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

Background and Objective: Intercostal neuralgia (ICN) is a debilitating neuropathic pain syndrome with heterogeneous etiologies, including post-thoracotomy pain, and iatrogenic nerve injury. Despite its significant functional and psychosocial burden, management remains challenging, and literature on surgical interventions is limited. This review aims to synthesize current evidence on surgical options for ICN, with a focus on techniques relevant to plastic and peripheral nerve surgery. Methods: A narrative review was conducted from database inception through March 2026 using MEDLINE and Embase via Ovid, and PubMed. Search terms included "intercostal neuralgia", "intercostal nerve injury", "post-thoracotomy pain", "neurectomy", "neurolysis", "targeted muscle reinnervation (TMR)", and "regenerative peripheral nerve interface (RPNI)". Eligible studies included primary research, systematic reviews, and meta-analyses evaluating surgical management, operative techniques, and clinical outcomes of ICN. Key Content and Findings: Surgical management is typically reserved for refractory ICN after failure of pharmacologic and interventional therapies. Intercostal neurectomy remains the most widely studied technique, demonstrating substantial and durable pain reduction, with success rates exceeding 80% in several case series. Neurolysis and nerve decompression offer benefit in selected patients with compressive etiologies. Minimally invasive approaches, including percutaneous endoscopic neurectomy and radiofrequency ablation (RFA), provide effective pain relief with lower procedural morbidity. Emerging reconstructive techniques such as TMR and RPNI represent a paradigm shift by addressing the underlying pathophysiology of neuroma formation. Early evidence suggests significant pain reduction and improved quality of life; however, data remain limited to small cohorts. Conclusions: Surgical interventions offer promising and potentially durable relief for refractory ICN, particularly when guided by accurate diagnosis and patient selection. While traditional approaches focus on interrupting nociceptive signaling, emerging nerve reconstruction techniques may provide more definitive solutions by preventing maladaptive nerve regeneration. Further high-quality studies are needed to establish standardized treatment algorithms and clarify the role of these novel techniques in ICN management.