Intercostal Neurectomy And Regenerative Or Dermatosensory Peripheral Nerve Interface For Chronic Mastectomy Pain
Sarah Hart, MD1, Shailesh Agarwal, MD2, Jennifer Hamill, MPH1, Niki Matusko, BS1, David Brown, MD1.
1University of Michigan, Ann Arbor, MI, USA, 2Brigham and Women's Hospital, Boston, MA, USA.
Chronic post-mastectomy pain due to intercostal cutaneous nerve injury can affect up to 40% of patients, causing diminished quality of life and increased risk of opioid dependence. It is a poorly recognized etiology, yet diagnosis and treatment can be straightforward. Neurectomy with “physiological capping” of the nerve end with muscle (regenerative) or dermis (dermatosensory) peripheral nerve interface (RPNI or DSPNI, respectively) has shown to significantly reduce neuromatous pain in limb amputees. We proposed that intercostal sensory neurectomy, combined with RPNI or DSPNI, would significantly reduce chronic post-mastectomy pain.
Retrospective review was performed for seven patients (2016 - 2019) with a history of breast surgery and chronic pain, who underwent intercostal neurectomy with RPNI or DSPNI. Patient demographics, comorbidities, pain scores, length of follow up, surgical techniques and complications were reviewed.
Neurogenic pain was diagnosed by history (unrelenting pain greater than three months postoperatively, limited to the chest or back) and physical exam (tenderness in specific intercostal spaces over the anterior, lateral and/or posterior divisions of the nerves and positive Tinel signs) in all seven patients. Five patients underwent preoperative confirmatory nerve blocks with local anesthetic.
During the operation, nerves were easily located on the muscle fascia, via a vertical incision in the mid-axillary line or 3cm lateral to the posterior midline. Neurectomy was performed at the level of the fascia, followed by wrapping of the proximal stump with a muscle or dermal graft. Average patient age was 51.9 years with an average BMI of 27.2. Patients presented an average of 56.9 months post-breast surgery. Five patients presented with anterior chest pain and two with posterior pain. The average number of RPNIs/DSPNIs performed per patient was 3.14 (SD 1.86). The average length of the operation was 129 minutes (SD 41.8). There was a significant reduction in VAS pain scores following surgery, from 9 (range 4-10) preoperatively to 1 (range 0-6) postoperatively (p = 0.02, Wilcoxon signed-rank test). One patient had a postoperative surgical site infection treated with oral antibiotics. Average follow-up was 6.14 months.
Peripheral nerve injury causing chronic neuropathic pain is an under-recognized but easily diagnosed and treated cause of post-mastectomy pain. In an initial retrospective case series with seven patients, neurectomy combined with RPNI or DSPNI resulted in clinically and statistically significant pain relief with minimal complications.
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