BACKGROUND: The breast is innervated by the intercostal nerves and the brachial plexus. We propose a technique to perform breast surgery without general anesthesia using the erector spinae plane (ESP) block and selective block of four nerves that arise from the brachial plexus innervate the breast and the axilla (SBP block). CASE: A 77-year-old man with breast cancer was scheduled for radical mastectomy and axillary clearance. He had a previous history of myocardial infarction with dilated cardiomyopathy and severely impaired ejection fraction. The surgery was performed under regional anesthesia with combined ESP and SBP block. The patient did not require opioids or other supplemental analgesics intra- or postoperatively and was discharged uneventfully. CONCLUSIONS: SBP is a novel block that selectively blocks branches of the brachial plexus that innervate the breast.
Aged ; Analgesics ; Analgesics, Opioid ; Anesthesia, Conduction ; Anesthesia, General ; Axilla ; Brachial Plexus Block ; Brachial Plexus ; Breast Neoplasms ; Breast ; Cardiomyopathy, Dilated ; Humans ; Intercostal Nerves ; Mastectomy, Radical ; Myocardial Infarction

BACKGROUND: Breast cancer is complicated by a high incidence of chronic postoperative pain (25%–60%). Regional anesthesia might play an important role in lowering the incidence of chronic pain; however it is not known if the pectoral nerve block (PECS block), which is commonly used for breast surgery, is able to prevent this complication. Our main objective was therefore to detect any association between the PECS block and chronic pain at 3, 6, 9, and 12 months in patients undergoing breast surgery. METHODS: We conducted a prospective, monocentric, observational study. We enrolled 140 consecutive patients undergoing breast surgery and divided them in patients receiving a PECS block and general anesthesia (PECS group) and patients receiving only general anesthesia (GA group). Then we considered both intraoperative variables (intravenous opioids administration), postoperative data (pain suffered by the patients during the first 24 postoperative hours and the need for additional analgesic administration) and development and persistence of chronic pain (at 3, 6, 9, and 12 mo). RESULTS: The PECS group had a lower incidence of chronic pain at 3 months (14.9% vs. 31.8%, P = 0.039), needed less intraoperative opioids (fentanyl 1.61 μg/kg/hr vs. 3.3 μg/kg/hr, P < 0.001) and had less postoperative pain (3 vs. 4, P = 0.017). CONCLUSIONS: The PECS block might play an important role in lowering incidence of chronic pain, but further studies are needed.
Analgesics, Opioid ; Anesthesia, Conduction ; Anesthesia, General ; Anesthesia, Local ; Breast Neoplasms ; Breast ; Chronic Pain ; Clinical Study ; Humans ; Incidence ; Nerve Block ; Observational Study ; Pain, Postoperative ; Prospective Studies ; Thoracic Nerves

Intercostal neuralgia is neuropathic pain that develops in the thorax and abdomen. It usually occurs as a result of injury or inflammation associated with the intercostal nerve triggered by trauma, surgery, or herpes zoster. Primary intercostal neuroma is a rare cause of intercostal neuralgia. A 69-year-old male patient without a history of thoracic trauma or surgery underwent repeated testing and intermittent treatment for refractory pain in the right chest and abdomen for several years. However, the treatment had limited effect. Abdominal computed tomography performed to diagnose recent pain aggravation revealed schwannoma of the 11th intercostal nerve. The patient's pain was relieved following surgical excision of the tumor.
Abdomen ; Aged ; Herpes Zoster ; Humans ; Inflammation ; Intercostal Nerves ; Male ; Neuralgia ; Neurilemmoma ; Neuroma ; Pain, Intractable ; Thorax

BACKGROUND: We report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center. METHODS: Between January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%). RESULTS: Twenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality. CONCLUSION: Nonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon’s experience, for appropriately selected patients.
Anesthesia ; Anesthesia, Local ; Anoxia ; Arteries ; Chest Tubes ; Chylothorax ; Hospital Mortality ; Humans ; Intercostal Nerves ; Intubation ; Ion Transport* ; Length of Stay ; Lung Diseases ; Lung Neoplasms ; Mastectomy, Segmental ; Minimally Invasive Surgical Procedures ; Neoplasm Metastasis ; Pleural Diseases ; Pleural Effusion ; Pneumonia ; Thoracic Surgery ; Thoracic Surgery, Video-Assisted*

