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Background: The incidence of minimally invasive heart surgery via mini-thoracotomy (MT; right anterior thoracotomy) is on the rise, accompanied by an increase in post-MT intercostal nerve neuralgia and the risk of lung herniation through the incision site. While various methods have been proposed to address these issues, none have been commonly effective. In this case report, we attempted to simultaneously address these problems by performing intercostal cryoablation (IC) and mesh repair., Case Presentation: A 43-year-old male was referred to our hospital for chronic post-thoracotomy neuralgia following heart surgery via MT, involving patch closure of an atrial septal defect and tricuspid annuloplasty. He presented with intercostal nerve neuralgia and lung herniation accompanied by severe pain. Despite medication and lidocaine injections, there was no relief. Consequently, he underwent surgical treatment with IC for chronic MT wound pain and simultaneously underwent mesh repair for a lung hernia. He was discharged from hospital free of complications. Subsequently, he no longer required further pain medication and experienced a favorable recovery., Conclusion: Our findings suggest that concurrent IC and mesh repair can effectively relieve chronic post-MT intercostal nerve neuralgia and severe lung herniation pain in patients who underwent MT surgery, leading to a decrease in opioid medication usage., (© 2024. The Author(s).)

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., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Serratus anterior plane block has been used for pain management during the acute period of conditions affecting the thorax, such as postthoracotomy recovery, rib fracture, and breast surgery recovery. Here, we report the use of serratus anterior plane block in posttraumatic chronic pain treatment. We describe a case of posttraumatic chronic intercostal neuralgia, in which successful pain relief was achieved via repeated injections of local anesthetic and steroid combinations in the serratus anterior plane under ultrasonographic guidance. This novel technique is easy to administer, reliable, and warrants further investigation with regard to its use for rehabilitation of patients who are experiencing posttraumatic chronic neuropathies of the chest wall.

Endoscopic surgery has revolutionized the field of minimally invasive surgery. Nerve injury after laparoscopic surgery is presumably rare, with only scarce reports in the literature; however, the use of these techniques for new purposes presents the opportunity for novel complications. The authors report a case of subcostal nerve injury after an anterior laparoscopic approach to a posterior abdominal wall lipoma.A 62-year-old woman presented with a left abdominal flank bulge (pseudohernia) that developed after laparoscopic posterior flank wall lipoma resection. Imaging demonstrated frank ballooning of the oblique muscles; denervation atrophy and thinning of the external oblique, internal oblique, and transverse abdominis muscles; and thinning of the rectus abdominis muscle. The patient underwent subcostal nerve repair and removal of a foreign plastic material from the laparoscopic procedure. At 8 months, she has regained substantial improvement in abdominal wall strength.Although endoscopic procedures have resulted in significant reduction in morbidity, "minimally invasive" approaches should not be confused with "low risk" when approaching novel pathology. The subcostal nerve is at risk of injury in posterior abdominal wall surgery, whether laparoscopic or not. With the pseudohernia and abdominal bulge after this surgery, the cosmetic appeal of laparoscopic incisions was definitively undone. Selecting an approach based on the anatomy of adjacent structures may lead to a better functional result.

