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Cirocchi R, Matteucci M, Randolph J, Duro F, Properzi L, Avenia S, Amato B, Iandoli R, Tebala G, Boselli C, Covarelli P, Sapienza P. Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis. World J Surg Oncol 2024; 22:92. [PMID: 38605346 PMCID: PMC11007944 DOI: 10.1186/s12957-024-03374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
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.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy.
| | - Matteo Matteucci
- Department of Medicine and Surgery, University of Milan, Milan, 20122, Italy
| | - Justus Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, 30341, USA
| | - Francesca Duro
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Luca Properzi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Bruno Amato
- Department of Public Health, University of Naples "Federico II", Naples, 80131, Italy
| | - Ruggiero Iandoli
- Department of General Surgery, P.O Frangipane Ariano Irpino, Avellino, 83031, Italy
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, AOSP of Terni, Terni, 05100, Italy
| | - Carlo Boselli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Piero Covarelli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Paolo Sapienza
- Department of Surgery, "Sapienza" University of Rome, Roma, 00161, Italy
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Al-dardery NM, Khaity AM, Albakri KA, Abdelsattar AT, Benmelouka AY, Lee T, Foppiani JA, Lin SJ. Preservation versus dissection of the intercostobrachial nerve for breast cancer surgeries: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:1003-1011. [PMID: 38333310 PMCID: PMC10849353 DOI: 10.1097/ms9.0000000000001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction This meta-analysis aimed to compare the efficacy of preservation of the intercostobrachial nerve (ICBN) versus its dissection for patients who underwent breast surgery. Methods The authors searched Web of Science, PubMed, Cochrane CENTRAL, and Scopus from inception until March 2023. Records were screened for eligible studies, and all relevant outcomes were pooled as an odds ratio (OR) with the corresponding 95% CI in the meta-analysis models using RevMan version 5.4. Results These results from 11 studies (1021 patients) favored preservation of the ICBN over its dissection in terms of anaesthesia and hypaesthesia [OR 0.50, (95% CI, 0.31-0.82); P = 0.006] and [OR 0.33, (95% CI, 0.16-0.68); P = 0.003], respectively. Whereas the overall effect favored ICBN dissection over preservation in the case of hyperaesthesia [OR 4.34, (95% CI, 1.43-13.15); P = 0.01]. Conversely, no significant variance was detected between the two groups in terms of pain [OR 0.68, (95% CI, 0.28-1.61) P = 0.38], paraesthesia [OR 0.88, (95% CI, 0.49-1.60); P = 0.68], and analgesia [OR 1.46, (95% CI, 0.05-45.69); P = 0.83]. Conclusion This meta-analysis revealed that the preservation of the ICBN has a significant effect on the disturbance of sensory parameters of hypaesthesia and anaesthesia when compared to its dissection. Further studies with larger sample sizes are recommended to precisely compare both techniques on a wider range of parameters.
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Affiliation(s)
| | | | | | | | | | | | - Jose A. Foppiani
- 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Jin J, Chen Q, Min S, Du X, Zhang D, Qin P. Prevalence and predictors of chronic postsurgical pain after colorectal surgery: A prospective study. Colorectal Dis 2021; 23:1878-1889. [PMID: 33738887 DOI: 10.1111/codi.15640] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/03/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022]
Abstract
AIM The aim was to investigate the incidence, characteristics and the potential predictors of chronic postsurgical pain (CPSP) after colorectal surgery. METHOD Patients who underwent colorectal surgery at our institution from July 2014 to December 2016 were prospectively enrolled in this study. Perioperative potential demographic, clinical and psychological predictors for CPSP were collected. The follow-up visits were conducted through telephone interviews at 3 and 6 months postoperatively. The interview questionnaire comprised items regarding pain intensity, frequency, site, analgesic administration and impact on activities of daily living. RESULTS A total of 624 patients completed the 6-month follow-up and were included in the analysis. CPSP was reported by 32.1% of these patients at 3 months and 21.8% at 6 months after colorectal surgery. The pain interfered with several activities of daily living in a considerable proportion of CPSP cases. At 3 months, the identified predictors of CPSP were young age, preoperative abdominal pain and pain elsewhere, preoperative anxiety and depression, longer duration of surgery, and high pain intensity on movement within 24 h after surgery. Predictors of CPSP at 6 months were young age, preoperative abdominal pain, preoperative anxiety, longer duration of surgery, and high pain intensity on movement within 24 h after surgery. CONCLUSION Chronic pain after colorectal surgery is a common complication associated with young age, preoperative abdominal pain and pain elsewhere, preoperative anxiety and depression, longer duration of surgery, and high pain intensity on movement within 24 h after surgery.
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Affiliation(s)
- Juying Jin
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibin Chen
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xunsong Du
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Zhang
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peipei Qin
- Department of Anesthesiology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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van Tonder DJ, Lorke DE, Nyirenda T, Keough N. An uncommon, unilateral motor variation of the intercostobrachial nerve. Morphologie 2021; 106:209-213. [PMID: 34183262 DOI: 10.1016/j.morpho.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
The intercostobrachial nerve (ICBN) is commonly defined as a purely sensory nerve supplying the skin of the lateral chest wall, axilla, and medial arm. However, numerous branching patterns and distributions, including motor, have been reported. This report describes an uncommon variant of the right ICBN observed in both an 86-year-old white female cadaver and a 77-year-old white male cadaver. In both cases the ICBN presented with an additional muscular branch, termed the "medial pectoral branch", piercing and therefore innervating the pectoralis major and minor muscles. Clinically, the ICBN is relevant during surgical access to the axilla and can result in sensory deficits (persistent pain/loss of sensory function) to this region following injury. However, damage to the variation observed in these cadavers may result in additional partial motor loss to pectoralis major and minor.
