Post Breast Surgery Pains – Nerve Blocks Help

Post breast cancer surgery Pains are often do to injury to the Intercostobrachial nerve. Up to now, there has been little literature on whether blocking nerve actually helps – now a pilot study suggests pain can be cut in half.

Pain Physician. 2016 Feb;19(2):E309-18.
Ultrasound Guided Intercostobrachial Nerve Blockade in Patients with Persistent Pain after Breast Cancer Surgery: A Pilot Study.
Wijayasinghe N(1), Duriaud HM(1), Kehlet H(1), Anderson KG(1).
http://www.painphysicianjournal.com/current/pdf?article=MjUyMg%3D%3D&journal=94

  •  “Persistent pain after breast cancer surgery (PPBCS) is predominantly a neuropathic pain syndrome affecting 25 – 60% of patients treated for breast cancer.”

Intercostobrachial nerve (ICBN) damage suggested by

  • pain in the axilla (armpit)
  • pain lateral chest wall
  • pain upper arm
  • “sensory disturbances in the territory of ICBN”

Course of ICBN:

  • comes from from the lateral cutaneous branch of the second intercostal nerve.
  • It pierces the external intercostal muscle
  • Then pierces serratus anterior
  • Then crosses the axilla
  • Then down  the  medial and posterior of upper arm.

I have discussed its course at length with lots of pictures here:
The Intercostobrachial Nerve(ICBN) -What is it and Why Can’t Breast Cancer Surgeons Deal Better With It? – and What Can You Do With It After.
http://painmuse.org/?p=2280

  • 6 patients with persistent pain after breast surgery and with axilla and  upper arm pains
  • Decreased sensation to light brushing, hot and cold were checked. Dr. Pam Squire teaches use of a cold and warm tuning fork as a reliable instrument. – put it in ice or warm under tap.

Areas involved:

ICBN_damagezone

  • given its “reliable course in the second intercostal space (IC2) in the chest wall” it was injected under ultrasound control at the “inferior edge of the second rib above the serratus anterior but under the pectoralis minor” with Ten mL 0.5% bupivacaine with 22 gauge needle

ICBN_blockResults are pains on pain on movement plus tenderness:

ICBN Block_changes

Comment –

  • 3/6 got over 50% improvement with just one shot.
  • I would use a 30 gauge needle, 1.5 mls of 5% lidocaine and inject just under the 2nd rib more medially. I would repeat 3 times done weekly because I am not a one shot wonder with God like results first time.
  • Thought that comes to mind is “what already?”  Though this nerve has been implicated as a source of trouble –  “it is surprising that the ICBN block has never been attempted.” I suspect it is because breast surgeons don’t know how to do it and the anesthetist is done with the patient after surgery. It is tragic and abominable…
  • Authors need to be congratulated for their work and I hope they don’t mind me using their images which are available freely online.
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