Role of intercostal nerve block and cryoneurolysis in the management of rib fractures: a narrative review

Introduction

Background

Blunt chest trauma, frequently accompanied by rib fractures, remains one of the leading causes of acute and chronic pain, significantly reducing patients’ quality of life and delaying their return to daily activities (1,2). According to epidemiological studies, rib fractures are associated with mortality rates of up to 10% and complication rates of approximately 13%, with severe pain contributing considerably to these unfavorable outcomes (3-7). Adequate pain control is crucial for preventing respiratory complications and getting patients back to activities of daily living quicker by allowing patients to adequately perform breathing exercises, cough effectively, avoid shallow breathing induced by pain, and move more freely. Moreover, inadequate pain management following chest wall surgery may lead to the development of post-thoracotomy pain syndrome and progression to chronic pain, thereby complicating rehabilitation and impairing quality of life (8,9).

Contemporary protocols for managing patients with rib fractures emphasize aggressive pain control, maintaining adequate pulmonary hygiene, and early mobilization (10-12). Over the past decade, compelling evidence has emerged indicating that timely analgesia and surgical stabilization of rib fractures (SSRF) can reduce the incidence of complications, shorten hospital stays, and decrease the severity of both acute and chronic pain (13-18). Nonetheless, traditional analgesic strategies continue to rely heavily on opioid analgesics, which although highly potent, are associated with serious side effects such as nausea, vomiting, pruritus, constipation, delirium, immunosuppression, and respiratory depression (19). In addition, opioids have been linked to hyperalgesia and the growing issue of opioid dependence, especially in the United States, is currently viewed as a serious public health threat (20). This highlights the importance of developing strategies to minimize or eliminate the use of opioids.

Among the adjuvant and non-opioid methods commonly used are acetaminophen, nonsteroidal anti-inflammatory drugs, anticonvulsants (gabapentin, pregabalin), muscle relaxants, and Lidoderm patches (21,22). Regional analgesic techniques, particularly epidural catheter anesthesia, have demonstrated high efficacy in numerous studies (23-26). However, placing an epidural catheter can be challenging in patients with polytrauma who have injuries to the thoracic spine or spinal cord, coagulopathies, severe traumatic brain injury, or infectious complications (26-28). Consequently, the key question arises: is there a better way we ensure adequate acute pain control in multiple rib fractures while simultaneously reducing the risk of chronic pain through modern, minimally invasive technologies?

One promising avenue is the use of advanced regional anesthesia techniques, such as intercostal nerve blocks (ICNBs) and cryoneurolysis. These methods are thought to provide targeted and effective analgesia while decreasing the opioid burden, thereby minimizing the risk of adverse effects (29,30). Nevertheless, questions remain regarding the technical details of these procedures, the duration of their analgesic effect, possible complications, and their impact on long-term outcomes.

Rationale and knowledge gap

Recent reviews have examined ICNB and intercostal cryoneurolysis separately, either focusing on narrow patient cohorts (e.g., thoracotomy, paediatric pectus repair, chronic pain) or mentioning them only briefly in chest-trauma analgesia (31-35). None has directly compared these modalities in adult traumatic rib-fracture patients, evaluated their sequential or combined use, or included the pivotal ultrasound-guided cryoneurolysis and liposomal-bupivacaine ICNB studies published in 2023–2025. Consequently, clinicians still lack an up-to-date, evidence-based framework for selecting and integrating these techniques.

Objectives

This review aims to summarize current findings on the role of intercostal nerve blockade and cryoneurolysis in the management of rib fractures, highlighting existing controversies, and outlining potential directions for future research. We present this article in accordance with the Narrative Review reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-14/rc).

Methods

A targeted literature search was performed in PubMed, Embase, Cochrane Library, Google Scholar, and Web of Science for articles published in English up to April 2025 (Table 1). The search focused on analgesic methods for rib fractures, including both invasive and minimally invasive approaches. A combination of MeSH terms and free-text keywords was used, encompassing “rib fractures”, “intercostal nerve block”, “cryoanalgesia”, “cryoablation”, “cryoneurolysis”, “pain management”, and “post-thoracotomy pain syndrome”.