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Affiliation(s)
- D J van Tonder
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates.
| | - D E Lorke
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - T Nyirenda
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - N Keough
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates; Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
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Melhem J, Amarin M, Odeh G, Al-Bustami N, Al-Lauzy H, Ayoub R. Intercostobrachial Nerve (ICBN) Preservation Versus Sacrifice in Axillary Dissection: Randomized Controlled Trial. Am J Clin Oncol 2021; 44:206-209. [PMID: 33710131 DOI: 10.1097/coc.0000000000000809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jamal Melhem
- Department of General Surgery.,Division of Breast Surgical Oncology
| | - Marzouq Amarin
- Department of General Surgery.,Division of Plastic Surgery
| | | | - Nadwa Al-Bustami
- Pathology, School of Medicine, University of Jordan, Amman, Jordan
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Sharp E, Roberts M, Żurada‐Zielińska A, Zurada A, Gielecki J, Tubbs RS, Loukas M. The most commonly injured nerves at surgery: A comprehensive review. Clin Anat 2020; 34:244-262. [DOI: 10.1002/ca.23696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Elizabeth Sharp
- Department of Internal Medicine Mount Sinai Health System New York New York USA
| | - Melissa Roberts
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
| | | | - Anna Zurada
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Jerzy Gielecki
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Richard Shane Tubbs
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Neurosurgery and Ochsner Neuroscience Institute Ochsner Health System New Orleans Louisiana USA
- Department of Structural & Cellular Biology Tulane University School of Medicine New Orleans Louisiana USA
- Department of Neurosurgery Tulane University School of Medicine New Orleans Louisiana USA
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
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Kaur N, Kumar R, Jain A, Saxena AK. Sensory Changes and Postmastectomy Pain Following Preservation of Intercostobrachial Nerve in Breast Cancer Surgery: a Prospective Randomized Study. Indian J Surg Oncol 2020; 12:108-113. [PMID: 33814840 DOI: 10.1007/s13193-020-01193-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022] Open
Abstract
Surgery for breast cancer leads to sensory changes and persistent pain in about 20-60% of patients and is usually attributed to section of the intercostobrachial nerve (ICBN). However, the opinion is divided about the benefit of preservation of ICBN. Hence, this study was designed to assess the role of preservation of ICBN on sensory changes and acute and persistent pain following mastectomy. The study was conducted on patients undergoing modified radical mastectomy for breast cancer. At the time of surgery, ICBN was sacrificed in group I (N = 29), and preserved in group II (N = 24). Patients underwent sensory assessment for touch and pain in predefined areas after surgery. They were also assessed for acute post-operative pain and persistent pain (PP) on day 30 and 90 by numeric pain rating scale. PP was also evaluated by douleur neuropathique 4 questionnaire for assessment of its neuropathic character. Preservation of ICBN resulted in significantly better preserved sensation on lateral aspect of mastectomy incision, axilla, and medial aspect of the arm. Frequency and severity of acute post-operative pain were similar between the two groups. However, PP was significantly reduced in ICBN preserved group. At 3 months, 31% patients in group I and 12.5% in group II had clinically significant pain (p = 0.024). DN 4 assessment showed neuropathic character of pain in 20.6% and 8.33% in group I and II respectively. In our study, preservation of ICBN resulted in reduced rates of sensory loss and persistent neuropathic pain.
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Affiliation(s)
- Navneet Kaur
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ram Kumar
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ayush Jain
- Department of Surgery, UCMS & GTB Hospital University of Delhi, Dilshad Garden, Delhi, 110095 India
| | - Ashok Kumar Saxena
- Department of Anesthesia and critical care, UCMS & GTB Hospital, Delhi, India
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Siddiqui AU, Gurudiwan R, Siddiqui AT, Satapathy BC, Gupta P. Aberrant bifurcation of intercostobrachial nerve in the axilla: A case report. Morphologie 2020; 104:70-72. [PMID: 31473078 DOI: 10.1016/j.morpho.2019.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 06/10/2023]
Abstract
Intercostobrachial nerve (ICBN) studies have been undertaken by many authors as it is a highly variable structure with numerous patterns reported worldwide. ICBN is a frequently damaged structure in Axillary Lymph Node Dissection (ALND) or mastectomy. Compression of this nerve, due to the enlargement of axillary lymph nodes from cancer breast may be presented as referred pain along the medial side of arm. Different patterns on the course and distribution of the ICBN have been described in literature. We encountered a lesser known variation of the ICBN where it pierced the second intercostal space as a single trunk and immediately divided into two branches. The putative clinical implications of this aberrant bifurcation are of value in significantly diminishing complications such as pain and sensory disturbances presenting after mastectomy and ALND. The findings of the presentation may be of use by surgeons and interventionists in approaching the area in a more precautious manner.
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Affiliation(s)
- A U Siddiqui
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India.
| | - R Gurudiwan
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India
| | - A T Siddiqui
- Department of Cardiothoracic and Vascular Surgery, Kind Saud Medical City, Riyadh, Saudi Arabia
| | - B C Satapathy
- Department of Anatomy, All India Institute of Medical Sciences, Mangalagiri, Vijayawada, Andhra Pradesh, India
| | - P Gupta
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India
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Chirappapha P, Arunnart M, Lertsithichai P, Supsamutchai C, Sukarayothin T, Leesombatpaiboon M. Evaluation the effect of preserving intercostobrachial nerve in axillary dissection for breast cancer patient. Gland Surg 2019; 8:599-608. [PMID: 32042666 DOI: 10.21037/gs.2019.10.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The Intercostobrachial nerve (ICBN) is responsible for sensory function in the axillar and upper arm. The majority of surgeons routinely sacrifice the ICBN during axillary lymph node dissection (ALND) because of technical difficulties. Therefore, the aim of this study was to assess the effects of the preservation or division of the ICBN on the incidence of post-operative sensory disturbance, health-related quality of life (HRQOL), and the physical functions of the upper limbs. Methods We performed a randomized double-blind trial comparing the incidence of sensory disturbance, HRQOL and physical functions of upper limbs in the preservation and the removal of the ICBN. Clinicians performed sensory evaluation at 2 weeks and 3 months after surgery. The sensory evaluation included questionnaires (subjective evaluation) and physical examination (objective evaluation) to evaluate sensory disturbance of the upper arm. HRQOL and physical function of upper limbs was accessed before surgery and at three months after surgery, using Short Form-36 and QuickDASH questionnaires, both in Thai language versions. Results At the end of the surgical procedures there were 15 patients in the preserved group (group P) and 28 patients in the non-preserved group (group N). In as-treated analysis, there was no significant difference between the groups in pain, sensory loss, physical examination of touch and pinprick sensation, and areas of sensory dullness. HRQOL found that the reported pain in P group was higher than N group in both intention-to-treat and as-treated analysis. In the QuickDASH scores of physical functions of the upper limbs there was a significant difference, 9.1 in group P and 20.5 in group N (P=0.013). Conclusions ICBN preservation provides no benefit to improving sensation, but there are benefits in HRQOL and physical functions of upper limbs at three months after surgery.
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Affiliation(s)
- Prakasit Chirappapha
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Methas Arunnart
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panuwat Lertsithichai
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chairat Supsamutchai
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thongchai Sukarayothin
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Monchai Leesombatpaiboon
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Kokosis G, Chopra K, Darrach H, Dellon AL, Williams EH. Re-visiting post-breast surgery pain syndrome: risk factors, peripheral nerve associations and clinical implications. Gland Surg 2019; 8:407-415. [PMID: 31538066 DOI: 10.21037/gs.2019.07.05] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aesthetic and reconstructive breast surgery is among the most common operations performed by plastic surgeons. The prevalence of persistent pain after breast surgery remains underappreciated by plastic surgeons. Post breast surgery pain syndrome (PBSPS) is reported to range between 20-60%. It is the purpose of this paper to revisit chronic pain as a combination of the breast intervention and relate this to the peripheral nerve(s) transmitting the pain message, in order to understand the underlying etiology and to improve breast pain treatment outcomes.
