Intercostal Nerve Injury Research Articles

Intercostal nerve electrodiagnostic testing in rib fractures.

Intercostal nerve injury can occur after rib fractures, resulting in denervation of the abdominal musculature. Loss of innervation to the rectus abdominis and intercostal muscles can cause pain, atrophy, and eventual eventration, which may be an underrecognized and thus undertreated complication of rib fractures. We investigated the clinical utility of intercostal nerve electrodiagnostic testing following rib fractures to diagnose and localize nerve injury at levels T7 and below. Five patients with displaced bicortical rib fractures involving the 7th-11th ribs and clinical eventration of the ipsilateral abdominal wall underwent intercostal nerve conduction studies (NCS) and needle electromyography (EMG) on the affected side. EMG of the rectus abdominis and intercostal muscles was performed with ultrasound guidance, and ultrasound measurements of rectus abdominis thickness were obtained to assess for atrophy. Average patient age was 59.4 years and average body mass index (BMI) was 31.5 kg/m2. Intercostal NCS and EMG were able to reliably diagnose and localize intercostal nerve damage after rib fractures. Ultrasound demonstrated an average rectus abdominis transverse cross-sectional thickness of 0.534 cm on the affected side, compared with 1.024 cm on the non-affected side. Intercostal electrodiagnostic studies can diagnose and localize intercostal nerve damage after displaced rib fractures. Musculoskeletal ultrasound can be used to diagnose and quantify rectus abdominis atrophy and to accurately and safely guide needle EMG to the intercostal and rectus abdominis muscles.

Greater ipsilateral rectus muscle atrophy after robotic thoracic surgery compared with open and video-assisted thoracoscopic surgery approaches

ObjectiveRobotic thoracic surgery provides another minimally invasive approach in addition to video-assisted thoracoscopic surgery (VATS) that yields less pain and faster recovery compared with open surgery. However, robotic incisions are generally placed more inferiorly, which may increase the risk of intercostal nerve injury that affects the abdominal wall. We hypothesized that a robotic approach causes greater ipsilateral rectus muscle atrophy compared with open and VATS approaches. MethodsThe cross-sectional area and density of bilateral rectus abdominis muscles were measured on computed tomography scans in patients who underwent lobectomy in 2018. The differences between the contralateral and ipsilateral muscles were compared between preoperative and 6-month surveillance scans. Changes were compared among the open, VATS, and robotic approaches through a mixed effects model after adjustments of correlation and covariates. ResultsOf 99 lobectomies, 25 (25.3%) were open, 56 (56.6%) VATS, and 18 (18.1%) robotic. The difference between the contralateral and ipsilateral rectus muscle cross-sectional area was significantly larger at 6 months after robotic surgery compared with open (31.4% vs 9.5%, P = .049) and VATS (31.4% vs 14.1%, P = .021). There were no significant differences in the cross-sectional area between the open and VATS approach. ConclusionsIn this retrospective analysis, there was greater ipsilateral rectus muscle atrophy associated with robotic thoracic surgery compared with open or VATS approaches. These findings should be correlated with clinical symptoms and followed to assess for resolution or persistence.

Outside the Cage Subcostal RATS Lobectomy: Technical Aspects and Results of the First Series of a Novel Approach to Pulmonary Lobectomy.

The goal of minimally invasive surgery is to reduce trauma to patients and improve their postoperative outcomes. In this context, the utilization of robot-assisted thoracic surgery (RATS) in the treatment of lung cancer has increased worldwide. The feasibility of single-incision major pulmonary resections by RATS was recently reported, with the objective of minimizing the surgical trauma of the traditional multiportal RATS approach. However, both techniques require intercostal incisions, potentially causing immediate and chronic pain resulting from intercostal nerve injury. To reduce postoperative pain resulting from intercostal approaches, we developed a nonintercostal, outside the thoracic cage (OTC) approach for RATS lobectomy, avoiding intercostal instrumentation. This report aims to describe the results of the first reported series of OTC subcostal RATS lobectomies. Retrospective analysis of a series of the first consecutive patients operated on using the novel OTC subcostal RATS lobectomy technique. Between August and December 2022, a total of 10 consecutive cases were analyzed. The median age was 63 (55 to 84) years, the mean body mass index was 29 (24 to 45) kg/m2, and the median American Society of Anesthesiologists score was III (II to IV). No serious adverse events were observed, and there was no conversion of the surgical technique. The mean operative time was 132.6 (98 to 223) min. The median length of stay was 2 days. No pain-related complications, readmissions, or 30-day mortality were observed. This series demonstrates that OTC RATS lobectomy is feasible and safe. A phase I clinical trial is currently underway to prospectively assess the safety of the technique as well as its clinical relevance.

