Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis.

BACKGROUND: The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023. MATERIALS AND METHODS: The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google. RESULTS: We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%). CONCLUSIONS: The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

Aberrant Cutaneous Nerve Loops in the Axilla.

During routine dissection classes, conducted for first year undergraduate medical students, we encountered a rare anatomical variation in relation to the intercostobrachial nerve (ICBN). The ICBN represents the lateral undivided cutaneous branch of second intercostal nerve. In this case, the ICBN formed nerve loops with branches of the lateral cutaneous branch of the third intercostal nerve. These loops eventually gave branches that probably supplied the floor of the axilla and proximal arm. Nowadays, this ICBN is gaining clinical importance during the axillary lymph node dissections and mammary gland surgeries. Damage to the ICBN, may results in the sensory deficits in patients undergoing surgery. In our case report, ICBN was making aberrant nerve loop along with the branches from the third intercostal nerve. Knowledge regarding the origin, formation and route of ICBN is of clinical significance to axillary surgeons, radiologist and anesthesiologists.

Anatomical information for intercostobrachial nerve preservation in axillary lymph node dissection for breast cancer.

This study aimed to provide additional anatomical information for axillary lymph node dissection (ALND) through in vivo anatomy studies of intercostobrachial nerve (ICBN) preservation in order to provide theoretical and practical experience for clinicians. A total of 156 patients with breast cancer underwent ALND at the Department of Gynecology of Baotou Tumor Hospital between June 2009 and March 2010. The origin, destination, main source, length, branch type, and direction of ICBN in axilla were observed, as well as its relationship with adjacent major blood vessels and nerves within the axilla. There were 120 cases of single trunk, 23 cases of double trunks, 9 cases of multiple trunks, and 4 cases without trunks in 156 patients with ICBN preservation. The transverse diameter at the origin of the ICBN was 1.89 ± 0.44 mm with a length of 94.45 ± 12.08 mm; the distances were 77.19 ± 21.04 mm, 29.34 ± 6.73 mm, 90.04 ± 13.13 mm, and 28.63 ± 13.01 mm from origin to the inferior margin at the midpoint of the clavicle, inferior margin of the axillary vein, the bottom of axilla, and branch point, respectively. The identification, dissection, and preservation of ICBN was simple and easy in a modified radical mastectomy for breast cancer and breast-conserving surgery, which only took 10-20 min, but effectively reduced the incidence of post-mastectomy pain syndrome and significantly improved the quality of life for patients after surgery.

Human pulmonary dirofilariasis coexisting with intercostal neurilemmoma: a case report and literature review.

Human pulmonary dirofilariasis (HPD) is a rare zoonotic infection caused by Dirofilaria immitis. Dogs are the definite hosts and humans are infected occasionally via a vector, generally a mosquito. Most thoracic neurilemmoma arise in the mediastinum and fewer tumors originate peripherally from the intercostal nerves. Most patients with HPD or thoracic neurilemmoma are asymptomatic and these diseases are often discovered incidentally. We present a 53-year-old female who was found to have a pulmonary nodule and a chest wall nodule during a routine health examination. She underwent a video-assisted thoracoscopic surgery (VATS) with partial lung resection and local excision of the chest wall. The pathological examination revealed a coiled, degenerating Dirofilariasis immitis worm surrounded by granulomatous inflammation with caseous necrosis and a neurilemmoma composed of S-100 protein immunoreactive but smooth muscle actin negative spindle cells. Because these diseases are self-limiting and make further treatment unnecessary, video-assisted thoracoscopic surgery (VATS) is considered preferable and less invasive for definitive diagnosis and management.

Carbon-Assisted Minimally Invasive Transtubular Approach for Intercostal Nerve Schwannoma.

BACKGROUND AND OBJECTIVES: The intraoperative localization of an intercostal nerve schwannoma (INS) is extremely difficult because the lesion is generally not palpable, and the fluoroscopic visualization of anatomic landmarks in the ribs is unsatisfactory. Using activated carbon suspension to mark the soft-tissue approach could improve INS localization. We present a novel, simple, reproducible carbon-assisted minimally invasive transtubular approach for an INS. METHODS: The patient was a 57-year-old man with a painful 12th left INS arising below the floating rib. A computed tomography image-guided, tumor-to-skin marking with aqueous carbon suspension was performed 48 hours before surgery. A minimally invasive transtubular approach following the carbon path allowed a precise tumor location. RESULTS: The INS was completely removed. The patient's thoracic radicular pain was immediately relieved after surgery. He was discharged the following day with residual numbness on the left thoracic side. At the 5-year follow-up, no tumor recurrence was noted in the control MRI. CONCLUSION: This article presents an alternative novel technique for resecting an intercostal schwannoma. Using a transtubular approach with carbon-marking assistance allowed a tumor gross total resection with immediate pain relief and a successful outcome.