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Affiliation(s)
- George Kokosis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Karan Chopra
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Eric H Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Comparison of Incidence and Severity of Chronic Postsurgical Pain Following Ear Surgery. J Craniofac Surg 2018; 29:e552-e555. [DOI: 10.1097/scs.0000000000004532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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[Impact of the preservation of the branches of intercostobrachial nerve on the quality of life of patients operated for a breast cancer]. Bull Cancer 2017; 104:858-868. [PMID: 28917551 DOI: 10.1016/j.bulcan.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/21/2022]
Abstract
AIM The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer. METHODS This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure. RESULTS Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P<0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P<0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar. CONCLUSION Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.
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Chronic pain and other symptoms among breast cancer survivors: prevalence, predictors, and effects on quality of life. Breast Cancer Res Treat 2017; 167:157-169. [DOI: 10.1007/s10549-017-4485-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/23/2017] [Indexed: 10/19/2022]
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Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials. Ann Surg 2017; 264:64-72. [PMID: 26756767 DOI: 10.1097/sla.0000000000001613] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to establish whether an inguinal neurectomy at the time of hernia repair would reduce the risk of postoperative pain for open tension-free sutured mesh repair. BACKGROUND Inguinal hernia repair is a common operative procedure. The development of postoperative pain is uncommon, but at times debilitating. The role of inguinal neurectomy is currently unknown, with no single large study available, and previous reviews included only a few heterogeneous studies. METHODS Relevant randomized trials were identified from searches of MEDLINE, EMBASE, and EBM Review databases until October 2014. Meta-analysis was performed based on Cochrane Methods using RevMan v5.3 software. Pain, pain scores, sensory changes, and complications over short (half to <3 months), mid (3 to <12 mo), and long term (≥12 mo) were recorded. RESULTS All included studies performed Lichtenstein hernia repair. Eleven studies on 1031 patients showed significant reduction in pain with neurectomy for short (RR = 0.61, 0.40-0.93) and midterm (RR = 0.30, 0.20-0.46), but not for long term (RR = 0.50, 0.25-1.01). Three studies (270 patients) showed significantly reduced short-term pain (RR = 0.69, 0.52-0.90). No studies included genitofemoral neurectomy. Rates of hematoma, infection, urinary retention, and recurrence were not different between groups. CONCLUSIONS Routine ilioinguinal neurectomy during Lichtenstein-type herniorrhaphy seems to be a safe and effective method to reduce pain in the short and midterm, but may have little long-term impact. Iliohypogastric neurectomy seems to reduce pain in at least the short term.
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Acquired Exchange Protein Directly Activated by Cyclic Adenosine Monophosphate Activity Induced by p38 Mitogen-activated Protein Kinase in Primary Afferent Neurons Contributes to Sustaining Postincisional Nociception. Anesthesiology 2017; 126:150-162. [PMID: 27984207 DOI: 10.1097/aln.0000000000001401] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The molecular mechanisms responsible for sustained pain after tissue injury are largely unknown. The aim of this study was to clarify the role of exchange protein directly activated by cyclic adenosine monophosphate (EPAC) in sustained postincisional nociception, using tissue injury-induced nociceptor priming, and involvement of p38 mitogen-activated protein kinase (p38MAPK) in EPAC-mediated nociceptor priming. METHODS Plantar incisions were made in the hind paws of Sprague-Dawley rats (n = 144). Nociceptor priming was confirmed by behavior testing followed by prostaglandin E2 injection 14 to 21 days after the incision. ESI-09, a selective EPAC inhibitor, was administered to assess its effects on nociceptor priming. Expression of two isoforms of EPAC (EPAC1/EPAC2) in dorsal root ganglions from naive rats and those 14 days after the incision was detected by immunohistochemistry and Western blotting. Separately, FR167653, a selective p38MAPK inhibitor, was administered to assess its effect on EPAC1/EPAC2 expression and the development of nociceptor priming. RESULTS Prostaglandin E2 injection 14 to 21 days after the plantar incision induced persistent mechanical hyperalgesia for 7 days. EPAC1/EPAC2 expression in dorsal root ganglion neurons was trivial in naive rats (7.7 ± 4.8% for EPAC1; 6.3 ± 4.1% for EPAC2) but markedly increased 14 days after the incision (21.0 ± 9.4% and 20.1 ± 3.8%, respectively). ESI-09 treatment inhibited prostaglandin E2-induced persistent mechanical hypersensitivity but had no effect on incision-induced acute nociceptive hypersensitivity. Treatment with FR167653 before the incision inhibited the development of nociceptor priming and incision-induced EPAC1/EPAC2 expression (8.5 ± 5.4% and 7.6 ± 3.3%, respectively). CONCLUSIONS Transient inflammatory stimulation causes long-lasting nociceptive hypersensitivity via nociceptor priming during the subacute period after incision. Acquired EPAC activity by p38MAPK in the dorsal root ganglion neurons is a key for this event.
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Henry BM, Graves MJ, Pękala JR, Sanna B, Hsieh WC, Tubbs RS, Walocha JA, Tomaszewski KA. Origin, Branching, and Communications of the Intercostobrachial Nerve: a Meta-Analysis with Implications for Mastectomy and Axillary Lymph Node Dissection in Breast Cancer. Cureus 2017; 9:e1101. [PMID: 28428928 PMCID: PMC5393909 DOI: 10.7759/cureus.1101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/17/2017] [Indexed: 12/20/2022] Open
Abstract
The intercostobrachial nerve (ICBN), which usually originates from the lateral cutaneous branch of the second intercostal nerve, innervates areas of the axilla, lateral chest, and medial arm. It is at risk for injury during operative procedures that are often used in the management of breast cancer and such injury has been associated with postoperative sensory loss and neuropathic pain, decreasing the quality of life. PubMed, Excerpta Medica Database (EMBASE), ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), Scientific Electronic Library Online (SciELO), Biosciences Information Service (BIOSIS), and Web of Science were searched comprehensively. Data concerning the prevalence, branching, origin and communications of the ICBN were extracted and pooled into a meta-analysis. A total of 16 studies (1,567 axillas) reported data indicating that the ICBN was present in 98.4% of person. It most often (90.6%) originated from fibers at the T2 spinal level and commonly coursed in two branching patterns: as a single trunk in 47.0% of cases and as a bifurcating pattern in 42.2%. In the latter cases, the bifurcation was usually unequal (63.4%). Additionally, the ICBN presented with anastomosing communication to the brachial plexus in 41.3% of cases. The ICBN is a prevalent and variable structure at significant risk for injury during operative procedures of the axilla. In view of the postoperative pain and paresthesia experienced by patients following injury, surgeons need to exercise caution and aim to preserve the ICBN when possible. Ultimately, careful dissection and knowledge of ICBN anatomy could allow postoperative complications to be reduced and patient's quality of life increased.
