Intraoperative Intercostal Nerve Block for Postoperative Pain Control in Pre-Pectoral versus Subpectoral Direct-to-Implant Breast Reconstruction: A Retrospective Study.

Background and Objectives: Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks (ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction. Materials and Methods: Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants. Results: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6, p = 0.047), lower maximum VAS scores on the operative day (5 versus 7.5, p = 0.030), and POD 1 (4 versus 6, p = 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7, p = 0.005), lower maximum VAS scores on the operative day (4.5 versus 8, p = 0.004), and POD 1 (4 versus 6, p = 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction. Conclusions: Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.

Pseudoaneurysm of the Thoracoabdominal Aortic Graft Due to Intercostal Nerve Block.

Pseudoaneurysms of the descending aorta after open graft replacement usually occur in patients with connective tissue disorders and form at anastomotic or cannulation sites. We present a case of an iatrogenic pseudoaneurysm in the descending thoracic aortic graft body caused by intercostal nerve block. The patient had undergone repair for thoracoabdominal aortic aneurysm 4 years prior and underwent a series of intercostal nerve blocks after experiencing persistent postthoracotomy pain. A pseudoaneurysm in the descending thoracic graft, contiguous with the chest wall, was encountered. He underwent successful pseudoaneurysm resection with redo graft replacement, resulting in significant pain relief.

Paralysis of the Rectus Abdominis Muscle after a Video-Assisted Thoracoscopic Surgery.

The rectus abdominis muscle is innervated by intercostal nerves T7-T12, and most thoracotomies are performed through the fourth to sixth intercostal spaces, so direct nerve damage to the rectus abdominis seems unlikely. However, at least one trocar is inserted below the seventh intercostal space in most multi-port video-assisted thoracoscopic surgeries (VATSs), and injury of the seventh or lower intercostal nerve with related paralysis of the rectus abdominis is possible, albeit rare. Only two cases of rectus abdominis paralysis caused by after VATSs have been reported, and these cases were not permanent injuries. This is the first report of permanent paralysis of the rectus abdominis after VATSs.

Local Application of Ultrasound Attenuates Neuropathic Allodynia and Proinflammatory Cytokines in Rats After Thoracotomy.

BACKGROUND AND OBJECTIVES: We aimed to investigate the effect of therapeutic ultrasound (TU) on pain sensitivity and the concentration inflammatory cytokines in a thoracotomy rat model. METHODS: Rats were distributed randomly into 4 groups: (1) sham operated, (2) thoracotomy and rib retraction (TRR), (3) TRR rats that received TU (TRR + TU-1), and (4) TRR rats that received TU with the ultrasound turned off (TRR + TU-0). Ultrasound was set at 1-MHz frequency (1.0-W/cm intensity and 100% duty cycle for 5 minutes), began on postoperative day (POD) 10, and then continued once per day, 5 days a week for 3 weeks. RESULTS: The TRR and TRR + TU-0 rats encountered tactile hypersensitivity from PODs 10 to 28. Mechanical withdrawal thresholds were increased (all P < 0.05) following 5 days of TU, but thresholds remained significantly lower than baseline values. Therapeutic ultrasound increased the subcutaneous, but not body temperature. All groups receiving TRR demonstrated an increase in concentration of interleukin 1ß and tumor necrosis factor α (TNF-α) on POD 14; however, the rise in TNF-α concentration was less in the TU-treated group than in the others. The decrease in concentration was greatest in the TRR + TU-1 group and similar between the TRR and TRR + TU-0 groups. CONCLUSIONS: Mechanical allodynia was partially resolved with TU. Tissue temperature increased with ultrasound, while TU restricted the up-regulation of interleukin 1ß and TNF-α around the injured intercostal nerve.

Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial.

BACKGROUND: Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. METHODS: Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. DISCUSSION: Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. TRIAL REGISTRATION: Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015.

Intercostal neuralgia as a symptom of an osteoblastoma in thoracic spine.