Successful resection of schwannoma from an intercostal nerve causing bloody pleural effusion: report of a case.

We report a case of schwannoma arising from the 9th intercostal nerve, which caused a bloodstained pleural effusion. The patient, a 37-year-old woman, presented with left-sided back pain. A chest X-ray showed left pleural effusion, which was subsequently found to be bloodstained but without malignant cells. Chest magnetic resonance imaging showed a 76-mm tumor arising from the 9th intercostal nerve. The tumor and intercostal nerve were successfully resected. Histological examination revealed that the tumor comprised spindle cells with both Antoni types A and B patterns. There were necrotic changes and cystic degeneration, but no atypical or mitotic cells. Based on these findings, benign schwannoma was diagnosed. Schwannoma is rarely accompanied by bloody pleural effusion, which we assume was caused by partial tumor rupture. Magnetic resonance imaging proved very useful in localizing and characterizing the tumor in this case.

Treatment and Management of Twelfth Rib Syndrome: A Best Practices Comprehensive Review.

BACKGROUND: Twelfth rib syndrome, or slipping of the 12th rib, is an often overlooked cause for chronic chest, back, flank, and abdominal pain from irritation of the 12th intercostal nerve. Diagnosis is clinical and follows the exclusion of other causes of pain. This syndrome is usually accompanied by long-suffering, consequent psychiatric comorbidities, and increased health care costs, which are secondary to the delayed diagnosis. OBJECTIVES: This manuscript is a review of twelfth rib syndrome and its management options. The review provides etiology, pathophysiology, and epidemiology of twelfth rib syndrome. Additionally, diagnosis and current options for treatment and management are presented. STUDY DESIGN: This is a narrative review of twelfth rib syndrome. SETTING: A database review. METHODS: A PubMed search was conducted to ascertain seminal literature regarding twelfth rib syndrome. RESULTS: Conservative treatment is usually the first line, including local heat or ice packs, rest, and oral over-the-counter analgesics. Transcutaneous stimulation and 12th intercostal nerve cryotherapy have also been described with some success. Nerve blocks can additionally be tried and are usually effective in the immediate term; there is a paucity of evidence to suggest long-term efficacy. Surgical removal of all or part of the 12th rib and possibly the 11th rib, as well as the next line of therapy, may provide long-lasting relief of pain. LIMITATIONS: Further large scale clinical studies are needed to assess the most effective management of twelfth rib syndrome. CONCLUSIONS: Twelfth rib syndrome is usually diagnosed late and causes significant morbidity and suffering. The actual epidemiology is unclear given the difficulty of diagnosis. Nerve blocks and surgical rib resection appear to be effective in treating this syndrome, however, further evidence is required to properly evaluate them. Familiarity with this syndrome is crucial in reaching a prompter diagnosis.

Intercostobrachial Nerve (ICBN) Preservation Versus Sacrifice in Axillary Dissection: Randomized Controlled Trial.

OBJECTIVES: Whether to preserve or sacrifice the intercostobrachial nerves (ICBN) is a controversial issue. In this trial, we aim to assess the effects of preservation of the ICBN during axillary dissection for patients with breast cancer in terms of pain score immediately postoperatively and several hours later, need for simple analgesia and narcotics, numbness and arm swelling. MATERIALS AND METHODS: This is a single-institution, single-surgeon randomized controlled trial where a sample of 48 patients with breast cancer, of various age groups, were allocated randomly to any of the 2; preservation or sacrifice categories. Postoperatively, patients were asked by a physician to fill a predesigned questionnaire to assess the studied items during hospitalization and after discharge. RESULTS: Among the 48 included patients, ICBN was sacrificed in 24 patients; of which 18 patients (75%) developed numbness in the inner aspect of the arm. While in the ICBN preservation group (24 patients) only 6 patients suffered numbness (25%) with a significant P-value of 0.001. Estimated duration of surgery with ICBN preservation was 100±22.02 minutes, while it is significantly shorter in the ICBN sacrifice group (83.48±21.55). However, with regard to other variables of pain, seroma formation, need of simple analgesia and narcotics, hospital admission days and arm swelling, there was no significant difference between the 2 groups. CONCLUSION: This study can conclude that preservation of ICBN during axillary dissection in patients with breast CA can save these patients' additional suffering from inner arm numbness. That is at the expense of surgery duration, around 20 minutes longer, for the surgeon to take his/her time in carefully dissecting the axilla properly without injuring these ICBN.

Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections.