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Affiliation(s)
| | - Matthew J Graves
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub R Pękala
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | | | | | | | - Jerzy A Walocha
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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Juhl AA, Christiansen P, Damsgaard TE. Persistent Pain after Breast Cancer Treatment: A Questionnaire-Based Study on the Prevalence, Associated Treatment Variables, and Pain Type. J Breast Cancer 2016; 19:447-454. [PMID: 28053634 PMCID: PMC5204052 DOI: 10.4048/jbc.2016.19.4.447] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/10/2016] [Indexed: 12/22/2022] Open
Abstract
Purpose Persistent pain is a common side effect of breast cancer treatment. The present study aimed to assess the prevalence, associated treatment-related factors, and the type of pain (neuropathic or nociceptive) in patients who had undergone a unilateral mastectomy. Methods All women who underwent a unilateral mastectomy at a University Hospital between 2009 and 2013 were eligible for inclusion. Women with breast reconstruction or active cancer were excluded. Participants were mailed a questionnaire evaluating the prevalence, location, intensity, and frequency of surgical site pain. Additionally, the painDETECT®, a validated instrument to evaluate neuropathic pain, was mailed to all participants. Results A total of 305 women were included, and of them, 261 (85.6%) completed the study questionnaire. After a median follow-up period of 3.0 years, 100 women (38.3%) reported experiencing pain at the surgical site. Body mass index ≥30 kg/m2, radiation therapy, and axillary lymph node dissection were significantly associated with persistent pain in univariate models. However, only body mass index ≥30 kg/m2 was independently associated with persistent pain (odds ratio, 2.13; 95% confidence interval, 1.06–4.27; p=0.034) in a multivariate analysis. Of the patients reporting pain, 71.0% were unlikely to have a neuropathic pain component. A moderate, but highly significant, positive correlation was observed between the pain intensity and the painDETECT® score (rs=0.47, p<0.001). Conclusion Persistent pain after breast cancer treatment continues to have a high prevalence. Our results indicate that the largest proportion of patients experiencing persistent pain after breast cancer treatment do not have a clear neuropathic pain component.
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Affiliation(s)
- Alexander Andersen Juhl
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peer Christiansen
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark.; Department of Surgery, Randers Regional Hospital/Aarhus University Hospital, Aarhus, Denmark.; Danish Breast Cancer Cooperative Group, Denmark
| | - Tine Engberg Damsgaard
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag 2016; 6:603-618. [DOI: 10.2217/pmt-2015-0008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.
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Affiliation(s)
- Gloria S Cheng
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian M Ilfeld
- University of California San Diego, San Diego, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Cheng GS, Ilfeld BM. An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery. PAIN MEDICINE 2016; 18:1344-1365. [DOI: 10.1093/pm/pnw172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Wang L, Guyatt GH, Kennedy SA, Romerosa B, Kwon HY, Kaushal A, Chang Y, Craigie S, de Almeida CPB, Couban RJ, Parascandalo SR, Izhar Z, Reid S, Khan JS, McGillion M, Busse JW. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ 2016; 188:E352-E361. [PMID: 27402075 DOI: 10.1503/cmaj.151276] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. METHODS We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case-control studies that explored the association between risk factors and persistent pain (lasting ≥ 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase. RESULTS Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24-1.48), radiotherapy (OR 1.35, 95% CI 1.16-1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73-3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03-1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01-1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy. INTERPRETATION Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.
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Affiliation(s)
- Li Wang
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Gordon H Guyatt
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Sean A Kennedy
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Beatriz Romerosa
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Henry Y Kwon
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Alka Kaushal
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Yaping Chang
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Samantha Craigie
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Carlos P B de Almeida
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Rachel J Couban
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Shawn R Parascandalo
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Zain Izhar
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Susan Reid
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - James S Khan
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Michael McGillion
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
| | - Jason W Busse
- Michael G. DeGroote Institute for Pain Research and Care (Wang, Craigie, Couban, Busse), Department of Anesthesia (Wang, Busse), Department of Clinical Epidemiology and Biostatistics (Guyatt, Kaushal, Chang, Izhar, Busse), Michael G. DeGroote School of Business (Izhar), Department of Surgery (Reid) and School of Nursing (McGillion), McMaster University, Hamilton, Ont.; Chinese Cochrane Centre (Wang), West China Hospital, Sichuan University, Chengdu, China; Department of Diagnostic Radiology (Kennedy) and Department of Anesthesiology (Khan), University of Toronto, Toronto, Ont.; Department of Anesthesia and Critical Care (Romerosa), University Hospital of Toledo, Toledo, Spain; Wayne State University School of Medicine (Kwon), Detroit, Mich.; Respiratory Sciences Program (de Almeida), Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; School of Medicine (Parascandalo), University College Cork, Cork, Ireland
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Johansen A, Schirmer H, Nielsen CS, Stubhaug A. Persistent post-surgical pain and signs of nerve injury: the Tromsø Study. Acta Anaesthesiol Scand 2016; 60:380-92. [PMID: 26537886 DOI: 10.1111/aas.12653] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 06/20/2015] [Accepted: 08/19/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contribution of nerve lesions and neuropathic pain to persistent post-surgical pain (PPSP) is poorly established. The aim of this study was to assess the association between PPSP and symptoms and signs of possible nerve injury in an unselected surgical sample. METHODS Eighty-one individuals with and without persistent pain after surgical procedures, were recruited from a cross-sectional study. Follow-up examination with questionnaires and quantitative sensory testing was performed 15-32 months later (21-64 months after surgery). RESULTS The median rating of maximum pain intensity among individuals with PPSP decreased from numerical rating scale 4/10 at baseline to 2/10 at follow-up, but considerable changes occurred in both directions. Individuals with PPSP at follow-up were significantly more likely to self-report sensory abnormalities than those without PPSP; however, results from sensory testing did not differ significantly between the groups. Self-report of sensory disturbances at the site of surgery was associated with increased warm detection thresholds and tactile pain thresholds. Among individuals with PPSP, 61% had positive findings on sensory testing, suggesting probable neuropathic pain. CONCLUSION In this study, associations between self-reported symptoms and PPSP were stronger than associations between self-reported symptoms and results of psychophysical tests. Fluctuations in pain intensity together with wide ranges for normal variability in sensory functions, hampers detection of significant group differences. Methodological aspects of quantitative sensory testing applied in a mixed clinical sample are discussed.
