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Learn more: PMC Disclaimer | PMC Copyright Notice A A Pract . 2026 Apr 10;20(4):e02195. doi: 10.1213/XAA.0000000000002195 Search in PMC Search in PubMed View in NLM Catalog Add to search Pecto-Intercostal Fascial Plane Radiofrequency Ablation for Chronic Post-Sternotomy Pain: A Case Report Yoshiki Okabe Yoshiki Okabe , MD 1 From the Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan. Find articles by Yoshiki Okabe 1 , Shogo Tsujikawa Shogo Tsujikawa , MD, PhD 1 From the Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan. Find articles by Shogo Tsujikawa 1, ✉ , Takashi Mori Takashi Mori , MD, PhD 1 From the Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan. Find articles by Takashi Mori 1 Author information Article notes Copyright and License information 1 From the Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan. ✉ Address correspondence to Shogo Tsujikawa, MD, PhD, Department of Anesthesiology, Osaka Metropolitan University Graduate School of Medicine, l-5-7, Asahimachi, Abenoku, Osaka 545-8586, Japan. Address e-mail to [email protected] . ✉ Corresponding author. Accepted 2026 Mar 20; Collection date 2026 Apr. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. PMC Copyright notice PMCID: PMC13075783 PMID: 41961989 Abstract Chronic post-sternotomy pain is a clinical problem that can impair quality of life. We report a case of refractory chest pain after coronary artery bypass grafting that was successfully treated using pecto-intercostal fascial plane radiofrequency ablation (PIFP-RFA). A 72-year-old man presented with persistent anterior chest pain that was unresponsive to medication for 1 year. Diagnostic PIFP blocks produced temporary complete pain relief, prompting the decision to perform RFA. Ultrasound-guided PIFP-RFA at the third and fourth parasternal intercostal levels bilaterally achieved complete pain resolution. This case highlights the safety and potential long-term efficacy of PIFP-RFA in patients receiving antithrombotic therapy. Post-sternotomy pain is a frequent complication after cardiac surgery. Although typically transient, 30% to 40% of patients report pain persistent pain beyond three months, and approximately 11% to 56% develop chronic post-sternotomy pain syndrome (PSPS). 1 The pain is often neuropathic, resulting from injury to or entrapment of the anterior cutaneous branches of the intercostal nerves (T2–T6) during sternotomy or sternal wire placement. 2 Traditional management includes multimodal analgesia—nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and neuropathic agents such as gabapentin or pregabalin—along with physiotherapy and psychological support. However, some patients experience refractory symptoms despite multiple therapeutic interventions. Several parasternal block techniques have been described for managing chronic anterior thoracic pain, including the pecto-intercostal fascial plane (PIFP) block, which targets a relatively superficial fascial plane located between the pectoralis major and intercostal muscles. 3 Although the efficacy of the PIFP block for anterior chest pain after cardiovascular surgery has been demonstrated, no reports to date have described the long-term efficacy of radiofrequency ablation (RFA) performed via the PIFP approach for chronic pain. Here, we report the application of this analgesic technique for persistent anterior chest wall pain after sternotomy. Written informed consent was obtained from the patient for publication of this case report. This manuscript adheres to the applicable EQUATOR guideline. CASE DESCRIPTION A 72-year-old man (height, 173 cm; weight, 81 kg) with a medical history of non-insulin-dependent diabetes mellitus and hyperlipidemia, both controlled with oral medications, presented with angina pectoris. He subsequently underwent coronary artery bypass grafting with cardiopulmonary bypass under general anesthesia. The procedure was performed using the left internal thoracic artery and the great saphenous vein for grafting and was completed without complications. He was extubated on postoperative day 1 and discharged as scheduled. After discharge, the patient experienced persistent anterior chest wall pain. Despite analgesic management with NSAIDs, mirogabalin, a serotonin–noradrenaline reuptake inhibitor (SNRI), and a weak opioid, pain did not improve, and he was referred to our department. At initial consultation, he reported anterior chest pain corresponding to the surgical incision at the T3–T4 dermatomes, with a Numeric Rating Scale (NRS) score of 7 and marked tenderness with allodynia and burning sensations. Psychological assessment revealed a Pain Catastrophizing Scale score of 45, indicating prominent catastrophizing. Escalation of the weak opioid provided no additional analgesia; therefore, bilateral single-shot PIFP blocks were performed under ultrasound guidance using a 13 to 6 MHz linear transducer (FUJIFILM-Sonocite). The pectoralis major and intercostal muscles were identified 1 cm lateral to the sternal border, and a 60-mm thermocatellane needle (Terumo Corporation) was advanced in-plane in the caudocranial direction at the third and fourth rib levels (Figure). After negative aspiration, 5 mL of 1% mepivacaine was