Dorsal Root Entry Zone Lesioning Following Unresponsive Spinal Cord Stimulation for Post-Traumatic Neuropathic Pain

Spinal cord stimulation (SCS) and dorsal root entry zone (DREZ) lesioning are important therapeutic options for intractable post-traumatic neuropathic pain (PNP). However, surgical choice is controversial due to the need to maximize pain relief and reduce complications. This study aims to retrospectively analyze the effect and complications of DREZ lesioning for patients with PNP who were unresponsive to SCS and provide a surgical reference. Demographic data and surgical characteristics of patients with PNP who underwent DREZ lesioning after an unresponsive SCS were reviewed. Long-term outcomes including numeric rating scale, global impression of change, and long-term complications were assessed. Kaplan-Meier analysis was used to evaluate pain-free survival. Of 19 patients with PNP, 8 had brachial plexus injury (BPI), 7 had spinal cord injury, 2 had cauda equina injury, 1 had intercostal nerve injury, and 1 had lumbosacral plexus injury. All patients were unresponsive or had a recurrence of pain after SCS, with an average pain-relief rate of 9.3%. After DREZ lesioning, the mean numeric rating scale scores significantly decreased from 7.6 ± 1.5 to 1.8 ± 1.7, with an average pain-relief rate of 75.3%. Seven patients (36.8%) experienced worsened neurologic dysfunction at the last follow-up. Patients with BPI had a significantly better outcome than other pathologies (P < 0.001) after DREZ lesioning. DREZ lesioning is an effective alternative procedure to SCS for patients with PNP who have lost limb function. Particularly for those with BPI, DREZ lesioning has shown good efficacy and can be considered a preferred surgical option.

Transient flank bulge after percutaneous nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is considered as the “gold standard” treatment for large (&gt;2 cm) and complex kidney stones. We present a case of transient tone loss of the anterolateral abdominal wall, which is a rare complication after PCNL. Case Report: A 50-year-old male with a complete staghorn stone of the right kidney underwent standard PCNL in prone position at the 11th intercostal space. On the 6th post-operative day the patient complained on painless bulge in the right flank. Computed tomography (CT) scan in supine position revealed no signs of herniation, retroperitoneal hematoma, or residual fragments. Flank bulge was attributed to the muscle tone loss either because of the 11th intercostal nerve injury by the needle or nerve compression by the Amplatz sheath. Within next six months flank bulge has completely resolved. Conclusion: Flank bulge after PCNL although rare but possible and transient condition. Nerve injury seems to be the most likely cause.

Post-thoracotomy pain syndrome in the era of minimally invasive thoracic surgery.

Post-thoracotomy pain syndrome (PTPS) is defined as pain around the wound that persists for more than 2 months after surgery. Persistent pain not only increases the use of analgesics and their side effects but also causes many social problems, such as decreased activities of daily living, decreased quality of life, and increased medical costs. In particular, thoracic surgery is associated with a higher frequency and severity of chronic pain than is surgery for other diseases. The basic principles of postoperative pain treatment, not limited to thoracic surgery, are multimodal analgesic methods (using combinations of several drugs to minimize opioid use) and around-the-clock treatment (administering analgesics at a fixed time and in sufficient doses). Thoracic surgeons must always be aware of the following three points: acute severe postoperative pain is a major risk factor for chronic pain; neuropathic pain due to intercostal nerve injury is a major cause of postoperative pain after thoracic surgery, and its presence must not be overlooked from the acute stage; and analgesics must be administered in sufficient quantities according to dosage and volume. The frequency of PTPS has decreased compared with that in the standard thoracotomy era because of the development of analgesia and the widespread use of minimally invasive procedures such as thoracoscopic surgery and robot-assisted surgery. However, no consistently effective prevention or treatment strategies for PTPS have yet been established. In this review, we focus on PTPS in the era of minimally invasive surgery and discuss the role of thoracic surgeons in its management.