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Affiliation(s)
- A. Johansen
- Division of Surgical Medicine and Intensive Care; University Hospital of North Norway; Tromsø Norway
- Department of Community Medicine; The Arctic University of Norway; Tromsø Norway
| | - H. Schirmer
- Division of Cardiothoracic and Respiratory Medicine; University Hospital of North Norway; Tromsø Norway
- Department of Clinical Medicine; The Arctic University of Norway; Tromsø Norway
| | - C. S. Nielsen
- Division of Mental Health; Norwegian Institute of Public Health; Oslo Norway
- Department of Pain Management and Research; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
| | - A. Stubhaug
- Department of Pain Management and Research; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
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Andersen KG, Duriaud HM, Aasvang EK, Kehlet H. Association between sensory dysfunction and pain 1 week after breast cancer surgery: a psychophysical study. Acta Anaesthesiol Scand 2016; 60:259-69. [PMID: 26446738 DOI: 10.1111/aas.12641] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 08/24/2015] [Accepted: 09/05/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Breast cancer patients treated with axillary lymph node dissection (ALND) have a higher risk of both acute and persistent pain than those treated with sentinel lymph node biopsy (SLNB). This could be attributed to a higher risk of nerve injury with ALND. We hypothesized that (1) pain patients have more pronounced sensory dysfunction than pain-free patients, (2) ALND have more sensory dysfunction and pain than SLNB patients and (3) patients with preserved intercostobrachial nerve (ICBN) preservation have less sensory dysfunction compared to a sectioned ICBN. METHODS Twenty-seven patients treated with ALND and 27 with SLNB examined with a standardized Quantitative Sensory Testing (QST) protocol, including sensory mapping, mechanical and thermal thresholds, as well as recording intraoperative ICBN handling and pain status 1 week post-operative. RESULTS The area of cold hypoaesthesia was significantly associated with movement-related pain (P = 0.004), with a similar tendency for warmth (P = 0.018) and brush (P = 0.030) hypoaesthesia areas. 14 (26%) of the patients had moderate/severe pain at rest and 13 (24%) during movement without differences between ALND and SLNB, but ALND was associated with more sensory dysfunction than SLNB. Patients with sectioned ICBN reported lower pain intensity than those with preserved ICBN (P = 0.005), but without differences in sensory dysfunction. CONCLUSION Pain was increased in patients having larger areas of hypoaesthesia and reduced in patients where ICBN-section was done. Sensory dysfunction was related to extent of axillary surgery, but not with ICBN handling. Our data suggest that acute pain after breast cancer surgery may be related to nerve injury.
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Affiliation(s)
- K. G. Andersen
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Department of Breast Surgery; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - H. M. Duriaud
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - E. K. Aasvang
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - H. Kehlet
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Hucker T, Winter N, Chou J. Challenges and Advances in Pain Management for the Cancer Patient. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0120-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Rustagi SM, Sharma M, Singh N, Mehta V, Suri RK, Rath G. Peripheral communications of intercostobrachial nerve Peripheral communications of the intercostobrachial nerve in relation to the alar thoracic artery. Adv Biomed Res 2015; 4:51. [PMID: 25802820 PMCID: PMC4361959 DOI: 10.4103/2277-9175.151555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 07/26/2014] [Indexed: 11/04/2022] Open
Abstract
The intercostobrachial nerve (ICBN) is often encountered during axillary dissection for axillary lymph node dissection (ALND) for diagnostic and therapeutic surgery for mastectomy. The present report is a case observed in the Department of Anatomy at Vardhman Mahavir Medical College, Delhi during routine dissection of the upper extremity of a male cadaver for first year undergraduate medical students. On the right side, the medial cord of brachial plexus gave two medial cutaneous nerves of arm. Both the nerves were seen communicating with the branches of the ICBN. The ICBN and one of its branches were surrounding the termination of an alar thoracic artery. These peripheral neural connections of the ICBN with the branches of the medial cord can be a cause of sensory impairment during axillary procedures done for mastectomy or exploration of long thoracic nerves. The alar thoracic artery found in relation to the ICBN could further be a cause of vascular complications during such procedures.
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Affiliation(s)
- Shaifaly Madan Rustagi
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Mona Sharma
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Nidhi Singh
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Vandana Mehta
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Rajesh K Suri
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Gayatri Rath
- Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
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Schreiber KL, Kehlet H, Belfer I, Edwards RR. Predicting, preventing and managing persistent pain after breast cancer surgery: the importance of psychosocial factors. Pain Manag 2014; 4:445-59. [DOI: 10.2217/pmt.14.33] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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ANDERSEN KG, AASVANG EK, KROMAN N, KEHLET H. Intercostobrachial nerve handling and pain after axillary lymph node dissection for breast cancer. Acta Anaesthesiol Scand 2014; 58:1240-8. [PMID: 25307709 DOI: 10.1111/aas.12393] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moderate to severe pain in the first week after axillary lymph node dissection (ALND) for breast cancer is experienced by approximately 50% of the patients. Damage to the intercostobrachial nerve (ICBN) has been proposed as a risk factor for the development of persistent pain following breast cancer surgery but with limited information on acute post-operative pain. The aim of the present study was to examine the influence of ICBN handling on pain during the first week after ALND. METHODS The study was part of a larger prospective cohort study on persistent pain after breast cancer treatment. Pain and sensory disturbances were assessed pre-operatively, within the first 72 h post-operatively and a week after surgery. Intraoperative handling of the nerve was recorded by the surgeon as preserved, partially preserved or sectioned. RESULTS One hundred forty-one patients were treated with ALND level I + II, and the ICBN could be identified in 125 (89%) patients. Of the 17 not identified, eight were stated as without any sign of the nerve and were included in analysis as sectioned. Thus, the analysis included 133 patients in which 45 (34%) of these the ICBN was preserved, 39 (29%) partially preserved and 49 (37%) sectioned. At 1 week after surgery, 104 patients (78%) reported pain, whereas 35 (26%) reported moderate to severe pain. There was no difference between the ICBN groups in pain scores or sensory disturbances measured pre-operatively compared to 1 week post-operatively. CONCLUSION The type of ICBN handling during ALND may not influence acute post-operative pain in the first week after surgery.