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

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

Background: Lateral approaches to the spine are increasing in popularity. However, details of the innervation pattern of the abdominal oblique muscles with the initial dissection have not been well studied., Methods: Ten adult fresh-frozen cadavers (20 sides) were placed in the lateral position. On each side, the region in which transpsoas approaches are performed, between the iliac crest and the 12th rib, was dissected. The nerves, their course, and their muscular supply were studied., Results: The subcostal nerve is the predominant nerve supply for the anterolateral abdominal muscle innervation. It is larger and has a wider field of distribution and more branches (8 on average) compared with the L1 (4 on average) and 11th intercostal nerves (2 on average 2). The proximal 6-10 cm of each nerve has few if any branches. The subcostal nerve is often (75%) located up to 5 cm inferior to the 12th rib in its initial course. The area of least concentration ("safe zone") is located at an approximate midpoint between the lower edge of the 12th rib and the superior-most aspect of the iliac crest. A previously undescribed branch of the subcostal nerve was found traveling posterior to the quadratus lumborum and joining the remaining subcostal nerve in an anastomosis at or near the lateral position., Conclusions: Knowledge of the innervation and nerve dominance patterns might help decrease postoperative complications such as sensory deficits or abdominal wall hernias. The subcostal nerve is the dominant nerve in both size and innervation of the oblique muscles in the lateral position, transpsoas approach., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The aim of our study was to evaluate the extent to which the preservation or the section of the intercostobrachial nerve (ICBN) influences the development of postoperatoryparesthesia and to assess whether the development of paresthesiamay change the patient's life quality after surgical treatment for breast carcinoma., Material and Methods: We performed a nonrandomized retrospective study including 100 patients who underwent axillary lymph node dissection for infiltrating breast carcinoma associated with axillary lymph node metastases. Using a questionnaire we studied the patients general life quality in the postoperative period. For the statistical analysis we used GraphPad Prism, Fisher'™s exact test and Chi square test. Results: 100 patients were included in our study with a mean age of 59.7 years. In 50 cases, the ICBN was preserved (Group 1),while in the remaining 50 cases the ICBN was sectioned during surgery (Group 2). Significantly more patients from Group 2 complained about postoperative paresthesia (p=0.026). In our series, the management of the ICBN cannot be significantly correlated with the impairment of the patients daily activities (p=0.2), sleeping cycle (p=0.2), and general life quality after surgery (p=0.67). We can conclude that the management of ICBN has a great influence on the development of postoperative paresthesia. Although the paresthesia does not have a negative effect on the patient'™s life quality in the postoperative period, in our opinion it is important to preserve the ICBN in order to prevent postoperative paresthesia., (Celsius.)

Background: Breast procedures are among the most common surgeries performed by Plastic Surgeons. The prevalence of persistent pain remains unknown. Our experience has been that persistent breast pain is often related to intercostal nerve trauma. The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with post-operative breast pain., Methods: A retrospective review of 10 patients with breast pain was stratified according to the index surgical procedures: implant-based reconstruction (7), breast reduction (1), breast augmentation (1), and mastopexy (1). Outcomes were assessed with a numerical analog score. Physical examination demonstrated painful trigger points along the pathway of one or more intercostal nerves. Prior to surgery, each patient improved ≥5 points after a diagnostic Xylocaine/Marcaine local anesthesia block of the suspected intercostal nerves. At surgery, one or more intercostal nerves were resected and implanted into adjacent muscles., Results: At a mean of 16.5 months, there were six excellent, one good, and three poor self-reported results. Intercostal nerves resected included the intercostal-brachial (5 patients), 3rd (7 patients), 4th (8 patients), 5th (9 patients), 6th (7 patients), and 7th (1 patient). Multiple intercostal nerves were resected as follows: 3 nerves (4 patients), 4 nerves (1 patient), 5 nerves (3 patients), 6 nerves (1 patient), and 8 nerves (1 patient)., Conclusions: Intercostal neuromas can be the source of breast pain following breast surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be used in patients with breast pain. © 2016 Wiley Periodicals, Inc. Microsurgery 36:535-538, 2016., (© 2016 Wiley Periodicals, Inc.)

This article describes an alternative suture technique for thoracotomy incisions. A modified mattress suture technique is used to fix the intercostal muscles. The described technique can prevent rib fractures and reduce the incidence of intercostal nerve injury. Also, this technique is easy to perform and is effective., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine the occurrence of flank symptoms, flank muscle atrophy, bulge, and hernia formation after open and laparoscopic partial nephrectomy (LPN)., Patients and Methods: Our prospective Institutional Review Board-approved database was queried to identify 50 consecutive patients who were treated with open partial nephrectomy (OPN) and 50 consecutive patients who were treated with LPN between September 2006 and May 2008. Study patients had: Solitary clinical T1 renal tumor, preoperative and ≥6 month postoperative CT scan performed at our institution, and a confirmed renal-cell carcinoma on the final pathology report. Patients with previous abdominal surgery and neuromuscular disorders were excluded. Oncocare software was used to measure abdominal wall musculature on preoperative and postoperative CT scan. Bilateral flanks were compared for muscle volume, bulge, and hernia. Patients were administered a phone questionnaire to assess postoperative flank symptoms., Results: No statistical significant difference was found in the demographics between the two groups. Median age (range) was 59.9 years (20.6-80.7) in the OPN group and 57.5 years (25-78) in the LPN group (P=0.89). Median (range) body mass index and American Society of Anesthesiologists scores were similar between the two groups. On CT scans, median percent variation (range) in abdominal wall muscle volume was significantly greater in the OPN group: -1.03% (-31.4-1.5) vs-0.39% (-5.2-1.8) (P=0.006). The median extent of flank bulge on CT scans (range) was also greater in the OPN group: 0.75 cm (-1.9-7.6) vs 0 cm (-2.7-2.8) (P=0.0004). The OPN group was also more symptomatic, including paresthesia 48% vs 8% (P=0.0053); numbness 44% vs 0% (P=0.002); and flank bulge 57% vs 12% (P=0.007)., Conclusions: Minimally invasive partial nephrectomy has lesser deleterious impact on flank muscle volume compared with OPN with fewer symptoms of flank bulge, paresthesia, and numbness.