Inclusion criteria: original studies (randomised or non-randomised trials, prospective or retrospective cohort studies) and systematic reviews or meta-analyses that investigated ICNBs or intercostal cryoneurolysis in patients with rib fractures. Both non-operative management and surgical stabilisation of rib fractures were eligible, and the treatment context was recorded when reported.

Exclusion criteria: (I) no direct focus on rib fractures; (II) regional techniques without an ICNB or cryo component; (III) lack of pain-related or clinical outcomes; (IV) publications not in English; and (V) editorials, letters, conference abstracts without a full paper.

The search returned 6,742 records. Removing 4,889 duplicates left 1,853 unique citations. Two reviewers (V.M. and Z.M.B.) screened titles and abstracts, excluding 1,632 records. Of 221 full texts assessed, 140 failed the eligibility criteria, leaving 81 studies for qualitative synthesis.

The focus of this review was to discuss modalities that can be used at the time of surgery, specifically SSRF. We recognize that many of these modalities can also be performed exclusive of surgery, but please see the section on non-surgical regional analgesic techniques for additional information regarding these procedures.

ICNB

Historical background

Since the early 20^th century, ICNB has been widely adopted as a modality for chest wall pain control (36,37). Initially, it was used as a stand-alone technique for surgical interventions on the chest wall and breast, as well as in combination with celiac plexus block during abdominal procedures (36). However, a key challenge has been the need to block multiple intercostal nerves sequentially to cover several dermatomes, which often complicates the procedure and causes patient discomfort.

The ICNB was first mentioned by Braun in 1907 in the German textbook Die Lokalanästhesie, where he also provided a detailed description of paravertebral blockade for thoracic and spinal surgeries (37). In the 1940s, its indications expanded to include postoperative pain management. Notably, study by McCleery et al. demonstrated that for upper abdominal surgeries, ICNB reduced the incidence of pulmonary complications and significantly decreased opioid requirements (38).

A large-scale study by Moore et al. [1962] involving 4,333 patients who underwent ICNB over a 12-year period confirmed its high efficacy for both thoracic and abdominal operations, particularly for postoperative pain relief (39). An important advance in reducing the need for multiple injections came in 1981, when O’Kelly and Garry proposed the use of a catheter for continuous anesthetic administration through a single intercostal space—an approach that provided prolonged pain control in patients with multiple rib fractures (40). Later, in 1988, Doppler ultrasound was introduced to improve visualization of intercostal nerves and enhance the accuracy of the block (41).

Technique of ICNB

Intercostal nerves are mixed nerves containing motor and sensory fibers from the ventral rami of the thoracic spinal nerves (T1–T11) (37). They run along the inferior margin of each corresponding rib, providing innervation to the pleura, peritoneum, as well as the skin and muscles of the thoracic and abdominal wall (42,43). Because each intercostal nerve supplies a relatively narrow dermatomal band, blocking several adjacent segments is often required (43). Typically, 3–5 mL of local anesthetic is injected per level, with the total dose calculated according to the patient’s body weight and the maximum permissible dose of the drug.

The procedure can be performed in various patient positions (lateral decubitus, supine, or seated), provided there is adequate exposure of the chest wall and patient comfort. After skin preparation with an antiseptic solution, a small volume of local anesthetic (1–2 mL) can be injected subcutaneously to minimize procedural pain. Using anatomical landmarks, the operator palpates the rib at the target level (for instance, identifying the scapular angle, which corresponds to approximately the seventh rib), follows its posterolateral curvature, and gently stretches the skin at the puncture site. A 22 G needle (~50 mm) is introduced at a 20° cephalad angle until contact is made with the inferior border of the rib (44). The skin traction is then released, and the needle is advanced an additional 1–3 mm through the fascia of the internal intercostal muscle. Before injecting the anesthetic, aspiration is performed to rule out intravascular placement followed by injection of 3–5 mL of local anesthetic. If necessary, the process is repeated at adjacent levels.

Under ultrasound guidance, a high-frequency linear transducer is initially placed transversely over the spine to visualize vertebral bodies and ribs, then moved laterally to obtain a clear view of the intercostal muscles and the pleura (seen as a hyperechoic, mobile line). Ribs appear as curved, highly echogenic structures with acoustic shadowing. In-plane needle insertion is generally preferred, targeting the inferior margin of the upper rib between the internal and innermost intercostal muscles. Local anesthetic is administered in fractional increments, with aspiration before each injection while real-time ultrasound confirms tissue hydrodissection and the downward displacement of the pleura (45). Ultrasound guidance increases both precision and safety by accurately placing the local anesthetic proximal to the lateral branch of the intercostal nerve, thereby reducing the risk of pneumothorax and intravascular injection.