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Affiliation(s)
- K. G. ANDERSEN
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Department of Breast Surgery; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - E. K. AASVANG
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - N. KROMAN
- Department of Breast Surgery; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - H. KEHLET
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Ahmed M, Cook LJ, Douek M. Preservation of the intercostobrachial nerve during axillary node clearance for breast cancer. Hippokratia 2014. [DOI: 10.1002/14651858.cd011229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Muneer Ahmed
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
| | - Lorna J Cook
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
| | - Michael Douek
- King's College London; Department of Research Oncology; Great Maze Pond London UK SE1 9RT
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Lamacraft G. The transition from acute to chronic pain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Warrier S, Hwang S, Koh CE, Shepherd H, Mak C, Carmalt H, Solomon M. Preservation or division of the intercostobrachial nerve in axillary dissection for breast cancer: Meta-analysis of Randomised Controlled Trials. Breast 2014; 23:310-6. [DOI: 10.1016/j.breast.2014.01.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 01/06/2014] [Accepted: 01/19/2014] [Indexed: 11/28/2022] Open
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Abstract
Purpose The present study aimed to measure the thickness of the subcutaneous adipose tissue (SAT) at the site of the surgical incision for axillary lymph node dissection (ALND) and to record potential anatomical variations in the medial cutaneous nerve of the arm (MCNA), the intercostobrachial nerve (ICBN), the lateral thoracic vein (LTV), the lateral thoracic artery (LTA) and the pectoral muscle pedicle (PMP), considering that some details of the anatomy of these structures within the axilla are still unclear. Methods A prospective study was conducted in 100 consecutive patients with breast cancer who underwent ALND as part of surgical treatment. The anatomy of the dissected axilla was video recorded. Results The SAT thickness ranged from 8 mm to 60 mm, with an average thickness of 25.9 mm. A positive correlation was observed between the SAT thickness and the body mass index (BMI) of the evaluated patients (r = 0.68; p < 0.0001). The MCNA was the anatomical structure that was least commonly observed in the axilla (22% of cases), while the PMP was the most constant element, identified in 100% of cases. All of the studied anatomical structures observed within the axilla showed variation in at least one of the aspects analyzed, i.e., the point of entry and exit, path, number and location of divisions or branches. Conclusion The present study demonstrated wide variation in thickness of the SAT overlying the axilla and identified the existence of broad normative anatomical variation of the axilla. Electronic supplementary material The online version of this article (doi:10.1186/2193-1801-3-306) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emerson Wander Silva Soares
- Biological Science and Health Center, Western Paraná State University, (Universidade Estadual do Oeste do Paraná, UNIOESTE), Cascavel, Paraná, Brazil ; Department of Surgical Oncology, Study and Treatment Cancer Center of Western Paraná, (União Oeste Paranaense de Estudos e Combate ao Câncer, UOPECCAN), Cascavel, Paraná, Brazil
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The Course of the Intercostobrachial Nerve in the Axillary Region and As It Is Related to Transaxillary Breast Augmentation. Ann Plast Surg 2014; 72:337-9. [DOI: 10.1097/sap.0b013e31825c07ba] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Belfer I, Schreiber KL, Shaffer JR, Shnol H, Blaney K, Morando A, Englert D, Greco C, Brufsky A, Ahrendt G, Kehlet H, Edwards RR, Bovbjerg DH. Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors. THE JOURNAL OF PAIN 2013; 14:1185-95. [PMID: 23890847 DOI: 10.1016/j.jpain.2013.05.002] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/03/2013] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Persistent postmastectomy pain (PPMP) is increasingly recognized as a major individual and public health problem. Although previous studies have investigated surgical, medical, and demographic risk factors, in this study we aimed to more clearly elucidate the relationship of psychosocial factors to PPMP. Postmastectomy patients (611) were queried about pain location, severity, and burden 38.3 ± 35.4 months postoperatively. Validated questionnaires for depressive symptoms, anxiety, sleep, perceived stress, emotional stability, somatization, and catastrophizing were administered. Detailed surgical, medical, and treatment information was abstracted from patients' medical records. One third (32.5%) of patients reported PPMP, defined as ≥3/10 pain severity in the breast, axilla, side, or arm, which did not vary according to time since surgery. Multiple regression analysis revealed significant and independent associations between PPMP and psychosocial factors, including catastrophizing, somatization, anxiety, and sleep disturbance. Conversely, treatment-related factors including surgical type, axillary node dissection, surgical complication, recurrence, tumor size, radiation, and chemotherapy were not significantly associated with PPMP. These data confirm previous studies suggesting that PPMP is relatively common and provide new evidence of significant associations between psychosocial characteristics such as catastrophizing with PPMP, regardless of the surgical and medical treatment that patients receive, which may lead to novel strategies in PPMP prevention and treatment. PERSPECTIVE This cross-sectional cohort study of 611 postmastectomy patients investigated severity, location, and frequency of pain a mean of 3.2 years after surgery. Significant associations between pain severity and individual psychosocial attributes such as catastrophizing were found, whereas demographic, surgical, medical, and treatment-related factors were not associated with persistent pain.
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Affiliation(s)
- Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania; University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
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Schreiber KL, Martel MO, Shnol H, Shaffer JR, Greco C, Viray N, Taylor LN, McLaughlin M, Brufsky A, Ahrendt G, Bovbjerg D, Edwards RR, Belfer I. Persistent pain in postmastectomy patients: comparison of psychophysical, medical, surgical, and psychosocial characteristics between patients with and without pain. Pain 2012; 154:660-668. [PMID: 23290256 DOI: 10.1016/j.pain.2012.11.015] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 11/09/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
Persistent postmastectomy pain (PPMP) is a major individual and public health problem. Increasingly, psychosocial factors such as anxiety and catastrophizing are being revealed as crucial contributors to individual differences in pain processing and outcomes. Furthermore, differences in patients' responses to standardized quantitative sensory testing (QST) may aid in the discernment of who is at risk for acute and chronic pain after surgery. However, characterization of the variables that differentiate those with PPMP from those whose acute postoperative pain resolves is currently incomplete. The purpose of this study was to investigate important surgical, treatment-related, demographic, psychophysical, and psychosocial factors associated with PPMP by comparing PPMP cases with PPMP-free controls. Pain was assessed using the breast cancer pain questionnaire to determine the presence and extent of PPMP. Psychosocial and demographic information were gathered via phone interview, and women underwent a QST session. Consistent with most prior research, surgical and disease-related variables did not differ significantly between cases and controls. Furthermore, treatment with radiation, chemotherapy, or hormone therapy was also not more common among those with PPMP. In contrast, women with PPMP did show elevated levels of distress-related psychosocial factors such as anxiety, depression, catastrophizing, and somatization. Finally, QST in nonsurgical body areas revealed increased sensitivity to mechanical stimulation among PPMP cases, while thermal pain responses were not different between the groups. These findings suggest that an individual's psychophysical and psychosocial profile may be more strongly related to PPMP than their surgical treatment.