Subcostal robotic-assisted pulmonary resection: Left lingular segmentectomy.

There is continued interest in finding an optimal approach for thoracic surgery. The intercostal space has been accepted as the standard route for video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS). However, the intercostal approach causes postoperative chronic pain and related complications due to intercostal nerve injury. To overcome the shortcomings of the intercostal approach, the subcostal VATS has been proposed.1 However, the long distance from the costal arch to the hilum and the interference from the hip and abdomen make this procedure difficult.

Rectus Sheath Hematoma after Contralateral Intercostal Neuropathy as a Complication of Video-Assisted Thoracoscopic Surgery in a Patient with Asthma: A Case Report

Rectus sheath hematoma (RSH) in patients who have undergone video-assisted thoracoscopic surgery (VATS) has not been reported to date. This report describes a case of RSH in a patient with right abdominal muscle atrophy due to an intercostal nerve injury following VATS. A 61-year-old male patient complained of a bulge in the right upper abdominal quadrant after undergoing VATS. Computed tomography (CT) revealed atrophied right abdominal muscles, including the rectus abdominis, and the electrodiagnostic findings were compatible with right 8th and 9th intercostal neuropathy. The patient visited the emergency room 444 days after undergoing VATS, complaining of a left abdominal mass and pain. He had a severe cough 2 weeks prior due to underlying asthma. CT revealed an RSH in the left abdomen that shrank after 4 weeks of observation. In cases of abdominal muscle weakness due to intercostal neuropathy following VATS, the precipitating factors for RSH must be managed thoroughly.

Effective Treatment of Chronic Mastectomy Pain with Intercostal Sensory Neurectomy.

Chronic postmastectomy pain affects up to 40 percent of patients and leads to diminished quality of life and increased risk of opioid dependence. The cause of this pain is incompletely understood; however, one hypothesis is that direct injury to cutaneous intercostal nerves at the time of mastectomy and/or reconstruction leads to chronic pain. As a result, proximal neurectomy of the involved sensory nerve(s) has been suggested to be effective for these patients. The purpose of this study was to determine whether chronic pain in postmastectomy patients can be diagnosed reliably in an office setting and pain reduced by intercostal sensory neurectomy. The authors performed a retrospective review of seven patients with a history of breast surgery and chronic pain who underwent intercostal neurectomy combined with muscle or dermal wrapping of the proximal end of the resected nerve. All patients were diagnosed by history and physical examination, and suspected nerves were further identified with local anesthetic nerve blocks. An average of 3.14 neurectomies were performed per patient (range, one to six). There was a significant reduction in visual analogue scale pain scores following surgery, from 9 preoperatively to 1 postoperatively (p = 0.02). Eighty-six percent of patients were pain-free or "considerably improved" at their latest follow-up appointment (average, 6.14 months). It is concluded that intercostal sensory nerve injury at the time of mastectomy and/or reconstruction can lead to chronic mastectomy pain, which can be easily diagnosed and effectively treated with intercostal neurectomy. Therapeutic, IV.

Characteristics of clinical application of electroacupuncture therapy for peripheral neuropathy based on data mining