administered bilaterally because of the localized nature of the pain. The procedure was performed without discontinuing aspirin therapy, and prolonged compression was applied after needle withdrawal to prevent hemorrhage. Because the block produced clear analgesia, pain was attributed to the anterior cutaneous branches of the intercostal nerves. To achieve longer-lasting analgesia, pulsed radiofrequency (PRF) treatment targeting the anterior cutaneous branches of the intercostal nerves at bilateral T3 and T4 was performed 1 week later. A radiofrequency needle (TOP Neuropole SC-K Disposable thermocouple Needles, Straight Sharp 6 cm 22G, 5-mm active tip; TOP Corporation) was inserted under ultrasound guidance, and correct placement between the pectoralis major and intercostal muscles was confirmed, followed by sensory stimulation. Although the targeted nerve could not be visually identified, radiating pain concordant with the symptomatic area was elicited at 100 Hz and 0.3 V; PRF (42°C for 360 seconds) was then applied at two sites per side (four treatment points). His pain decreased to an NRS score of 3; however, analgesic medications could not be tapered, and pain gradually recurred within 1 month. Therefore, PIFP-RFA was scheduled. Figure. Open in a new tab Various approaches to parasternal block techniques. Linear ultrasound images of the pecto-intercostal fascial plane (PIFP), deep parasternal intercostal plane (DPIP), and transversus thoracis muscle plane (TTMP) blocks. Similar to the PRF procedure, test stimulation under ultrasound guidance between the pectoralis major and intercostal muscles reproduced radiating pain consistent with the patient’s symptoms. After 0.5 mL of 2% lidocaine was administered, thermal coagulation was performed at four sites in total (two per side) at 90°C for 90 seconds. No procedure-related complications, including dysesthesia, neuritis, hematoma, infection, or pneumothorax, occurred after PIFP-RFA. His pain decreased to an NRS score of 2; all analgesic medications were discontinued, and the treatment course was completed at 6-month follow-up. DISCUSSION Persistent parasternal pain after cardiac surgery, when untreated or insufficiently managed, may progress from a localized nociceptive process into a complex chronic pain syndrome characterized by central sensitization, neuroplastic changes, and psychological distress. 4 These alterations lower pain thresholds and expand pain perception beyond the surgical site. This case highlights the successful use of bilateral PIFP RFA as part of a multimodal analgesic strategy for PSPS. The patient was receiving antithrombotic therapy after cardiovascular surgery; therefore, performing PIFP RFA under ultrasound guidance at a relatively superficial anatomical layer is crucial, as it may reduce procedure-related complications and provide safer, long-lasting analgesia. Chronic PSPS is a prevalent but underrecognized complication, with an incidence of 17% to 56% depending on study design, chronicity definition, and follow-up duration. 5 Approximately 5% to 10% of patients develop severe, function-limiting pain persisting beyond 6 months, adversely affecting quality of life and rehabilitation, as in this case. 6 Pain is typically localized to the parasternal or anterior thoracic region and exhibits neuropathic features such as burning, shooting sensations, and allodynia. The development of chronic PSPS is multifactorial, with the severity of acute postoperative pain being one of the strongest predictors. Patients who experience uncontrolled pain during the first postoperative days are significantly more likely to develop chronic pain, emphasizing the importance of aggressive early analgesia. 1 Demographic factors, including younger age and female sex, have been linked to increased susceptibility, possibly reflecting differences in pain perception, hormonal modulation, or psychosocial coping. Surgical and perioperative factors also contribute. Harvesting the internal thoracic artery may injure adjacent intercostal nerves; re-sternotomy, prolonged sternal retraction, emergency procedures, or wound infection further increase this risk. Mechanical causes, such as sternal instability, nonunion, or sternal wire irritation, further perpetuate nociceptive input. Anxiety, depression, and pain catastrophizing amplify central sensitization, whereas comorbidities, including hypothyroidism, previous percutaneous coronary intervention, and reduced left ventricular ejection fraction, have been identified as independent risk variables. 