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Affiliation(s)
- Kristin L Schreiber
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, MA, USA Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA Department of Psychiatry, Brigham & Women's Hospital, Boston, MA, USA
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Impact of preservation of the intercostobrachial nerve during axillary dissection on sensory change and health-related quality of life 2 years after breast cancer surgery. Breast Cancer 2012; 21:183-90. [DOI: 10.1007/s12282-012-0374-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/18/2012] [Indexed: 10/27/2022]
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36
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Khan A, Chakravorty A, Gui GPH. In vivo study of the surgical anatomy of the axilla. Br J Surg 2012; 99:871-7. [DOI: 10.1002/bjs.8737] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2012] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations.
Methods
Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded.
Results
Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)—three variants; lateral thoracic vein in 12 patients (16 per cent)—four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure.
Conclusion
Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery.
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Affiliation(s)
- A Khan
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - A Chakravorty
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - G P H Gui
- Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Andersen KG, Kehlet H. Persistent Pain After Breast Cancer Treatment: A Critical Review of Risk Factors and Strategies for Prevention. THE JOURNAL OF PAIN 2011; 12:725-46. [DOI: 10.1016/j.jpain.2010.12.005] [Citation(s) in RCA: 320] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 11/25/2010] [Accepted: 12/08/2010] [Indexed: 01/09/2023]
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Abstract
The transition from acute to chronic pain appears to occur in discrete pathophysiological and histopathological steps. Stimuli initiating a nociceptive response vary, but receptors and endogenous defence mechanisms in the periphery interact in a similar manner regardless of the insult. Chemical, mechanical, and thermal receptors, along with leucocytes and macrophages, determine the intensity, location, and duration of noxious events. Noxious stimuli are transduced to the dorsal horn of the spinal cord, where amino acid and peptide transmitters activate second-order neurones. Spinal neurones then transmit signals to the brain. The resultant actions by the individual involve sensory-discriminative, motivational-affective, and modulatory processes in an attempt to limit or stop the painful process. Under normal conditions, noxious stimuli diminish as healing progresses and pain sensation lessens until minimal or no pain is detected. Persistent, intense pain, however, activates secondary mechanisms both at the periphery and within the central nervous system that cause allodynia, hyperalgesia, and hyperpathia that can diminish normal functioning. These changes begin in the periphery with upregulation of cyclo-oxygenase-2 and interleukin-1β-sensitizing first-order neurones, which eventually sensitize second-order spinal neurones by activating N-methyl-d-aspartic acid channels and signalling microglia to alter neuronal cytoarchitecture. Throughout these processes, prostaglandins, endocannabinoids, ion-specific channels, and scavenger cells all play a key role in the transformation of acute to chronic pain. A better understanding of the interplay among these substances will assist in the development of agents designed to ameliorate or reverse chronic pain.
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Affiliation(s)
- C Voscopoulos
- Department of Anesthesiology, Critical Care, and Pain Medicine, University at Buffalo, Buffalo, NY, USA
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Lovrincevic M, Lema MJ, Hsu BH. Postmastectomy Pain. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Holmes A, Williamson O, Hogg M, Arnold C, Prosser A, Clements J, Konstantatos A, O'Donnell M. Predictors of pain severity 3 months after serious injury. PAIN MEDICINE 2010; 11:990-1000. [PMID: 20642728 DOI: 10.1111/j.1526-4637.2010.00890.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.
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Affiliation(s)
- Alex Holmes
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
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Clough KB, Nasr R, Nos C, Vieira M, Inguenault C, Poulet B. New anatomical classification of the axilla with implications for sentinel node biopsy. Br J Surg 2010; 97:1659-65. [DOI: 10.1002/bjs.7217] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
The exact anatomical location of the sentinel lymph node (SLN) in the axilla has not ascertained clinically, but could be useful both for teaching purposes and to reduce the morbidity of SLN biopsy. The aim of the study was to determine the position of the SLN in the axilla and to demonstrate that this location is not random.
Methods
A consecutive series of 242 patients with stage I breast cancer (T1/T2 N0) or ductal carcinoma in situ who underwent SLN localization by peritumoral injection were included in a prospective study to map the location of the SLN in the axilla. A new anatomical classification of the lower part of the axilla based on the intersection of two anatomical landmarks, the lateral thoracic vein (LTV) and the second intercostobrachial nerve (ICBN), is described. These two constant elements form the basis of four axillary zones (A, B, C and D).
Results
In 98·2 per cent of patients the axillary SLN was located medially, alongside the LTV, either below the second ICBN (zone A, 86·8 per cent) or above it (zone B, 11·5 per cent). In only four patients (1·8 per cent) was the SLN located laterally in the axilla.
Conclusion
Regardless of the site of the tumour in the breast, 98·2 per cent of SLNs were found in the medial part of the axilla, alongside the LTV. This information should help to avoid unnecessary lateral dissections.
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Affiliation(s)
- K B Clough
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - R Nasr
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - C Nos
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - M Vieira
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - C Inguenault
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
| | - B Poulet
- The Paris Breast Centre (L'Institut du Sein), 7 Avenue Bugeaud, 75116 Paris, France
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Gahm J, Wickman M, Brandberg Y. Bilateral prophylactic mastectomy in women with inherited risk of breast cancer--prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery. Breast 2010; 19:462-9. [PMID: 20605453 DOI: 10.1016/j.breast.2010.05.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 04/19/2010] [Accepted: 05/06/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Mastectomy due to breast cancer is associated with chronic pain and a negative impact on sexuality. The purposes of the study were to analyze the prevalence of pain and discomfort in the breasts, impact on sexuality, quality of life, and feelings of regret after bilateral prophylactic mastectomy and immediate reconstruction with implants. METHODS Fifty-nine women operated 2004-2006 were included. A questionnaire was sent out two years after the procedure. Complications and re-operations were recorded. RESULTS Mean follow-up time was 29 months. 93% of patients answered the questionnaire. 69% reported pain and 71% discomfort in the breasts. Lost or much reduced sexual sensations were reported by 85% and enjoyment of sex was negatively impacted for 75% of patients. Quality of life was not affected and feelings of regret were almost non-existent. CONCLUSIONS It is important to inform women approaching this prophylactic procedure about the risk of having unwanted secondary effects.