INTRODUCTION: Steroid injection around the intercostal nerves is one of the treatment options for intercostal neuralgia. The technique may be performed blindly, under fluoroscopic guidance (FSG) or with the use of ultrasound guidance (USG). This study is a retrospective comparison of image guidance for intercostal steroid injections. METHODS: After Institutional Review Board approval, a retrospective review of all patient charts who received intercostal steroid injections from 2005 to 2009 was performed. A total of 39 blocks were performed in that period. Of that 12 were USG blocks and 27 FSG blocks. The preprocedure visual analog scale (VAS) and postprocedure VAS and the duration of pain relief were compared between the 2 techniques. A Mann-Whitney test and Kruskal-Wallis test were performed looking for differences between the techniques. RESULTS: The median change in the VAS for FSG and USG were -5.000 and -4.000, respectively, and duration of pain relief with a median difference of 2 weeks (95% confidence interval of -4, 7). There were 2 occasions of intravascular spread noticed with the FSG although this should not affect the study result as the needle was repositioned and steroid injected only after contrast dye confirmation. CONCLUSION: With similar change in VAS scores and duration of pain relief between the 2 guidance methods based on this retrospective study, both image guidance techniques may offer similar pain relief.

The Efficacy of BurstDR Spinal Cord Stimulation for Chronic Abdominal Pain: A Clinical Series.

BACKGROUND: Chronic abdominal pain is a debilitating condition known for its multifactorial nature. Outcomes with spinal cord stimulation (SCS) for abdominal pain syndromes are noticeably absent in the literature. To date, there have been no published reports of novel waveforms of SCS for management of chronic abdominal pain. We assessed the efficacy and durability of BurstDR SCS in reducing abdominal pain and analgesic consumption. CASE DESCRIPTION: We performed a retrospective review of medical records from 3 patients with different etiologies of abdominal pain (postherniorrhaphy pain syndrome, Crohn disease, abdominal neuropathy). All patients underwent thoracic laminectomy for BurstDR SCS paddle lead and pulse generator placement after a successful trial stimulation period. Data were collected with a telephone survey after a minimum duration of >24 months following implantation. Pain scores were measured using a numeric rating scale. Two of 3 patients were entirely pain-free and reported Patient Global Impression of Change scores of 7 after a minimum follow-up of >24 months. While the third patient continued to have chronic as well as episodic abdominal pain, he was able to discontinue all narcotic pain medications and experienced a 33% decrease in frequency and 60% decrease in severity of monthly pain exacerbations. He reported satisfaction and a Patient Global Impression of Change of 6. CONCLUSIONS: BurstDR SCS is a new programming modality, and long-term follow-up is necessary to determine its durability. Despite varying etiologies of abdominal pain, this series suggests BurstDR SCS sustained for >2 years might be effective as a treatment for abdominal pain syndromes. Future studies of SCS would benefit from standardized abdominal pain scores and high-powered studies using global patient registries.

Schwannoma mimicking liver tumor.

Thoracic neurogenic tumors typically originate from the posterior mediastinum and the intercostal nerves. No report of a chest wall schwannoma extending toward the subphrenic areas and making a significant indentation into liver parenchyma exists to date. We present a liver tumor-mimicking schwannoma of the intercostal nerves. A 58-year-old woman presented with a painful lesion in the right subphrenic area and abdominal pain in the right upper quadrant for two months. Abdominal ultrasonography and magnetic resonance imaging revealed a tumor, 9.1 x 7.1 x 8.9 cm in size, with an inner cystic change in segment V and VI of the liver. The tumor was completely resected together with part of the 9th rib. Pathology confirmed a schwannoma and showed a tumor composed of spindle cells with oval to wavy nuclei. The patient was still asymptomatic at follow-up after 36 months, with no sign of recurrence.

Temporary claviculectomy approach for plexiform neurofibroma of the first intercostal nerve.

Plexiform neurofibroma at the thoracic inlet has rarely been reported and to our knowledge, the use of a temporary middle claviculectomy approach for thoracic inlet tumors has never been reported. We report a case of plexiform neurofibroma of the first intercostal nerve resected using a temporary claviculectomy approach. An abnormal shadow detected radiographically in a 16-year-old boy led to a diagnosis of neurofibromatosis 1 (NF-1) with a chest wall tumor at the thoracic inlet. The patient underwent resection of the tumor with the right first rib. The resected clavicle was reapproximated with a plate and postoperative shoulder function was satisfactory. The tumor was diagnosed pathologically as a plexiform neurofibroma and the patient's postoperative course was uneventful. The temporary middle claviculectomy approach provides excellent exposure of the subclavian vessels and brachial plexus before resection of the tumor. We recommend this approach for tumors of the anterior thoracic inlet.

Schwannomatosis of a single intercostal nerve: a case report.

Schwannomatosis is a rare form of neurofibromatosis and is characterized by more than one schwannoma without any sign of neurofibromatosis. We report a case of a 60-year-old male patient admitted with progressive chest discomfort who was found to have six encapsulated tumors along the seventh intercostal space with a maximum tumor size of 3x2x1 cm.

The intercostal nerve as a target for diagnostic biopsy.