An osteoblastoma is a benign bone lesion most commonly affecting the spine; it is frequently found in the posterior elements of the vertebra. When an osteoblastoma originates in the spine, it usually causes dull and localised dorsal pain, but the period between symptom development and diagnosis can be long. MRI shows intense peritumoural oedema accompanying the osteoblastoma. We present a case of a 15-year-old boy with osteoblastoma at the level of the T8-9 left laminae causing intercostal neuralgia without direct invasion to the intercostal nerve. Immediately after surgery, intercostal neuralgia was diminished. To our knowledge, this is the first case of an osteoblastoma with intercostal neuralgia, which is possibly the key symptom for diagnosing an osteoblastoma in the thoracic spine.

Cadaveric nerve allotransplantation in the treatment of persistent thoracic neuralgia.

When relief from neuralgia cannot be achieved with traditional methods, neurectomy may be considered to abate the stimulus, and primary opposition of the terminal nerve ending is recommended to prevent neuroma. Nerve repair with autograft is limited by autologous nerves available for large nerve defects. Cadaveric allografts provide an unlimited graft source without donor-site morbidities, but are rapidly rejected unless appropriate immunosuppression is achieved. An optimal treatment method for nerve allograft transplantation would minimize rejection while simultaneously permitting nerve regeneration. This report details a novel experience of nerve allograft transplantation using cadaveric nerve grafts to desensitize persistent postoperative thoracic neuralgia.

Chest tube insertion is one important factor leading to intercostal nerve impairment in thoracic surgery.

OBJECTIVES: Chest tube insertion seems to be one important factor leading to intercostal nerve impairment. The purpose of this prospective study was to objectively evaluate intercostal nerve damage using current perception threshold testing in association with chest tube insertion. METHODS: Sixteen patients were enrolled in this study. Intercostal nerve function was assessed with a series of 2000-Hz (Aß fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C(®)). Current perception threshold values at chest tube insertion were measured before surgery, during chest tube insertion and after removal of the chest tube. Intensities of ongoing pain were also assessed using a numeric rating scale (0-10). RESULTS: Current perception thresholds at each frequency after surgery were significantly higher than before surgery. Numeric rating scale scores for pain were significantly reduced from 3.3 to 1.9 after removal of the chest tube (p = 0.004). The correlation between current perception threshold value at 2000 Hz and intensity of ongoing pain was marginally significant (p = 0.058). CONCLUSIONS: This is the first study to objectively evaluate intercostal nerve damage at chest tube insertion. The results confirmed that chest tube insertion has clearly deleterious effects on intercostal nerve function.

Treatment of osteoporotic vertebral compression fractures with percutaneous kyphoplasty: a report of 196 cases.

The incidence of osteoporotic vertebral compression fracture (OVCF) is increased recently. Percutaneous kyphoplasty (PKP) has recently been shown to have a curative effect on OVCF. Unfortunately, related complications arising from PKP cannot be ignored, such as cement leaks, fever, and intercostal neuralgia. This study aimed to investigate the common complications of PKP in the treatment of OVCF patients and analyze the causes and assess prevention and control measures. A total of 196 patients (204 vertebrae) underwent PKP procedures at the Department of Spine Surgery, Shenzhen Sixth People's Hospital, Guangdong, China, from June 2004 to August 2010. The data on incidence rates of the various complications were compiled. All patients were successfully operated without death, paraplegia, or pulmonary embolism. Incidence of various complications resulting from different types of bone cement leakage was 27.45 %, including 0.51 % for postoperative elevated fever, 4.08 % for intercostal neuralgia, 2.55 % for trailing of bone cement, 0.51 % for refracture at adjacent vertebrae, and 0.51 % for cerebrospinal fluid leakage. These results suggest that PKP is an effective surgical technique for the treatment of OVCF, resulting in limited trauma with satisfactory curative effects. Skillful mastery of this technology will help reduce the incidence rate of complications.

Implantation of an intercostal nerve stimulator for chronic abdominal pain.

Chronic abdominal pain is not uncommon and can be difficult to manage. We present the case of a 17-year-old man with a 4-year history of chronic abdominal pain. The patient had previously undergone abdominal surgery by way of laparoscopic appendicectomy and right nephrectomy for a mal-rotated kidney. The patient continued to suffer right-sided abdominal pain which was not controlled by analgesia. We report the successful implantation of a right D11 intercostal nerve stimulator to control the patient's pain. This is the first report of an implantable intercostal nerve stimulator to control intractable chronic abdominal pain.

