Intercostal Nerve Cryoablation for Postoperative Pain Control After the Nuss Procedure in Children: A Systematic Review and Meta-Analysis

The Nuss procedure is the standard technique for Pectus Excavatum (PE) repair. Although minimally invasive, is associated with significant postoperative pain and high opioid use. Intercostal Nerve Cryoablation (INC) has emerged as an adjunct to multimodal analgesia (MMA) to improve pain control, reduce opioid use, and shorten hospital stay (LOS). This systematic review aims to assess INC outcomes following the Nuss procedure and is the first to focus exclusively on pediatric patients. The search was conducted in PubMed, Web of Science, Scopus, and Cochrane Library. Studies comparing INC to standard MMA in pediatric Nuss patients were included. Primary outcome was LOS; Secondary outcomes included opioid use, postoperative pain, complications, operative room time, and hospitalization costs. NIH tool was utilized for Bias assessment and R Software for Meta-analysis. Eleven studies were selected, comprising 922 patients (476 INC, 446 control). INC significantly reduced LOS (-2.2 days, 95%CI: -2.8;-1.8), although with increased operative room time (+23 minutes, 95%CI:10-39). Qualitative analysis showed reduced opioid use, from 50% to over 90% less with INC. Postoperative pain was not significantly different, except in two studies which favored INC. The rate of "any complication" and urinary retention were significantly lower in INC, with no differences regarding other complications. Impact on costs was conflicting and difficult to assess due to reporting heterogeneity. INC reduces LOS and opioid use in children undergoing the Nuss procedure, figuring as a promising adjunct to conventional MMA. Further studies are needed to assess long-term safety and cost-effectiveness.