Crossref] [PubMed]
19. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162-73. [Crossref] [PubMed]
20. Xue M, Yuan R, Yang Y, et al. Application of ultrasound-guided thoracic paravertebral block or intercostal nerve block for acute herpes zoster and prevention of post-herpetic neuralgia: A case-control retrospective trial. Scand J Pain 2024;
21. Tascón Padrón L, Emrich NLA, Schröder C, et al. Ultrasound-guided intercostal block for the management of intercostal neuralgia in pregnant women: Case series and review of the literature. Int J Gynaecol Obstet 2025;170:532-7. [Crossref] [PubMed]
22. Kang J, Liu Y, Niu L, et al. Anesthesia upstream of the alcoholic lesion point alleviates the pain of alcohol neurolysis for intercostal neuralgia: a prospective randomized clinical trial. Clinics (Sao Paulo) 2020;75:e1296. [Crossref] [PubMed]
23. Weksler N, Klein M, Gurevitch B, et al. Phenol neurolysis for severe chronic nonmalignant pain: is the old also obsolete? Pain Med 2007;8:332-7. [Crossref] [PubMed]
24. Green CR, de Rosayro AM, Tait AR. The role of cryoanalgesia for chronic thoracic pain: results of a long-term follow up. J Natl Med Assoc 2002;94:716-20.
25. Verhagen J, Sorensen A, Tracy S, et al. Percutaneous cryoneurolysis for intercostal neuralgia due to bifid rib in a pediatric patient. Pediatr Radiol 2026;56:491-5. [Crossref] [PubMed]
26. Schenk R, Donaldson M, Parent-Nichols J, et al. Effectiveness of cervicothoracic and thoracic manual physical therapy in managing upper quarter disorders - a systematic review. J Man Manip Ther 2022;30:46-55. [Crossref] [PubMed]
27. Williams EH, Williams CG, Rosson GD, et al. Neurectomy for treatment of intercostal neuralgia. Ann Thorac Surg 2008;85:1766-70. [Crossref] [PubMed]
28. Nagarkar P, Ramanadham S, Chamseddin K, et al. Neurectomy for the Treatment of Chronic Postoperative Pain after Surgery of the Trunk. Plast Reconstr Surg 2017;139:204-11. [Crossref] [PubMed]
29. Ducic I, Larson EE. Outcomes of surgical treatment for chronic postoperative breast and abdominal pain attributed to the intercostal nerve. J Am Coll Surg 2006;203:304-10. [Crossref] [PubMed]
30. Hart SE, Agarwal S, Hamill JB, et al. Effective Treatment of Chronic Mastectomy Pain with Intercostal Sensory Neurectomy. Plast Reconstr Surg 2022;149:876e-80e.
31. Broyles JM, Tuffaha SH, Williams EH, et al. Pain after breast surgery: Etiology, diagnosis, and definitive management. Microsurgery 2016;36:535-8. [Crossref] [PubMed]
32. Wei J, Gao S, Li W, et al. Percutaneous Endoscopic Intercostal Neurectomy for Refractory Intercostal Neuralgia. Pain Physician 2021;24:E1147-53.
33. Wei T, Hou H, Zhou LL, et al. Effect of ultrasound-guided pulsed radiofrequency on intercostal neuralgia after lung cancer surgery: A retrospective study. Medicine (Baltimore) 2021;100:e25338. [Crossref] [PubMed]
34. Engel AJ. Utility of intercostal nerve conventional thermal radiofrequency ablations in the injured worker after blunt trauma. Pain Physician 2012;15:E711-8.
35. Vachirakorntong B, Kawana E, Zhitny VP, et al. Radiofrequency Ablation's Effectiveness for Treating Abdominal and Thoracic Chronic Pain Syndromes: A Systematic Review of the Current Literature. Pain Physician 2023;26:E737-59.