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

Objectives: Pain control after thoracotomy is an important issue that affects the outcome in thoracic surgery. Intercostal nerve preservation (ICNP) has increased interest in the outcomes of conventional thoracotomy. The current study critically evaluates the role of preservation of the intercostal nerve in early and late pain control and its benefit in patients undergoing thoracotomy., Methods: Data obtained prospectively between January 2006 and December 2010 by a study colleague at our division of General Thoracic Surgery were retrospectively analysed. There were 491 patients who underwent thoracotomy. Eighty-one patients were excluded from the study due to incompatible data. Patients were divided into two groups according to the intercostal nerve state: Group I consisted of patients with ICNP and Group II consisted of patients with intercostal nerve sacrifice., Results: Group I consisted of 288 patients [206 male (71%), P < 0.001, mean age 66 years]. Group II consisted of 122 patients [79 male (64%), P = 0.001, mean age 66 years]. There was less use of opiate in Group I (P = 0.019). Early mobilization of the patients was significantly higher in Group I (P = 0.031). The rate of pneumonia and re-admission to the intensive care unit was higher in Group II (P = 0.017 and 0.023, respectively). The rate of pain-free patients at discharge was significantly higher in Group I (P = 0.028). A 2-week follow-up after hospital discharge showed parasternal hypoesthesia to be more in Group II (P = 0.034). Significant patient contentment in Group I was noticed (P = 0.014). Chronic post-thoracotomy pain (CPTP) was higher in Group II (P = 0.016)., Conclusions: ICNP without harvesting an intercostal muscle flap achieves excellent outcomes in controlling acute post-thoracotomy pain and CPTP. ICNP is an effective, simple method to perform, and it should be considered as standard in performing thoracotomy.

Background: Complications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed., Methods: In our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques., Results: A cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage., Conclusion: Abdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.

Postmastectomy syndrome often follows the radical surgery oа the breast cancer. The intersection of the branches of the intercostal nerve is an infrequent cause of the postmastectomy syndrome development. We studied the long-term follow up results in 30 patients after radical mastectomy by Madden with preservation of the branches of the intercostal nerve on the level of Th1-Th3. The method demonstrated the decrease of the postmastectomy syndrome and the improvement of quality of life.

A best evidence topic was written according to a structured protocol. The question addressed was to identify which thoracotomy closure method lends itself to the least postoperative pain. Altogether 109 papers were found using the reported search; of which, seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the closure by intracostal sutures with intercostal nerve sparing offers a superior postoperative pain profile for thoracotomy patients when compared with conventional techniques. Up to 1-year follow-up has shown that this technique (avoiding strangulation of the intercostal nerve) leads to lower postoperative pain and analgesic use, better ambulation and a quicker return to daily activities. Three papers (including two randomized trials) found intracostal sutures with intercostal nerve sparing techniques to be superior to conventional methods such as pericostal suture closure. Rib approximation with intercostal nerve sparing was found to be superior to rib approximation without nerve sparing in one study. Two studies associated with the creation of an intercostal muscle flap prior to the insertion of a rib retractor to be associated with significantly reduced postoperative pain. One study described a novel 'edge-closure' technique, comparable to the closure with intracostal sutures without drilling, to be superior to conventional closure with pericostal sutures. Postoperative pain is a significant issue faced by thoracic surgeons both in-hospital and in the longer term where patients may complain of chronic thoracotomy pain. We would therefore recommend that some form of intercostal nerve protection be implemented during thoracotomy opening and closure.