Atypical chest pain: evidence of intercostobrachial nerve sensitization in Complex Regional Pain Syndrome.

BACKGROUND: Atypical chest pain is a common complaint among Complex Regional Pain Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by CRPS spread and become a source of atypical chest pain. OBJECTIVE: To evaluate the sensitivity of chest areas in CRPS patients and normal controls. DESIGN: Prospective investigation of pressure algometry in chest areas to determine chest wall sensitivity. METHODS: CRPS patients and normal controls volunteered to participate in our study. Each individual was examined to meet inclusion criteria. Patients' report of chest pain history was collected from every participant. Pressure algometry was used to measure pressure sensitivity in the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular tenth rib, and midsternal. Each of these measurements were compared to an intra-participant abdominal measure to control for an individuals generalized sensitivity. The ratios of chest wall sensitivities were compared between CRPS patients and normal controls. RESULTS: A history of chest pain was reported by a majority (94%) of CRPS patients and a minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater than control subjects (p< 0.02 throughout), indicating increased chest wall sensitivity. LIMITATIONS: This study is limited by the relatively small number of patients (n=35) and controls (n=21) used. CONCLUSION: The results of this study support the idea that chest pain is greater in CRPS patients than normal controls. The ICBN could be the source of this sensitization by CRPS spread from the brachial plexus.

Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post-thoracotomy pain control.

Epidural analgesia is regarded as the gold method for controlling post-thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post-thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid-related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia-like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1-72.1%), and no significance between the groups. The incidence of allodynia-like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post-thoracotomy acute pain. The incidence of post-thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain.

[Infiltrations, blocks and neurolysis in musculoskeletal pathology]. / Infiltrations, blocs et neurolyses en pathologie ostéo-articulaire.

Computed Tomography fluoroscopy for blocks and neurolysis provides a minimally-invasive, accurate and rapid alternative to surgery. Spinal and peri-spinal ultrasound-guided procedures, excluding peripheral procedures, will be discussed as well. The imaging-guided procedures discussed are performed using small needles. These percutaneous procedures must be performed with maximum patient comfort and cause as little complications as possible. These procedures should be performed by an experienced radiologist after discussion with the treating clinician.

A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery.

OBJECTIVE: Our aim was to investigate the prevalence of intra-operative nerve damage and its association with chronic pain. METHODS: Our prospective study of 33 patients used nerve conduction studies to assess intercostal nerve function during elective thoracic surgical procedures. We used two methods to study nerve conduction: pre-operative magnetic stimulation (in 10 patients) and intra-operative nerve conduction studies (in all patients) We correlated these findings with specific intra-operative parameters, pain and psychological questionnaires pre-op and 3 month post-op and altered cutaneous sensation. RESULTS: Magstim (magnetic stimulation) assessments were not reliable and were therefore abandoned. Intraoperative intercostal nerve studies revealed two distinct patterns of nerve injury and also that nerve injury was less in those cases where a rib was not resected. However, intercostal nerve damage detected at the time of operation is not associated with chronic pain or altered cutaneous sensation at 3 months post-op. CONCLUSIONS: The study findings suggest that either the amount of intra-operative intercostal nerve damage is not indicative of long-term nerve damage or that there is a more significant cause for chronic pain other than intercostal nerve injury.

Intercostal nerve mononeuropathy: study of 14 cases.

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.

Intercostal nerve mononeuropathy: study of 14 cases

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.

Este trabalho apresenta estudo retrospectivo de 14 pacientes com mononeuropatia de nervo intercostal (MNI), obtidos dentre 5.560 exames eletromiográficos, realizados de janeiro de 1991 até junho de 2004, em nosso Hospital Universitário. MNI foi encontrada em 14 pacientes, tendo como causas prováveis intervenções cirúrgicas torácicas em 6 (43%), neuropatia por herpes-zoster em 4 (28%), provável neurite de nervo intercostal em 2 (14%), neoplasia pulmonar em 1 (7%) e radiculopatia em 1 (7%). As principais causas de MNI de nosso Serviço são similares às da literatura. Os antidepressivos tricíclicos e anticonvulsivantes foram os fármacos mais utilizados no controle da dor.