Contemporary research and clinical outcomes

Several recent randomized clinical trials in adults undergoing thoracic surgery have shown that ICNB provides moderate pain relief during the first 24 hours postoperatively (46-49). Its analgesic effect surpasses that of systemic opioid analgesia and is comparable to thoracic epidural analgesia (TEA), falling only slightly behind paravertebral block (PVB). These studies also report improvements in pulmonary function and a reduced risk of postoperative pulmonary complications underscoring the clinical importance of ICNB.

A retrospective review by Sheets et al. analyzed 116 cases of traumatic rib fractures and compared the effectiveness of ICNB with liposomal bupivacaine to epidural analgesia (50). ICNB was associated with a significantly shorter intensive care unit (ICU) stay (2±5 vs. 5±6 days; P=0.007) and a reduced overall length of hospital stay (8±6 vs. 11±9 days; P=0.02).

Indications, advantages, and limitations of ICNB

Key indications for ICNB include pain originating from the lateral and posterior aspects of the chest wall (e.g., traumatic rib fractures) as well as situations in which TEA is technically challenging or carries higher risk (51). Its primary advantages include straightforward execution under ultrasound guidance, reduced opioid requirements, and better pulmonary function (51).

However, ICNB does have some limitations. When multiple rib fractures or large areas of innervation are involved, multiple intercostal nerves need to be blocked, increasing both the total volume of anesthetic and the potential for systemic toxicity. Moreover, local anesthetic absorption in this region is rapid, resulting in relatively short analgesic duration that may necessitate repeated injections. There is also a risk of pneumothorax, especially in cases with poor visualization or limited operator experience (52-54). Because the analgesic effect of ICNB usually wears off within 24 to 48 hours, there is a risk of rebound pain, defined as a sudden increase in pain once the anesthetic effect subsides, which may in some cases contribute to the development of chronic pain (55,56). These limitations, including the short duration of effect, the risk of rebound pain, and the need for multiple injections, underscore the relevance of prolonged analgesic techniques. Continuous ICNB, which provides stable analgesia without repeated needle punctures, has gained increasing interest and will be discussed in the next subsection.

Continuous intercostal nerve blockade and elastomeric infusion pumps

Given the limited duration of a single-injection ICNB, the potential for rebound pain, and the necessity for repeated needle punctures, there has been growing interest in recent years in strategies that deliver more stable analgesia. One such approach is continuous ICNB in which a catheter placed in the intercostal space enables the uninterrupted administration of local anesthetics. This method avoids significant fluctuations in drug concentration, decreases the risk of rebound pain, and reduces the number of invasive procedures (57,58).

Elastomeric infusion pumps play a central role in continuous ICNB. These compact, lightweight, single-use devices are capable of delivering medication over two to seven days, depending on the capacity of the reservoir. They resemble small balloons with a soft outer shell and a cylindrical inner core (59). The pump connects to either a single- or dual-lumen catheter positioned in close proximity to the target nerves (e.g., near rib fractures or at the surgical site). Ropivacaine or bupivacaine are commonly used, offering reliable and consistent analgesia. Elastomeric pumps are available in several configurations with a fixed infusion rate, an adjustable rate, or with patient-controlled boluses. The infusion catheter can be inserted intraoperatively following SSRF or at the bedside in an awake patient under real-time ultrasound guidance. Bedside placement typically requires only a small subcutaneous dose of local anesthetic and does not require systemic sedation or general anesthesia.

Proper placement of the catheter requires careful dissection of the extrapleural space under direct visualization to avoid breaching the pleural cavity. A sterile tunneler facilitates catheter placement; subsequently, the tunneler is removed using its peel-away sheath. To prevent dislodgement, the catheter is secured to the chest wall and connected to the elastomeric pump. This system provides prolonged release of local anesthetic, minimizing both early postoperative pain and trauma-related discomfort while eliminating the need for multiple injections. Consequently, continuous ICNB with elastomeric pumps is increasingly recognized as a safe and patient-centered approach to extended analgesia in surgical and traumatic settings (60).