Post-thoracotomy pain is a symptom of high incidence among patients who have undergone thoracotomy and is a major risk factor in the pathogenesis of several postoperative complications. Chronic pain after thoracotomy reaches a high prevalence. Since the earliest studies, this pain has been seen to be related with intercostal nerve injury, thus the need to avoid these lesions during thoracotomy has been recommended. This review aims to establish the appropriate surgical procedure for closure of the thoracotomy through a systematic review of the literature and analysis of levels of evidence provided by the studies found. After an exhaustive search in MEDLINE, EMBASE, IME, IBECS and Cochrane Library, few studies were found. Each focuses on different aspects of thoracotomy surgical techniques, with a common denominator focused on the preservation of the intercostal nerves, and conclusions with different levels of evidence., (Copyright © 2011 SEPAR. Published by Elsevier Espana. All rights reserved.)

Clinically apparent injury to an intercostal nerve associated with paralysis of the upper rectus abdominis is a rare complication of video-assisted thoracoscopic surgery (VATS), with no reports available in the pediatric literature. We present the case of a 16-year-old boy who underwent VATS blebectomy and pleurodesis followed by tube thoracostomy for recurrent spontaneous pneumothorax. Definitive reexpansion of the lung was achieved with no immediate complications, but the child complained of abnormal sensation and motor dysfunction of the left upper rectus at his first follow-up visit 2 weeks after the operation. Isolated muscular paralysis persisted at 2-month follow-up, although there was no associated activity limitation. Video-assisted thoracoscopic surgery is now a common practice and recognized as less morbid than open thoracotomy, but there exists scant literature regarding intercostal nerve injury and associated rectus abdominis paralysis. This report reviews the relevant published literature, with emphasis on the mechanism of nerve injury and avoidance of this complication., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Chronic pain is a common complication after thoracic surgery. The most important factor appears to be intercostal nerve damage. The purpose of this prospective study was to objectively evaluate intercostal nerve damage associated with post-thoracotomy pain after three surgical procedures using current perception threshold testing., Methods: The 32 patients were classified into three groups: the video-assisted thoracic surgery group (n=7), the video-assisted minithoracotomy with metal retractors group (n=15), and the conventional thoracotomy group (n=10). Intercostal nerve function was assessed by a series of 2000-Hz (Aβ fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C). The current perception threshold values were measured before and 1, 2, 4, 12, and 24 weeks after surgery. The intensities of ongoing pain were also assessed using a numeric rating scale (0-10)., Results: The video-assisted thoracic surgery group showed no changes in any current perception threshold values and no residual pain more than 12 weeks after surgery. The video-assisted minithoracotomy with metal retractors group and the conventional thoracotomy group showed significantly higher current perception threshold values at 2000 Hz 1 week after surgery (p=0.0013, p=0.0012, respectively), with pain in approximately 70% of patients 12 weeks after surgery. The correlation between current perception threshold values at 2000 Hz and the intensities of ongoing pain 4 and 12 weeks after surgery was significant (p=0.03, p=0.04, respectively)., Conclusions: This is the first study that objectively evaluated pain after video-assisted thoracic surgery. The results suggest that the Aβ and Aδ fibers play a significant role in the development of intercostal nerve damage. The current perception threshold values clearly demonstrated that video-assisted thoracic surgery is a less-invasive procedure resulting in less post-thoracotomy pain and, they have some possibilities to objectively evaluate the ongoing pain after surgery., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Intracostal suture or intercostal muscle flap can reduce post-thoracotomy pain through the preservation of intercostal nerves below or above the incision. This study aims to test whether combining intracostal suture with intercostal muscle flap might achieve better pain relief than intracostal suture alone., Methods: This study included 144 consecutive patients who underwent pulmonary resection. Eighty patients entered the trial but eight were excluded. Seventy-two patients were randomly assigned to a muscle flap group, in which the fifth intercostal muscle and neurovascular bundle were raised and intracostal suture on the sixth rib was applied. For the control group, only intracostal suturing on the sixth rib was done. All patients had a functional epidural placed, which were removed 24h after surgery. Differences on average numeric rating scale (aNRS) scores were assessed in an early post-operative period from day 1 to day 7 and a later period from week 2 to week 12, when patients were resting or coughing. The doses of oxycodone demand and hyperalgesia-related intercostal dermatomes (HIDs) were recorded for analysis., Results: No differences were noted between the two groups in terms of length and width of the incision, or duration of rib retraction. Neither in different time periods (early or late) nor the activity status (while resting or coughing) yielded a statistical difference on aNRS scores between the muscle flap group and the control group (muscle flap group vs control group: mean (95% confidence intervals) from d ay 1 to day 7, 4.42 (1.56-7.28) vs 4.79 (2.03-7.55) on coughing (p=0.282); median (inter-quartile range, IQR) from day 1 to day 7, 1.71 (0.86-3) vs 2.50 (1.16-3.12) while resting (p=0.279); median (IQR) from week 2 to week 12, 0.43 (0-0.86) vs 0.48 (0.06-1.20) on coughing (p=0.595); median (IQR) from week 2 to week 12, 0 (0-0.14) vs 0.05 (0-0.14) while resting (p=0.856)). No differences were found in total oxycodone consumption from day 1 to day 7 between the two groups (Z=-1.821, p=0.069). The rate of HIDs in each intercostal space and median number of HIDs were similar between the two groups on day 1 (p>0.05) and day 7 (p>0.05)., Conclusions: The combination of intracostal suture with intercostal muscle flap may not necessarily achieve better post-thoracotomy pain control than using intracostal suture alone., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting., Methods: In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain., Results: At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0-0) than in the pedicled group (n = 20) (2.8% [0-13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks., Conclusions: Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A patient with severe right chest pain and mechanical allodynia induced by an intercostal drainage tube to his chest is presented. It was not relieved by treatment with diclofenac sodium and was worsened by movement and touch to the right chest wall. Mechanical allodynia was also present. The patient's wrenching pain disappeared immediately after stitch removal, but the dull pain and mechanical allodynia persisted, gradually decreasing to zero in 7 days.