Pain disaggregation theory--statistical nonsense or a pointer to a paradigm for quantum nociception?

BACKGROUND: The various patterns of patients' experience of treated acute post-thoracotomy pain exemplify the phenomenon of disaggregation. The intent in this study was to define a theory of disaggregation with a hard-wired neuroanatomical model of thoracotomy pain. METHODS: In order to distinguish the disaggregated nociception conducted along one of three possible pathways, the vagus, the phrenic and, in this study, the intercostal nerves, data from 143 patients undergoing thoracic surgery, and that from two previously conducted studies of multimodal analgesic regimens, were reviewed. The values of one subjective outcome measure (verbal rating score) at different stress levels-at rest, on raising the arm, and on coughing (dynamic pain scores)-were used to construct individuals' charts (pain profiles) of the progress of pain relief over time. These were batched, and analysed using statistics of summary measures. RESULTS: This was a crude exercise in the handling of redundant data, but there is a suggestion that it is possible to distinguish a disaggregated route by an effect of a treatment on a mass of nociception. CONCLUSIONS: This information could underpin a paradigm of quantum nociception, and has potential to quantify aspects of analgesia practice and current and future neurophysiological theories of pain. Prospective studies are warranted.

Phrenic and intercostal repetitive nerve stimulation: a useful electroneurophysiological method to detect the respiratory status of myasthenia gravis patients.

OBJECTIVE: To get a comprehensive recognition about the profile of phrenic repetitive nerve stimulation (PRNS) and intercostal repetitive nerve stimulation (IRNS) in healthy people, to investigate the electrophysiological features about respiratory function of myasthenia gravis (MG) patients, and to detect the predictive value of IRNS and PRNS on the respiratory deterioration of MG patients during the pulse treatment with large dosage of adrenal corticosteroid. SUBJECTS AND METHODS: Bilateral PRNS and IRNS with stimulation frequency of 3 and 5 Hz were tested in 28 healthy people and 113 MG patients; limb and cranial repetitive nerve stimulation (RNS), clinical score and forced vital capacity (FVC) were also recorded from those MG patients. Further more, PRNS and IRNS of 36 MG patients were tested 3 days before the beginning of their adrenal corticosteroid pulse treatment, FVC, clinical score and respiratory changes of the MG patients were simultaneously observed. RESULTS: For healthy people, there were no significant differences in the results of PRNS or IRNS in different age, sex and testing sides. After combining the left result with the right one, the amplitude decrement percentage in PRNS and IRNS was less than 7%. PRNS had more technical difficulty than IRNS. For 113 MG patients, FVC was dependent on the values of PRNS, IRNS and facial RNS. A subclinical respiratory dysfunction was found in patients with type I and II MG. The abnormal rate of PRNS in type IIb MG was similar to that in type III and IV MG, even though a difference in the percentage of amplitude decrement between them was observed. Meanwhile, both the abnormal rate and the percentage of amplitude decrement of IRNS had no difference between type IIb MG and type III and IV MG. The general incidence of abnormal PRNS and abnormal IRNS were higher than those of decreased FVC and clinical dyspnea, and the sensitivity of PRNS in type IIa MG patients was higher than that of IRNS. Among 36 MG patients under the adrenal corticosteroid pulse treatment, 14 showed the newly clinical dyspnea or worsened original one 2 to 13 days after the beginning of the therapy. There were significant difference of the above parameters between the patients with and without respiratory deterioration during the treatment. Logistic regression analysis showed that when the mean value of the bilateral IRNS amplitude decrement was larger than 30%, the odds ratio of the occurrence of the respiratory deterioration was 19.523, for both 3 and 5 Hz stimulation. CONCLUSIONS: It is recommended that PRNS and IRNS will be defined as abnormal when their amplitude reduces more than 15%. PRNS and IRNS are neurophysiological indices reflecting the damage of respiratory muscles in MG, they are helpful in evaluating the clinical condition correctly and making the classification of MG properly. It is necessary to test the PRNS and IRNS in type II MG patients regularly. Although the respiratory damage during the adrenal corticosteroid treatment was correlated with PRNS, IRNS, FVC, MG clinical score and type, only IRNS had predictive value on the respiratory deterioration during the treatment.