To investigate the application characteristics of electroacupuncture (EA) in the treatment of peripheral neuropathy, so as to provide a basis for clinical use of EA therapy. Keywords of "electroacupuncture""peripheral neuropathy" "facial paralysis" "trigeminal neuralgia" "sciatica" "common peroneal nerve injury" "diabetic peripheral neuropathy" "intercostal neuralgia" "gluteal epithelial neuritis" "ulnar nerve injury" "median nerve paralysis" "postherpetic neuralgia", and "great occipital neuralgia" were used to search articles in both English and Chinese published from 1999 to 2019 in databases of CNKI, Wanfang, VIP, CBM, Ovid, PubMed and Embase and related books such as electroacupuncture, and neurology, followed by establishing a database of "Electroacupuncture Treatment of Peripheral Neuropathy". Then, the collected articles were put into statistical analysis after sorting, screening, input, checking, and data extracting by using data mining technology and statistical software EpiData. Of the searched 1 528 papers, 778 were eligible, involving 13 types of peripheral neuropathy which the facial paralysis and facial spasm were most frequently seen, followed by trigeminal neuralgia and sciatica, with an effective rate being above 90% for nearly all the 13 diseases. The acupoints employed were chiefly those close to the affected area and distribute along the nerve trunk.In addition, about the needling techniques, the penetration needling was frequently used, and the triple needling, quintuple needling and accompanied needling were also used. Regarding the related needle manipulations, the uniform reinforcing-reduction technique was most frequently used. The duration of EA was 30 min, with a highest stimulating frequency of 50 Hz. The acupoint injection was frequently supplemented, followed by moxibustion, and the treatment sessions were usually about 30 times. EA therapy is frequently used in the treatment of peripheral neuropathy, and has some characteristics in acupoint selection, stimulating parameters and some additional needling techniques.

Comparison of post-operative pain and quality of life between uniportal subxiphoid and intercostal video-assisted thoracoscopic lobectomy.

BackgroundUniportal video-assisted thoracoscopic surgery (VATS) although considered less invasive than the multi-port techniques, is still an intercostal approach, resulting in intercostal nerve injury. Recently, some surgeons have tried to address this problem by attempting a subxiphoid approach. The aim of our study was to assess and compare results between intercostal and subxiphoid uniportal VATS lobectomy in terms of postoperative pain and quality of life (QoL).MethodsPatients from January 2014 to January 2018 undergoing subxiphoid and intercostal VATS lobectomy were prospectively assessed for pain and QoL at 1, 3, and 6 months following discharge. Postoperative pain was measured using a numeric rating scale (NRS) and QoL was assessed with the EuroQoL 5-dimension questionnaire (EQ5D)ResultsEight hundred and thirty-three patients undergoing lobectomy were included: 373 in the intercostal VATS group and 459 in the subxiphoid group. The proportion of patients with moderate or worse clinical pain was significantly lower at 1 and 3 months after subxiphoid VATS (P<0.01) compared with intercostal VATS. QoL was significantly higher following subxiphoid VATS at these same time points (P<0.001).ConclusionsUniportal subxiphoid VATS is a safe and feasible minimally invasive approach for undertaking pulmonary lobectomy that may result in reduced postoperative pain compared to conventional VATS. There may also be earlier return of QoL. A randomized controlled trial examining this further would provide further insight into our observations.

Subxiphoid single-port pulmonary bilateral metastasectomy

Pulmonary wedge resection for bilateral metastatic pulmonary tumor is generally performed via a bilateral lateral intercostal approach by one-stage or two-stage surgery. In 2014, we reported subxiphoid single-port pulmonary bilateral metastasectomy to resect bilateral pulmonary metastases via a single subxiphoid wound. This approach of bilateral pulmonary wedge resection via a 3-cm single wound in the epigastric fossa enables one-stage bilateral pulmonary resection with the patient in the supine position, without changing position, and because the intercostal space is not involved, there is no intercostal nerve injury. This procedure is a useful and enables minimally invasive surgery for patients who require surgery of the bilateral lungs, such as bilateral metastatic pulmonary tumors and bilateral spontaneous pneumothorax. However, one of the drawbacks of this approach is limited maneuverability. Future developments in instruments and surgical techniques including new single-port robot systems will help improve the limited maneuverability, given its benefits to the patient, as a surgical approach in thoracic surgeries.