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

Background: Intercostal neuralgia due to surgical injury of the intercostal nerve is difficult to treat. No treatment modality has given effective pain relief. Experience with other painful neuromas has demonstrated that neuroma resection and muscle implantation has been effective in the upper and lower extremities. This approach was applied to patients with intercostal neuralgia., Methods: A retrospective review was done of 5 consecutive patients who have had neurectomy of one or more intercostal nerves. Preoperative and postoperative pain levels, patient demographics, length of follow-up, and surgical technique were reviewed., Results: Average patient age was 51.0 years (range, 39.2 to 61.3). Patients presented an average of 42.8 months (range, 10 to 138) after the surgical procedure or trauma that created their painful intercostal neuromas. The mean maximum pain level was 10, and the mean average pain level was 8 (range, 7 to 9). Postoperatively, the mean maximum pain level was 3.4 (range, 0 to 9), and the mean average pain level was 2.2 (range, 0 to 7). The differences were significant: p less than 0.01 for maximum pain level and p less than 0.05 for average pain level. Average follow-up after surgery was 8.8 months (range, 6.5 to 10.9). The most common surgical technique used was intercostal nerve neurectomy proximal to the intercostal nerve neuroma and implantation of the cut nerve into the latissimus dorsi muscle., Conclusions: Intercostal neurectomy and implantation of the cut nerve into the latissimus dorsi or into the rib for severe intercostal neuralgia was an efficacious treatment in this small consecutive patient series.

Intercostal nerve damage is the probable cause of chronic post-thoracotomy pain, but the precise mechanism is not known. To reduce this pain, we devised a simple method of rib spreading and closure (intercostal bundle-splitting thoracotomy), which avoids the intercostal nerve during thoracotomy, and then verified its effectiveness. The devised method appears to result in less chronic pain than the conventional method.