7 The treatment of chronic PSPS remains challenging because pain encompasses both nociceptive and neuropathic components. First-line pharmacological therapies include NSAIDs, acetaminophen, and weak opioids; however, these agents often provide insufficient relief for neuropathic pain. 1 Adjuvant medications such as gabapentin, pregabalin, tricyclic antidepressants, or SNRIs are commonly used; however, their efficacy is partial and limited by adverse effects, including dizziness, somnolence, and cognitive impairment. Regional anesthesia techniques are increasingly recognized as pivotal for diagnosing and treating chronic anterior chest pain. Given that the sternum is innervated by the intercostal nerves arising from T2 through T6, nerve blocks targeting at these segments are considered appropriate therapeutic modalities. Although epidural, paravertebral, and intercostal nerve blocks at the subcostal level were considered viable options, they were deemed to carry an elevated risk of complications in this case owing to the patient’s ongoing antithrombotic therapy after cardiac surgery. Local anesthetic infiltration or parasternal intercostal nerve blocks provide temporary relief and diagnostic information to confirm peripheral pain. Several reports have described parasternal peripheral nerve blocks targeting the anterior cutaneous branches of the intercostal nerves for managing anterior chest wall pain. Parasternal blocks reported in the literature include the transversus thoracis muscle plane (TTMP), deep parasternal intercostal plane (DPIP), and PIFP blocks. 3 , 8 , 9 TTMP and DPIP blocks involve administration of local anesthetic into the fascial plane between the transversus thoracis and intercostal muscles, whereas the PIFP block entails injection into the fascial plane between the pectoralis major and intercostal muscles. Because the PIFP block targets a more superficial fascial layer than the TTMP and DPIP blocks, it reduces the risk of pleural puncture, pneumothorax, or vascular injury and allows safer administration in patients receiving antithrombotic therapy after cardiovascular surgery, as in this case. These techniques can be effective; however, their use is sometimes limited by short duration. More sustained techniques, such as cryoneurolysis, PRF, or RFA, provide longer-lasting benefits. 10 , 11 PRF produces neuromodulatory effects without significant neural destruction by maintaining tissue temperatures below 42°C, whereas conventional RFA generates higher temperatures that lead to thermal coagulation of nociceptive fibers and may therefore be associated with a higher risk of sensory adverse effects, such as transient neuritic pain or dysesthesia, although the absolute incidence of these complications appears to be low. 12 Compared with repeated local anesthetic injections, PRF and RFA reduce the need for ongoing procedures and decrease reliance on systemic analgesics. For this reason, we initially selected PRF to minimize the risk of post-procedural sensory disturbances. However, because PRF provided only partial and temporary analgesia in this patient, we proceeded to conventional RFA to achieve more durable pain relief. A published case report has demonstrated that DPIP RFA was effective for persistent chest wall pain after sternotomy with minimal complications. 9 In this case, RFA was performed using the PIFP approach, which has not been previously reported, and resulted in prolonged analgesia compared with earlier cases using the DPIP approach. Although the individual anterior cutaneous branches of the intercostal nerves are often too small to be directly visualized on ultrasound, they traverse the fascial plane between the pectoralis major and intercostal muscles. In our case, needle position was optimized under ultrasound guidance and confirmed by sensory stimulation reproducing concordant radiating pain. Integrating these approaches within a multimodal pain management framework can substantially improve postoperative recovery, reduce opioid dependence, and enhance quality of life after cardiac surgery. Corticosteroids may be administered after RFA in an attempt to prolong its effects and reduce post-procedural neuritis; however, routine steroid administration remains controversial, and available evidence suggests that it does not significantly reduce the incidence of post-neurotomy neuritis. 13 Therefore, since the patient had diabetes, we preferred not to use corticosteroids during the lesioning RFA procedure. Fortunately, no neuritis or pain recurrence was observed during the six-month follow-up period. Bilateral PIFP-RFA of the anterior intercostal branches achieved effective, long-lasting pain relief in a patient with refractory PSPS. Chronic PSPS is multifactorial, influenced by patient, surgical, and psychosocial factors. A tailored strategy combining diagnostic nerve blocks, ultrasound-guided fascial plane blocks, and RFA offers a safe, effective pathway to durable analgesia. Given its minimal invasiveness and compatibility with antiplatelet therapy, this approach deserves further evaluation through prospective studies to define its role in standardized chronic post-sternotomy pain management. This manuscript was handled by: Christina L. Jeng, MD, FASA, FASRA. Footnotes The authors declare no conflicts of interest. Funding: None. REFERENCES 1. Kleiman AM, Sanders DT, Nemergut EC, Huffmyer JL. Chronic poststernotomy pain: incidence, risk factors, treatment, prevention, and the anesthesiologist's role. Reg Anesth Pain Med. 2017;42:698–708. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Morales JF, Ricci MJ, Verma S, et al. How I do it — superficial parasternal intercostal plane catheter insertion. JTCVS Tech. 2025;30:107–110. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Joshi P, Borde D, Apsingekar P, et al. Pecto-intercostal fascial plane block: a novel technique for analgesia in patients with sternal dehiscence. 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