Ultrasound-Guided Thoracodorsal Nerve Block for Post-Breast Reconstruction Discomfort.

Abstract

CASE PRESENTATION A 76-yr-old woman with prediabetes and estrogen receptor–positive breast cancer diagnosed 2 yrs ago underwent a bilateral mastectomy and breast reconstruction with tissue expander and latissimus dorsi flap 1 yr ago. After the procedure, the patient developed constant muscle hyperactivity and a tight band-like feeling in the lateral aspect of the reconstructed breast flap. Subsequently, the tissue expanders were removed without a significant improvement of her symptoms. She denied numbness, tingling, lancinating, electricity-like pain, or pins/needles sensation. She tried physical therapy, a transcutaneous electrical nerve stimulation unit, and oral baclofen without significant relief. Ultrasound-guided thoracodorsal nerve block with 1% lidocaine and 0.25% bupivacaine was performed with consideration for the positive motor symptoms and lack of cutaneous sensory symptoms in the distribution of the latissimus dorsi flap, as illustrated in the Figures 1 and 2. The patient reported 100% relief of symptoms for 5 days and approximately 50% relief of symptoms for 2 wks. Repeated ultrasound-guided injection as per the patient’s request reproduced a similar pattern of symptom relief.FIGURE 1: Ultrasonographic images of the thoracodorsal nerve (yellow arrow) and surrounding structures using an 8- to 15-MHz linear array probe.FIGURE 2: Ultrasonographic-guided perineural block of thoracodorsal nerve using in-plane approach.More than 250,000 women were diagnosed with breast cancer in 2017 and more than 100,000 breast reconstruction procedures were performed.1,2 Latissimus dorsi flaps are frequently used as an option for salvage reconstruction given presence of healthy muscle tissue and consistent vascular supply. As high as 10% of patients who have latissimus dorsi flaps complain of persistent postsurgical pain lasting months or years. Complaints after latissimus dorsi–based reconstruction include abnormal muscle movement, breast deformity, significant muscle tone at rest, and pain, as illustrated in this case.1 Regarding peripheral nerve lesions, intercostobrachial cutaneous, intercostal, and long thoracic nerve injuries are well-known contributors to post–breast surgery pain syndrome.3,4 The thoracodorsal nerve is often underrecognized as the culprit for post–breast surgery pain syndrome. Surgical denervation of the thoracodorsal nerve was proposed but remains controversial because of potential detriments to the reconstruction.1 This case highlights the diagnostic and therapeutic role of ultrasound-guided thoracodorsal nerve blocks for the evaluation and management of post–breast surgery pain and discomfort.