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

Objective: To study the methods and the clinical value of preserving intercostobrachial nerve during the axillary lymph nodes excision in breast cancer operations., Methods: One hundred and sixty-two cases of stages I, II, IIIa breast cancer patients were divided into experimental group and control group respectively. The intercostobrachial nerves were preserved in experimental group and not in control group. Both groups were treated following the practice guideline of breast cancer, and found no recurrence during 4 to 36 months following up., Results: The postoperative arm sensory disturbance was 22.2% in the experimental group, which was significantly different from that of the control group 73.3% (chi(2) = 41.80, P < 0.01), the incidence of pain is 12.5% in experimental group, which was also significantly different from that of control group 31.1% (chi(2) = 7.86, P < 0.01)., Conclusion: Preserving intercostobrachial nerves may significantly decrease the postoperative morbidity of arm sensory disturbance and pain during axillary excision of stage I, II, IIIa breast cancer patients.

Objective: Previous work has suggested that intercostal nerve injury is a major factor in the aetiology of chronic post-thoracotomy pain. The aim of this study was to establish if there was identifiable intercostal nerve injury during thoracotomy., Methods: Intercostal nerves were stimulated and motor evoked potentials were recorded from intercostal muscles in 13 patients undergoing thoracotomy. Measurements were taken before and after entering the pleural space, after removal of the rib retractor and after intercostal space closure., Results: Intercostal nerves functioned normally before and after entering the pleural space. After the rib retractor was removed, there was a total conduction block in the nerve immediately above the incision in every patient. In the nerves above this, six had a total block, one a partial block and three had normal conduction. There was a total conduction block in the nerve immediately below the incision in all but one patient. Of the nerves below this, four had a total block, two a partial block and three had normal conduction. In the cases of total conduction block, there was either a discrete block at the level of the distal end of the rib retractor or impairment throughout the whole nerve. Intercostal space closure did not injure any previously uninjured nerve. In a solitary patient where rib retraction was not employed, there was no impairment of the intercostal nerves throughout the operation., Conclusions: This study demonstrates for the first time that intercostal nerve injury occurs routinely due to rib retraction during thoracotomy. We believe that it may be an important step toward understanding the cause of post-thoracotomy neuralgia.

Background: The prevalence of intercostal nerve damage associated with coronary artery bypass graft-internal thoracic (mammary) artery surgery is unknown., Methods: A total of 37 consecutive patients with coronary artery bypass graft surgery (all with left internal thoracic artery graft) who were attending a cardiac-related exercise program underwent a thorough examination. Nerve damage was considered to be "definite" in the presence of two consistent and well-demarcated sensory abnormalities over the anterior chest wall within the T1 to T6 anterior intercostal nerve territory, and was considered "possible" in the presence of one such abnormality., Results: Definite nerve damage was detected in 73% of the subjects, and possible nerve damage was found in another 11% at the site of internal thoracic artery harvesting. Protracted postoperative pain or unpleasant sensations, usually subsiding by 4 months, were reported by recollection by 81% of the subjects. Overall, the prevalence of persistent pain in those with definite nerve damage 5 to 28 months after surgery was 15%., Conclusions: Intercostal nerve damage seems to occur in three-quarters of all patients undergoing coronary artery bypass graft-internal thoracic artery surgery. A significant minority may continue to experience bothersome chronic chest wall pain.

A case of combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy is reported. The paresis possibly occurred by a lesion of the N. intercostalis when extending the incision for stone extraction. Possibly the paresis was a predisposing factor for the development of an incisional hernia. The causes of abdominal wall paresis are explored with a review of the literature. In spite of minimal trauma to the anterior abdominal wall in laparoscopic procedures, the risk of iatrogenic lesions remains.

Objective: This study was aimed at analyzing the degree of intercostal nerve impairment in posterolateral and muscle-sparing thoracotomy and at correlating the nerve damage to the severity of long-lasting postthoracotomy pain., Methods: Neurophysiologic recordings were performed 1 month after either posterolateral or muscle-sparing thoracotomy to assess the presence of the superficial abdominal reflexes (mediated in part by the intercostal nerves), the somatosensory-evoked responses after electrical stimulation of the surgical scar, and the electrical thresholds for tactile and pain sensations of the surgical incision., Results: The patients who underwent a posterolateral thoracotomy showed a higher degree of intercostal nerve impairment than the muscle-sparing thoracotomy patients as revealed by the disappearance of the abdominal reflexes, a larger reduction in amplitude of the somatosensory-evoked potentials, and a larger increase of the sensory thresholds to electrical stimulation for both tactile perception and pain. In addition, these neurophysiologic parameters were highly correlated to the postthoracotomy pain experienced by the patients 1 month after surgery, indicating a causal role for nerve impairment in the long-lasting postoperative pain., Conclusions: This study shows for the first time the pathophysiologic differences between posterolateral and muscle-sparing thoracotomy and suggests that the minor long-lasting postthoracotomy pain in muscle-sparing thoracotomy patients is partly due to a minor nerve damage. In addition, because nerve impairment is responsible for the long-lasting neuropathic component of postoperative pain, it is necessary to match specific treatments to the neuropathic pain-generating mechanisms.