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Affiliation(s)
- Jessica Gahm
- Department of Molecular Medicine and Surgery, Section of Reconstructive Plastic Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Pellerin M, Kimball Z, Tubbs RS, Nguyen S, Matusz P, Cohen-Gadol AA, Loukas M. The prefixed and postfixed brachial plexus: a review with surgical implications. Surg Radiol Anat 2010; 32:251-60. [DOI: 10.1007/s00276-009-0619-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/30/2009] [Indexed: 11/24/2022]
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Abstract
Phantom breast syndrome is a type of condition in which patients have a sensation of residual breast tissue and can include both non-painful sensations as well as phantom breast pain. The incidence varies in different studies, ranging from approximately 30% to as high as 80% of patients after mastectomy. It seriously affects quality of life through the combined impact of physical disability and emotional distress. The breast cancer incidence rate in India as well as Western countries has risen in recent years while survival rates have improved; this has effectively increased the number of women for whom post-treatment quality of life is important. In this context, chronic pain following treatment for breast cancer surgery is a significantly under-recognized and under-treated problem. Various types of chronic neuropathic pain may arise following breast cancer surgery due to surgical trauma. The cause of these syndromes is damage to various nerves during surgery. There are a number of assumed factors causing or perpetuating persistent neuropathic pain after breast cancer surgery. Most well-established risk factors for developing phantom breast pain and other related neuropathic pain syndromes are severe acute postoperative pain and greater postoperative use of analgesics. Based upon current evidence, the goals of prophylactic strategies could first target optimal peri-operative pain control and minimizing damage to nerves during surgery. There is some evidence that chronic pain and sensory abnormalities do decrease over time. The main group of oral medications studied includes anti-depressants, anticonvulsants, opioids, N-methyl-D-asparate receptor antagonists, mexilitine, topical lidocaine, cannabinoids, topical capsaicin and glysine antagonists. Neuromodulation techniques such as motor cortex stimulation, spinal cord stimulation, and intrathecal drug therapies have been used to treat various neuropathic pain syndromes.
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Affiliation(s)
- Ramesh
- Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Nootan K Shukla
- Department of Surgical Oncology, Dr. BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Anesthesiology, Dr. BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Decreasing arm morbidity by refining axillary surgery in breast cancer. Eur J Surg Oncol 2009; 35:335-8. [DOI: 10.1016/j.ejso.2008.06.1494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 05/08/2008] [Accepted: 06/09/2008] [Indexed: 11/18/2022] Open
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Vilholm OJ, Cold S, Rasmussen L, Sindrup SH. The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer. Br J Cancer 2008; 99:604-10. [PMID: 18682712 PMCID: PMC2527825 DOI: 10.1038/sj.bjc.6604534] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The prevalence of the postmastectomy pain syndrome (PMPS) and its clinical characteristics was assessed in a group of patients who had undergone surgery for breast cancer at the Department of Surgery, Odense University Hospital, within the period of 1 May 2003 to 30 April 2004. The study included 258 patients and a reference group of 774 women. A questionnaire was mailed to the patients 1 1/2 year after surgery and to the women in the reference group. The PMPS was defined as pain located in the area of the surgery or ipsilateral arm, present at least 4 days per week and with an average intensity of at least 3 on a numeric rating scale from 0 to 10. The prevalence of PMPS was found to be 23.9%. The odds ratio of developing PMPS was 2.88 (95% confidence interval 1.84-4.51). Significant risk factors were as follows: having undergone breast surgery earlier (OR 8.12), tumour located in the upper lateral quarter (OR 6.48) and young age (OR 1.04). This study shows that, although recent advances in the diagnostic and surgical procedures have reduced the frequency of the more invasive surgical procedures, there still is a considerable risk of developing PMPS after treatment of breast cancer.
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Affiliation(s)
- O J Vilholm
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, Odense 5000, Denmark.
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Brooks P, Malic C, Austen O. Intercostobrachial Nerve Injury from Axillary Dissection Resulting in Necrotizing Fasciitis After a Burn Injury. Breast J 2008; 14:385-7. [DOI: 10.1111/j.1524-4741.2008.00605.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ivanovic N, Granic M, Randjelovic T, Todorovic S. Fragmentation of axillary fibrofatty tissue during dissection facilitates preservation of the intercostobrachial nerve and the lateral thoracic vein. Breast 2008; 17:293-5. [DOI: 10.1016/j.breast.2007.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 09/21/2007] [Accepted: 11/11/2007] [Indexed: 11/27/2022] Open
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Ilioinguinal nerve excision in open mesh repair of inguinal hernia--results of a randomized clinical trial: simple solution for a difficult problem? Am J Surg 2008; 195:735-40. [PMID: 18440489 DOI: 10.1016/j.amjsurg.2007.09.037] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 09/17/2007] [Accepted: 09/17/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Inguinodynia is the second most common complication occurring after inguinal hernia repair. This study was undertaken to evaluate the effect of ilioinguinal nerve excision, a concept previously proposed to be performed during open hernia mesh repair, on postsurgical pain and hyposthesia. METHODS A double-blind randomized clinical trial was performed on 121 patients undergoing open anterior mesh repair of inguinal hernia in 1 center from April 2005 through June 2006. The ilioinguinal nerve was excised in half of the patients and preserved in the other half. Pain and hyposthesia at POD 1, 1 and 6 months after surgery, and 1 year after surgery was evaluated in both groups using a visual analog scale. Results were compared using chi-square analysis. RESULTS Of the total number of 121 patients who entered the study, with an age range of 18 to 86 years (mean +/- SD 45 +/- 18), 115 (95%) were male. Sixty-one were in the nerve-excision group, and 60 were in the nerve-preservation group. One hundred patients were followed-up until the end of the first year. Using the visual analog scale to detect pain severity on postsurgical day 1, mean scores in the nerve-excision and nerve-preservation groups were 2.2 +/- .8 (range 1 to 4) versus 2.8 +/- .7 (range 2 to 4.5), respectively (P < .001). At 1 month after surgery, these scores were .7 +/- .7 (range 0 to 3) versus 1.5 +/- .7 (range 0 to 3.5), respectively (P < .001). Between 6 months and 1 year after surgery, median scores of zero were detected in both groups. After postsurgical day 1, the median score of hyposthesia was near zero in both groups. Thirteen patients developed chronic inguinodynia (13%), 10 of whom were in the nerve-preservation group. Chronic postsurgical inguinodynia was seen in 6% of patients in the ilioinguinal nerve-excision and 21% of the patients in the ilioinguinal nerve-preservation group (P = .033). COMMENTS Neurectomy decreases postsurgical pain after elective inguinal hernia repair. Although chronic inguinodynia was less frequent in our study than reported by many previous studies, it is still wise to recommend ilioinguinal neurectomy in patients undergoing anterior inguinal hernia mesh repair.
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