Several randomized trials have demonstrated that continuous ICNB ensures effective postoperative analgesia following thoracotomy, leading to lower opioid requirements (61-64). Moreover, studies indicate that in cases of rib fractures, continuous ICNB significantly enhances pulmonary function, improves pain control, and shortens hospital stays.

In a prospective, nonrandomized study by Truitt et al. [2011], which involved 102 patients with three or more unilateral rib fractures, continuous ICNB was shown to be highly effective. Pain scores on the Numerical Pain Scale significantly decreased both at rest (from 7.5 to 2.6; P<0.05) and on coughing (from 9.4 to 3.6; P<0.05). The mean hospital length of stay was 2.9 days, notably lower than that in the historical control group (5.9 days) (65).

In 2015, Britt et al. conducted a retrospective study of 107 patients with two or more traumatic rib fractures, comparing continuous ICNB and epidural analgesia. The continuous ICNB group showed a significant reduction in the overall hospital length of stay; however, there were no differences in respiratory complications, duration of mechanical ventilation, or ICU length of stay between the groups (66).

A retrospective analysis by Uhlich et al. [2021] evaluated 933 patients with multiple rib fractures, 48 of whom received ICNBs. Their outcomes were compared with those of 96 matched controls. Patients treated with ICNB experienced a significantly higher number of days outside the hospital during a 30-day period (15.9±6.43 vs. 13.2±9.94; P=0.048), a lower incidence of pneumonia (4.2% vs. 16.7%; P=0.03), and a reduced in-hospital mortality rate (2.1% vs. 13.5%; P=0.03) (67).

Catheter placement for continuous ICNB is straightforward and minimally invasive, facilitating widespread adoption of the technique. It provides prolonged analgesia, promotes earlier patient mobilization, and reduces the need for systemic analgesics. Elastomeric pumps can be refilled as needed allowing catheter use for several days, and in some instances, patients are even discharged home with the pump in place for ongoing pain management (65).

In summary, intercostal nerve blockade has undergone a substantial evolution from the labor-intensive process of repeated anesthetic injections to safer, more effective, and longer-lasting analgesic methods made possible by continuous infusion and ultrasound guidance. Ongoing refinements of these techniques and the integration of innovative pain management modalities continue to expand their clinical utility and enhance patient outcomes.

Cryoneurolysis

Modern clinical practice extensively employs various minimally invasive methods for pain control. Among the most promising of these is nerve cryoneurolysis (or cryoanalgesia), which involves controlled cooling of nerve tissue to achieve prolonged analgesia. Since its introduction, this technology has undergone significant refinements: in 1961, Cooper et al. developed one of the earliest cryoprobes based on liquid nitrogen, capable of reaching −190 ℃ (68). In 1976, Lloyd and colleagues introduced the term “cryoanalgesia”, defining it as a low-temperature neuroablation technique for pain relief (69).

Further progress in the concept of cryoneurolysis is illustrated by Nelson et al., who in 1974 first described intraoperative intercostal cryoneurolysis in 38 patients. Their results showed a statistically significant reduction in postoperative opioid consumption compared to a control group (661.0 vs. 855.2 mg of meperidine; P<0.05) (70). Despite these promising findings and its widespread adoption, interest in intercostal cryoneurolysis among thoracic surgeons had waned by the mid-1990s. Possible explanations include inconsistent research outcomes, competition from epidural catheters, and reports of neuralgia in some patients.

Mechanisms of cryoneurolysis

Cryoneurolysis provides a temporary block of peripheral nerves by applying extremely low temperatures. According to Sunderland’s classification, cooling a nerve to −60 to −100 ℃ induces a second-degree injury (axonotmesis) in which the axon is disrupted but the connective tissue sheaths (endoneurium, perineurium, epineurium) remain intact (71). This “controlled” axonal disruption triggers a process of reversible injury with predictable regeneration, preventing neuroma formation and enabling prolonged analgesia. Axonal recovery occurs at a rate of 1–2 mm per day from the ablation zone outward while clinically relevant pain blockade can last from several weeks to a few months (72).