Objectives: To determine if intercostal nerve injury is related to postoperative flank "bulge" and to determine whether the extent of the retroperitoneal incision is related to the incidence of flank bulge following abdominal aortic aneurysm repair., Design: Bilateral dissection of the 11th intercostal nerve on seven cadavers; neurophysiological evaluation of five patients, three with a flank bulge and two without; and retrospective analysis of the extent of retroperitoneal incision and incidence of postoperative flank bulge in 63 consecutive patients., Setting: Urban academic medical center., Patients: Sixty-three consecutive patients who underwent retroperitoneal repair of an abdominal aortic aneurysm and neurophysiological evaluation of five volunteer patients., Interventions: Retroperitoneal repair of abdominal aortic aneurysms., Main Outcome Measure: Reduction of injury to the 11th intercostal nerve by avoiding extension of the retroperitoneal incision into the intercostal space., Results: Of 14 dissections of 11th intercostal nerves, there were bifurcations of the main trunk within the intercostal space in four, at the tip of the 11th rib in seven, and at least 2 cm distal to the tip of the rib in three. Neurophysiological evaluation revealed iterative discharges, polyphasia, fibrillation potentials, and altered recruitment patterns compatible with intercostal nerve injury in patients with a bulge but not in the opposite abdominal wall musculature or in patients without a bulge. Seven (11.11%) of 63 patients had a bulge. Thirty-one of 63 patients had incisions into the 11th intercostal space in which a bulge developed in six (19.35%). Thirty-two patients had incisions that avoided extension into the intercostal space; a bulge developed in one (0.03%) (P = .53)., Conclusions: Postoperative bulge is related to intercostal nerve injury with subsequent paralysis of abdominal wall musculature. Intercostal nerve injury can be reduced by avoiding extension of the incision into the 11th intercostal space.

Two patients who underwent coronary artery bypass grafting in which the internal mammary arteries were used, developed chronic, atypical chest pain. After further investigation a diagnosis of intercostal neuralgia was made. It is thought that this condition is due to damage to the intercostal nerves when the internal mammary arteries are dissected. Intercostal neuralgia should be included in the differential diagnosis of chest pain after coronary artery surgery, as its recognition may save the patient unnecessary investigation and suffering.

The effect of intercostal nerve transection on the number and size distribution of thoracic spinal ganglion cells has been investigated and correlated with transganglionic degeneration (TGD) in the spinal cord dorsal horn. Unilateral transections were made of 3 or 11 consecutive intercostal nerves. Twenty to 180 days later the animals were perfused and relevant ganglia from both sides embedded in resin, serially sectioned and stained. Counts of neuronal nucleoli were made and perikaryal areas of ganglion cells measured. The number of neurons was significantly reduced on the operated side 20 days postoperatively. The cell loss increased slightly to about 35% with longer survival times. Analysis of cell size spectra showed a bilaterally symmetrical picture in normal animals. No distortions of the cell size spectrum were observed at 20 to 70 days after nerve transections. Transganglionic degeneration was found in the dorsal horn from 20 to 70 days postoperative survival, but not at 180 days. The findings indicate that TGD in the dorsal horn is related to a loss of ganglion cells in the corresponding spinal ganglion. There does not seem to be a preferential loss of any particular size class of cells.

After surgery in the area of the armpit, and particularly after axillary lymphonodectomy during mastectomy, severe pain and paraesthesia can occur in the region of the medial and posterior side of the proximal upper arm. It is shown by means of four case reports that this discomfort can be caused by a lesion in the intercostobrachial nerve. The differential diagnosis must consider injury to the brachial plexus or a local metastasis.