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial

ObjectivesPost-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain. MethodsWe randomized 90 patients undergoing posterolateral thoracotomy for pulmonary resection at a tertiary level oncology center to standard posterolateral (control arm) or modified nerve-sparing thoracotomy. All patients received morphine via patient-controlled analgesia pumps. The primary outcome was the worst postoperative pain score in the first 3 postoperative days. Secondary outcomes included the average pain score and analgesic requirements in the first 3 postoperative days and the incidence of post-thoracotomy pain 6 months after surgery. ResultsNo significant differences were seen between the groups in acute or chronic post-thoracotomy measured by the numeric rating scale. There was no difference seen in the worst (mean) postoperative pain scores (3.71 vs 3.83, difference 0.12; 99% confidence interval [CI], −0.7 to +0.9; P = .7), average (mean) pain scores in the first 3 postoperative days (1.77 vs 1.85, difference 0.08; 99% CI, −0.4 to +0.6; P = .69), mean consumption of morphine (mg/kg) (1.45 vs 1.40, difference −0.05; 99% CI, −0.4 to +0.3; P = .73), or incidence of chronic postoperative pain (37.8% vs 40%, difference 4.9%; 99% CI, −22.8 to +30.7%; P = .73). ConclusionsThe modified nerve-sparing thoracotomy technique does not reduce post-thoracotomy pain compared with standard posterolateral thoracotomy.

Electro-physiological evidence of intercostal nerve injury after thoracotomy: an experimental study in a sheep model.

Although intercostal nerve injury is one of the major causes for post-thoracotomy pain, the exact mechanisms are still unclear. We sought to evaluate the electro-physiological changes of intercostal nerve injury after thoracotomy in a sheep model. Adult sheep underwent thoracotomy in the sixth intercostal space by employing diathermy to superior border of the seventh rib. In two sheep, ribs were then spread using retractor spreading for a distance of 7 cm for 30 minutes. In the third sheep, thoracotomy was followed by harvesting intercostal muscles including the neurovascular bundle adjacent to inferior edge of the sixth rib. Thereafter, ribs were spread in the same way, but with the muscle flap dangled between the blades for intercostal nerve protection (dangling muscle flap technique). The nerve conduction velocity of the intercostal nerve was recorded before and after incision of intercostal muscles, immediately and 30 minutes after retractor placement and 30 minutes after removal of the retractor. In the sheep undergoing conventional thoracotomy, the physiological conductivity of intercostal nerve was completely blocked immediately after retractor placement using the same stimulation intensity or even the supra-threshold intensity. The conduction block persisted for 30 minutes during the retractor placement and further 30 minutes after removal of the retractor. In contrast, intercostal nerve conduction was not impaired throughout the experiment with the dangling muscle flap technique. Our experiment provides electro-physiological evidence for intercostal nerve injury after thoracotomy. The injury is primarily attributed to mechanical compression caused by the rib retractor.

The Shanghai Pulmonary Hospital uniportal subxiphoid approach for lung segmentectomies.

Lung segmentectomy may be considered an oncologic equivalent treatment to lobectomy for non-small cell lung cancer (NSCLC) sized 20 mm or smaller. Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) could further improve the surgical outcome reducing the surgical stress and completely avoiding the intercostal nerve injury. The aim of this manuscript is to illustrate the Shanghai Pulmonary Hospital surgical techniques for uniportal subxiphoid VATS (SVATS) segmentectomies. A total of 79 consecutive patients underwent 84 subxiphoid segmentectomies for malignant or benign pulmonary diseases between September 2014 and January 2016. We here illustrate the surgical techniques and the early results. There were 45 segmentectomies in right-side group and 39 segmentectomies left-side group. The mean operation time was 2.38±0.77 hours, and mean operative blood loss was 126.09±136.17 mL. Nine segmentectomies (10.7%) had an intra-operative change of procedure and four were converted to thoracotomy, one had a lobectomy rather than a segmentectomy and four were converted to conventional VATS lobectomy. A total of 12 patients (15.1%) had postoperative complications, including 1 hematoma, 4 prolonged air-leaks and 8 arrhythmias. In the presented series that included our learning curve period we have experienced relative low conversion rates and few post-operatively complications showing that, SVATS segmentectomy can be considered a safe procedure with a relative low rate early post-operative complication.

Impact of intercostal paravertebral neurectomy on post thoracotomy pain syndrome after thoracotomy in lung cancer patients: a randomized controlled trial.