Technique of cryoneurolysis

Cryoneurolysis is technically performed with a cryoprobe using the Joule–Thomson effect (73). A high-pressure gas (nitrous oxide or carbon dioxide) passes through a narrow orifice at the probe’s distal tip and rapidly expands, causing the metal tip to cool (73). The resulting “ice ball” interacts with the targeted nerve, producing a reversible axonal injury distal to the contact point. Upon completion of the procedure, the gas is evacuated through an internal channel preventing its entry into the patient’s tissues (74).

Preservation of the connective tissue layers is crucial for achieving long-lasting analgesia: as axons regenerate within their native pathways, neuroma formation is prevented (74). Over time, normal sensation and/or motor function return, but significant analgesia persists throughout the regeneration period.

Most cryoneurolysis is done at the time of surgical intervention. In the case of SSRF, intercostal nerve cryoablation (INCA) can be performed from an intra- (via thoracoscopy) or extra-thoracic approach with direct visualization of the intercostal nerve (Figure 1). Various probes exist to allow for this intercostal nerve cryoneurolysis. It is important to perform this cryoneurolysis proximal to the rib fracture, however, it is important to stay approximately 4 cm from the thoracic spine as not to affect the thoracic ganglion (75). It is also important to limit cryoablation to intercostal nerves T3–T9 to avoid neurological complications such as Horner’s-like syndrome and flank pseudohernia, associated with levels above T3 and T9 and below, respectively (75,76). Intercostal nerve cryoneurolysis can also be performed percutaneously. Ultrasound guidance is commonly used, allowing real-time visualization of the nerve and the formation of the ice ball (77,78). A linear transducer (7–15 MHz) is typically employed for superficially located nerves, while convex or microconvex probes are used for deeper structures. The proceduralist advances the cryoprobe toward the target nerve under ultrasound guidance and can adjust positioning in response to changes in echogenicity during cooling. Where ultrasound guidance is challenging, computed tomography or fluoroscopy may be used instead (79). The advantage of percutaneous cryoneurolysis is that the patient does not need to undergo a surgical operation and therefore the associated risks. Although computed tomography or fluoroscopy are not as readily available as ultrasound to perform percutaneous cryoneurolysis, it may afford a patient a trip to the operating room to undergo the risk of general anesthetic, etc. It is also important to remember that ultrasonography is user dependent and based on the skill set of the proceduralist, therefore it may not be as comfortable for the provider looking to perform the bedside procedure.

Figure 1 Intercostal nerve cryoablation.

Evidence of effectiveness

Although cryoneurolysis is still considered a relatively novel technique, a number of studies support its efficacy. Many have been conducted in the context of pectus excavatum correction using the Nuss procedure, where cryoneurolysis has been shown to reduce opioid consumption and shorten hospital stays (80-85). There is also substantial evidence supporting cryoneurolysis for preventing and treating post-thoracotomy pain. Multiple investigations have demonstrated reductions in the need for narcotic analgesics and decreases in pain intensity compared to conventional approaches (86-89).

Regarding rib fractures, cryoneurolysis has most frequently been studied in conjunction with SSRF. In a large multicenter retrospective study by Bauman et al. involving 136 patients (92 received only SSRF, while 44 underwent SSRF with intraoperative INCA), the investigators found a significant decrease in overall length of hospital stay (9 vs. 10 days, P=0.026) and lower postoperative opioid consumption [88.6 vs. 113.7 morphine milligram equivalent (MME), P=0.026] for patients that had the added INCA to the SSRF procedure (75).

In the retrospective analysis by Fernandez et al., which included 68 patients who underwent SSRF (44 of whom received INCA), those treated with INCA demonstrated significantly lower opioid requirements. Specifically, the total MME was reduced by an average of 71.1% [95% confidence interval (CI): 36.9–86.7%; P=0.002] while the mean daily opioid consumption was 54.1% lower (95% CI: 15.1%–75.2%). Additionally, INCA use was associated with a reduced need for intubation (P=0.002) and tracheostomy (P=0.032) along with a higher likelihood of direct discharge home (P=0.044) (90).

Marturano et al. retrospectively analyzed 241 patients, of whom 51 received INCA during SSRF. Compared to SSRF alone, INCA was associated with reduced daily MME by 9.4 mg (P=0.035), decreased total postoperative opioid use by 73% (P=0.001), and was associated with shortened ICU stays (by a factor of 1.55; P=0.013) as well as ventilation time (which was 3.8 times longer in the SSRF only group) (91). Lastly, O’Connor et al. examined 26 patients with rib fractures who underwent SSRF 14 received cryoneurolysis at the time of surgery, while 12 were managed with an elastomeric pump for analgesia. The study reported statistically lower opioid consumption and reduced pain scores in the cryoneurolysis group (92).