36. Makharita MY, El Bendary HM, Sonbul ZM, et al. Ultrasound-guided Pulsed Radiofrequency in the Management of Thoracic Postherpetic Neuralgia: A Randomized, Double-blinded, Controlled Trial. Clin J Pain 2018;34:1017-24. [Crossref] [PubMed]
37. Raasveld FV, van Varsseveld OC, Hundepool CA, et al. Targeted muscle reinnervation for treatment of neuropathic pain in non-amputees - Indications and outcomes. J Plast Reconstr Aesthet Surg 2025;105:359-68. [Crossref] [PubMed]
38. Nag S, Kennedy P, Aris K, et al. The Role of Nerve Surgery in the Management of Post-Breast Surgery Pain Syndrome: A Systematic Review and Meta-analysis. Ann Plast Surg 2025;95:625-9. [Crossref] [PubMed]
39. Shamoun F, Shamoun V, Akhavan A, et al. Target Receptors of Regenerating Nerves: Neuroma Formation and Current Treatment Options. Front Mol Neurosci 2022;15:859221. [Crossref] [PubMed]
40. Kuiken TA, Marasco PD, Lock BA, et al. Redirection of cutaneous sensation from the hand to the chest skin of human amputees with targeted reinnervation. Proc Natl Acad Sci U S A 2007;104:20061-6. [Crossref] [PubMed]
41. Mauch JT, Kao DS, Friedly JL, et al. Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review. PM R 2023;15:1457-65. [Crossref] [PubMed]
42. Johnson ER, Powell J, Caldwell J, et al. Intercostal nerve conduction and posterior rhizotomy in the diagnosis and treatment of thoracic radiculopathy. J Neurol Neurosurg Psychiatry 1974;37:330-2. [Crossref] [PubMed]
43. Raikar S, Patil AA, Simmons A, Nilles-Melchert T. Surgical management of post-surgical intercostal thoracic-abdominal nerve neuroma. Egypt J Neurosurg 2021;36:8.
44. Abd-Elsayed A, Lee S, Jackson M. Radiofrequency Ablation for Treating Resistant Intercostal Neuralgia. Ochsner J 2018;18:91-3.
45. Gulati A, Shah R, Puttanniah V, et al. A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population. Pain Med 2015;16:802-10. [Crossref] [PubMed]
46. Abd-Elsayed A, Anis A, Kaye AD. Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias. Curr Pain Headache Rep 2018;22:5. [Crossref] [PubMed]
47. Koop O, Gries A, Eckert S, et al. The role of intercostal nerve preservation in pain control after thoracotomy. Eur J Cardiothorac Surg 2013;43:808-12. [Crossref] [PubMed]
48. Sakakura N, Usami N, Taniguchi T, et al. Assessment of long-term postoperative pain in open thoracotomy patients: pain reduction by the edge closure technique. Ann Thorac Surg 2010;89:1064-70. [Crossref] [PubMed]
49. Jiwnani S, Ranganathan P, Patil V, et al. Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial. J Thorac Cardiovasc Surg 2019;157:380-6. [Crossref] [PubMed]
50. Koryllos A, Althaus A, Poels M, et al. Impact of intercostal paravertebral neurectomy on post thoracotomy pain syndrome after thoracotomy in lung cancer patients: a randomized controlled trial. J Thorac Dis 2016;8:2427-33. [Crossref] [PubMed]
51. Gupta M, Scowcroft J, Kloster D, et al. 10-kHz Spinal Cord Stimulation for Chronic Postsurgical Pain: Results From a 12-Month Prospective, Multicenter Study. Pain Pract 2020;20:908-18. [Crossref] [PubMed]
52. Sayed D, Foster J, Nairizi A, et al. 10 kHz High-Frequency Spinal Cord Stimulation for Chronic Thoracic Pain: A Multicenter Case Series and a Guide for Optimal Anatomic Lead Placement. Pain Physician 2020;23:E369-76.
53. Chapman KB, Sayed D, Lamer T, et al. Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience. J Pain Res 2023;16:839-79. [Crossref] [PubMed]
54. Lo Bianco G, Papa A, Gazzerro G, et al. Dorsal Root Ganglion Stimulation for Chronic Postoperative Pain Following Thoracic Surgery: A Pilot Study. Neuromodulation 2021;24:774-8. [Crossref] [PubMed]
55. Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018;18:1048-67. [Crossref] [PubMed]
56. Esposito MF, Malayil R, Hanes M, et al. Unique Characteristics of the Dorsal Root Ganglion as a Target for Neuromodulation. Pain Med 2019;20:S23-30. [Crossref] [PubMed]
57. O'Connell NE, Ferraro MC, Gibson W, et al. Implanted spinal neuromodulation interventions for chronic pain in adults. Cochrane Database Syst Rev 2021;12:CD013756. [Crossref] [PubMed]
58. Strand N, D'Souza RS, Hagedorn JM, et al. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res 2022;15:2483-504. [Crossref] [PubMed]
59. Billet B, Wynendaele R, Vanquathem NE. A Novel Minimally Invasive Wireless Technology for Neuromodulation via Percutaneous Intercostal Nerve Stimulation for Post-Herpetic Neuralgia: A Case Report with Short-Term Follow-up. Pain Pract 2018;18:374-9. [Crossref] [PubMed]
60. Mitchell B, Verrills P, Vivian D, et al. Peripheral Nerve Field Stimulation Therapy for Patients With Thoracic Pain: A Prospective Study. Neuromodulation 2016;19:752-9. [Crossref] [PubMed]