Thoracotomy leads to chronic neuropathic pain in up to 50% of patients and is responsible for an impaired quality of life. Intercostal nerve injury has been suggested to be responsible for this pain. In the present study the impact of paravertebral intercostal neurectomy on post thoracotomy pain was assessed. In this single center parallel-group randomized controlled trial patients underwent muscle sparing anterolateral thoracotomy and anatomical lung resection for lung cancer. A subcostal approach was used for thoracotomy with single paravertebral neurectomy being performed at the beginning of the procedure at the level of the retracted intercostal space. For documentation of neuropathic pain the Leeds Assessment Score for Neuropathic Symptoms and Signs (LANSS) was used postoperatively. The primary endpoint was defined as LANSS ≥12 points on day 120. In addition, the numeric pain rating scale (NRS) was used to score pain intensity. Out of 172 patients initially randomized 161 patients were investigated following intraoperative and postoperative drop-out criteria. All patients required anatomical lung resection via thoracotomy. Five patients were lost for follow up. For the remaining 156 patients there was no difference between the two groups with regard to LANSS ≥12: 26.6% in patients with neurectomy and 28.8% in control-subjects (P=0.78). In addition, the NSR score at day 120 did not differ significantly at rest and during activity between the two groups (at rest: 21.7% vs. 15.8% P=0.439; activity: 24.5% vs. 21.9% P=0.735). Neurectomy was not shown to reduce the post thoracotomy pain syndrome in patients with anatomical lung resection following anterolateral muscle sparing thoracotomy.

The Shanghai Pulmonary Hospital subxiphoid approach for lobectomies.

Video-assisted thoracoscopic surgery (VATS) has recognized benefits. However, patients undergoing VATS also complain acute and sometime chronic postoperative pain due to the damage of the intercostal bundles. Subxiphoid uniportal VATS has been presented as alternative approach that can completely avoid the intercostal nerve injury and further reduce the surgical outcome. The aim of this manuscript is to illustrate the Shanghai Pulmonary Hospital uniportal subxiphoid lobectomy surgical techniques.

К вопросу о профилактике травматизации межреберных нервов при задней сепарационной герниопластике пупочных грыж

К вопросу о профилактике травматизации межреберных нервов при задней сепарационной герниопластике пупочных грыж

Preferences of the Thoracic-Surgery Academic Teaching Staff on Thoracotomy Opening/Closure and Post-Thoracotomy Pain Management

Background: A survey was conducted on preferences for thoracotomy opening and closure as well as post-thoracotomy pain management among academic teaching staff of thoracic surgeons in Turkey. It was aimed to assess the attitudes of the thoracic surgery training-center academicians on aforesaid topic. Methods: A 7-question questionnaire was performed by face-to-face interview or online by e-mail to the academic professionals working at resident-training centers. Eighty-eight randomly selected academicians were invited to complete the questionnaire, and 48 of them answered. Based on the complete and valid responses, the methods for opening and closure of thorax, the number of chest drains placed, the method of analgesia in per-or postoperative period and the analgesic agents used commonly were assessed. Results: Thirty-three (68.8%) of 48 were working at university hospitals and 24 (50.0%) were in age group of 40 - 49 years. Muscle-sparing (41.7%) and standard posterolateral thoracotomies (41.7%) were the most preferred incision. The most used method for closing thorax was pericostal sutures. Per-or postoperative analgesia was stated to be performed by all of the participants, while 45 (93.75%) of them reported that they preferred to administrate more than one procedure. Intercostal/paravertebral nerve block (26.4%), epidural analgesia (24.5%), systemic parenteral non-steroid drugs (24.5%) and systemic parenteral opioid (20.9%) were the most commonly used methods. Conclusion: Preventing intercostal nerve injury decreaseed post-thoracotomy pain, as well as the necessity of post-operative analgesic use. Conversely, most of the academic staff did not prefer the methods for preserving intercostal nerve. More than one analgesia procedure were said to be used by majority of the participants.

Does intracostal suture placement during closure reduce pain post-thoracotomy compared to routine pericostal closure?

Postero-lateral thoracotomies are routinely performed in thoracic surgery. Post-operatively, the pain can be incapacitating due to many factors including intercostal nerve injury. Therefore neurovascular bundle (NVB) protection may be a key element in improving pain control. Two methods of chest closure are used in our unit; traditional pericostal closure and intracostal closure.