Contraindications and complications

These disease processes are often difficult to diagnose and unless the patient has a history of these diseases, they may not be readily known in an acute setting or at the time of cryoneurolysis. However, if they are known, the recommendation would be to avoid this procedure. Relative contraindications to cryoneurolysis include Raynaud’s syndrome, cryoglobulinemia, and cold urticaria, as these conditions are associated with adverse vascular and immune responses to low temperatures. While complications are rare with both intraoperative and percutaneous cryoneurolysis, their risk profiles differ slightly. Intraoperative cryoablation is performed under direct visualization, and the routine placement of a chest tube during SSRF effectively eliminates concern for pneumothorax. In contrast, percutaneous cryoneurolysis carries a small but notable risk of pneumothorax, warranting a post-procedure chest radiograph (93,94). Both approaches may result in minimal bleeding at the probe insertion site and, in rare cases, incomplete nerve ablation, which can lead to transient neuralgia during axonal regeneration (93,94). Furthermore, if INCA occurs below intercostal nerve 9, patients sometimes can develop a flank pseudohernia due to these nerves simultaneously innervating the external and internal oblique muscles (95). Furthermore, if INCA is performed above intercostal nerve 3, patients can develop a “Horner’s-type” syndrome (75,76). Therefore, INCA should be avoided in these locations. One complication of cryoablation that has been reported is that of allodynia (a normally non-painful stimuli that can now cause pain) (75,96). Although extremely rare, the condition often resolves on its own or may require a short duration of medication (i.e., gabapentin, pregabalin, etc.) (96). It has been suggested that cryoablation can cause a traumatic neuroma, however, several papers have been published demonstrating cryoablation should not result in a traumatic neuroma (74,97-100). With rib fractures, the more probable cause of a traumatic neuroma is the rib fracture itself or if the patient undergoes rib fixation, it may result from intercostal nerve injury from a retractor, port placement, nerve manipulation, etc. Nonetheless, it is important to discuss the possibility of allodynia with the patient prior to performing INCA. Key technical and clinical differences among these three analgesic modalities are summarized in Table 2.

Strengths and limitations

Despite its contributions, this narrative review has several limitations. First, because it is not systematic, some relevant studies may have been missed. Second, the included sources differ markedly in anesthetic agents, block techniques, and sample sizes, which makes direct comparison difficult. Many of the available data also come from retrospective studies with small cohorts, reducing the strength and reproducibility of the evidence. Finally, most studies provide no long term follow up, preventing an adequate evaluation of delayed complications such as neurologic sequelae, neuroma formation, and cost effectiveness. This review has several key strengths. It provides a focused and timely analysis of ICNB and cryoneurolysis, as two promising techniques in the management of rib fracture pain. The comprehensive discussion of indications, contraindications, and procedural details makes it a valuable resource for surgical and critical care teams. By combining historical context with a critical appraisal of current evidence, the review supports the integration of these regional techniques into contemporary multimodal analgesia protocols.

Conclusion and future perspectives

Cryoneurolysis is gaining traction as a valuable pain adjunct in chest wall trauma, especially in the context of rib fractures and SSRF due to its efficacy and the reversible nature of the axonotmesis it induces. While ICNB remains an established and widely used method for managing chest wall pain, cryoneurolysis offers the benefit of prolonged analgesia with a low risk of complications, making it particularly attractive in perioperative settings and for managing chronic pain syndromes associated with various chest injuries. Further large-scale randomized studies are needed not only to confirm the efficacy of cryoneurolysis in patients with rib fractures but also to compare its benefits and limitations directly with those of ICNB. Such research would help to identify specific patient groups most likely to benefit from each modality and establish unified standards for their clinical application.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Christopher F. Janowak) for the series “Chest Trauma” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-14/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-14/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-14/coif). The series “Chest Trauma” was commissioned by the editorial office without any funding or sponsorship. Z.M.B. is a paid educational consultant for KLS-Martin, Zimmer-Biomet and Atricure, and Smith&Nephew. 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. This review did not require IRB approval.

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/.

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