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Chronic Mastectomy Pain Due to Nerve Injury is Easily Diagnosed and Effectively Treated with Intercostal Neurectomy
Sarah E Hart, MD1, Shailesh Agarwal, MD2, Jennifer B Hamill, MPH1, Niki Matusko, BS1 and David L Brown, MD3, (1)University of Michigan, Ann Arbor, MI, (2)Brigham and Women's Hospital, Boston, MA, (3)Plastic Surgery, University of Michigan, Ann Arbor, MI

Chronic Mastectomy Pain Due to Nerve Injury is Easily Diagnosed and Effectively Treated with Intercostal Neurectomy

 

Introduction

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 poorly recognized, 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 with RPNI or DSPNI would significantly reduce chronic post-mastectomy pain.

 

Materials and Methods

Retrospective review was performed for five patients (2016 – 2018) with a history of mastectomy 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.  

 

Results

Neurogenic pain was diagnosed by history (unrelenting pain more than three months postoperatively, limited to the chest or breast) and physical exam (tenderness in specific intercostal spaces over the lateral and/or posterior divisions of the nerves and positive Tinel signs) in all five patients. Four 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 48.6 years with an average BMI of 27.5.  Patients presented an average of 74.6 months post-mastectomy. Three patients presented with anterior chest pain and two with posterior pain. There was a significant reduction in VAS pain scores following surgery, from 9 (range 8-10) preoperatively to 0 (range 0-2) postoperatively (p = 0.04, Wilcoxon signed-rank test). Average follow-up was 7.2 months. The average number of neurectomies performed was 2.8 (SD 2.6). The average length of operation was 129 minutes (SD 41.8). One patient had a postoperative surgical site infection treated with oral antibiotics.

 

Conclusions

Peripheral nerve injury causing chronic post-mastectomy pain is an under-recognized but easily confirmed and treated diagnosis. In an initial case series, neurectomy and RPNI or DSPNI resulted in clinically significant pain relief with minimal complications.


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