OBJECTIVE Peripheral nerve biopsy is a useful tool in diagnosing peripheral neuropathies. Sural and gracilis nerves have become the most common targets for nerve biopsy. However, the yield of sural nerve biopsy is limited in patients who have motor neuropathies, and gracilis nerve biopsy presents technical challenges and increased complications. The authors propose the intercostal nerve as an alternative motor nerve target for biopsy. METHODS A total of 4 patients with suspected peripheral neuropathies underwent intercostal nerve biopsy at the authors' institution. A rib interspace that is inferior to the pectoralis muscle and anterior to the anterior axillary line is selected for the procedure. Generally the lower intercostal nerves (i.e., T7-11) are targeted. An incision is made over the inferior aspect of the superior rib at the chosen interspace. Blunt dissection is carried down to the neurovascular bundle and the nerve is isolated, ligated, and cut to send for pathological examination. RESULTS The average operative time for all cases was 73 minutes, with average blood loss of 8 ml. Biopsy results from 1 patient exhibited axonopathy, and the other 3 patients demonstrated axonopathy with demyelination. There were no short- or long-term postoperative complications. None of the patients reported sensory or motor deficits related to the biopsy at 6 weeks postoperatively. CONCLUSIONS The intercostal nerve can be an alternative target for biopsy, especially in patients with predominantly motor neuropathies, due to its mixed sensory and motor fibers, straightforward anatomy, minimal risk of serious sensory deficits, and no risk of motor impairment.

Giant intercostal nerve schwannoma in a patient with neurofibromatosis type 2.

PURPOSE: To describe a case of giant intercostal nerve schwannoma successfully resected in a patient with neurofibromatosis type 2. METHODS: A 44-year-old woman, with a history of neurofibromatosis type 2, presented with chest discomfort and mild dyspnea. She had undergone a recent resection of a large frontal parasagittal benign meningioma. Radiologic examinations showed a large lesion (9×12×9 cm) of the left hemithorax causing a complete atelectasis of left upper lobe. Bronchoscopy did not show any endobronchial alterations, apart from an ab estriseco compression of the left upper bronchial tree. A transthoracic needle biopsy was then performed and microscopic examination revealed a mesenchymal tumor composed of spindle-like cells. RESULTS: A video-assisted thoracoscopic surgery procedure was proposed. The tumor mass appeared to be tenaciously adherent to the parietal pleura in its anterolateral aspect, confirming the radiologic appearance. No invasion of the lung parenchyma or parietal pleural metastases were visible. Therefore, a left posterolateral thoracotomy at the fifth intercostal space was performed and a macroscopic complete resection was carried out. The recovery was uneventful and the patient was discharged on postoperative day 5. The histologic examination revealed a moderate cellular proliferation of spindle-shaped and oval to polygonal cells with frequent Verocay bodies; mitotic figures were rare. The tumor cells were strongly S-100 positive. The microscopic features were consistent with benign intercostal schwannoma. Eight years later, the patient is disease-free and asymptomatic. CONCLUSIONS: An unusual case of giant intercostal nerve schwannoma successfully resected in a patient with neurofibromatosis type 2 is described.

Multiple intercostal neurilemmomas in a Chinese woman.

Neurilemmomas are rare tumors of neural crest cell origin that occur most commonly in the head and neck region. Intercostal neurilemmomas are extremely rare and are mostly seen as solitary tumors in the posterior mediastinum. Only one case report of multiple intercostal neurilemmomas has been documented previously. In this article, we report a case of multiple intercostal neurilemmomas in a 54-year-old woman who had initially presented with progressive dull left chest pain over a 1-year period. A computed tomography scan revealed three tumors in the left thoracic cavity which were distributed as a string of beads along the third intercostal nerve. Histological and immunohistochemical testing confirmed a diagnosis of neurilemmomas. The patient underwent successful radical excision of the tumors through a thoracotomy approach, and her postoperative course was uneventful. Following the operation, she had no evidence of recurrences.

Resection of a dumbbell-shaped thoracic neurinoma by hemilaminectomy: a case report.

Neurinomas originating from intercostal nerve roots can grow both inside and outside of the spinal canal, forming dumbbell-shaped tumors. Such a neurinoma was discovered at the Th3 and Th4 levels in a 73-year-old woman during evaluation for breast cancer surgery. Magnetic resonance images (MRI) showed spinal cord compression by the tumor despite lack of neurologic symptoms. The tumor was resected successfully via hemilaminectomy with costotransversectomy. Postoperative course was uneventful, and no stabilization was needed after operation. Back pain was the only postoperative complication. Analgesics were administered for 1 month, and the pain resolved over 3 months. No recurrent neurinoma was found in follow-up images at 8 months. We consider hemilaminectomy safe and effective for complete resection of a dumbbell-shaped thoracic neurinoma.