Although the sternalis muscle has been well known to anatomists, it is quite unfamiliar to clinicians. During routine educational dissection, we came across a well-defined bilateral double sternalis muscle innervated by the intercostal nerve, respectively. The right sternalis muscle 1) became tendinous to insert into the sternum and 2) crossed midline and then intermingled with the left pectoralis major muscle, which could be classified into a double with single cross based on Snosek et al.'s criteria. The left sternalis muscle was composed of two bellies, which were combined at the midway, and became tendinous to insert into the contralateral manubrium, which could be classified into a bicipital diverging with double cross based on Snosek et al.'s criteria. The detailed knowledge on the sternalisis is important for clinicians as well as for anatomists, since the clinical importance of the sternalis muscle has been highlighted in recent years.
Anatomists ; Cadaver* ; Humans ; Intercostal Nerves ; Manubrium ; Sternum

Regional anesthesia for non-obstetric surgery in parturients is a method to decrease patient and fetal risk during general anesthesia. Thoracic interfascial nerve block can be used as an analgesic technique for surgical procedures of the thorax. The Pecs II block is an interfascial block that targets not only the medial and lateral pectoral nerves, but also the lateral cutaneous branch of the intercostal nerve. Pecto-intercostal fascial block (PIFB) targets the anterior cutaneous branch of the intercostal nerve. The authors successfully performed a modified Pecs II block and PIFB without complications in a parturient who refused general anesthesia for breast surgery.
Anesthesia, Conduction ; Anesthesia, General ; Breast* ; Female ; Humans ; Intercostal Nerves ; Methods ; Nerve Block* ; Pregnant Women* ; Thoracic Nerves ; Thorax

Regional anesthesia for non-obstetric surgery in parturients is a method to decrease patient and fetal risk during general anesthesia. Thoracic interfascial nerve block can be used as an analgesic technique for surgical procedures of the thorax. The Pecs II block is an interfascial block that targets not only the medial and lateral pectoral nerves, but also the lateral cutaneous branch of the intercostal nerve. Pecto-intercostal fascial block (PIFB) targets the anterior cutaneous branch of the intercostal nerve. The authors successfully performed a modified Pecs II block and PIFB without complications in a parturient who refused general anesthesia for breast surgery.
Anesthesia, Conduction ; Anesthesia, General ; Breast* ; Female ; Humans ; Intercostal Nerves ; Methods ; Nerve Block* ; Pregnant Women* ; Thoracic Nerves ; Thorax

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.
Anesthesia ; Anesthesia, Conduction* ; Anesthesia, General ; Anesthesia, Local ; Breast Neoplasms ; Breast* ; Female ; Fibroadenoma* ; Humans ; Mastectomy, Segmental ; Pain Management ; Physical Examination ; Thoracic Nerves ; Thoracic Wall ; Visceral Pain

The 12th rib syndrome is a disease that causes pain between the upper abdomen and the lower chest. It is assumed that the impinging on the nerves between the ribs causes pain in the lower chest, upper abdomen, and flank. A 74-year-old female patient visited a pain clinic complaining of pain in her back, and left chest wall at a 7 on the 0-10 Numeric Rating scale (NRS). She had a lateral fixation at T12-L2, 6 years earlier. After the operation, she had multiple osteoporotic compression fractures. When the spine was bent, the patient complained about a sharp pain in the left mid-axillary line and radiating pain toward the abdomen. On physical examination, the 10th rib was not felt, and an image of the rib-cage confirmed that the left 10th rib was severed. When applying pressure from the legs to the 9th rib of the patient, pain was reproduced. Therefore, the patient was diagnosed with 9th rib syndrome, and ultrasound-guided 9th and 10th intercostal nerve blocks were performed around the tips of the severed 10th rib. In addition, local anesthetics with triamcinolone were administered into the muscles beneath the 9th rib at the point of the greatest tenderness. The patient's pain was reduced to NRS 2 point. In this case, it is suspected that the patient had a partial resection of the left 10th rib in the past, and subsequent compression fractures at T8 and T9 led to the deformation of the rib cage, causing the tip of the remaining 10th rib to impinge on the 9th intercostal nerves, causing pain.
Abdomen ; Abdominal Pain ; Aged ; Anesthetics, Local ; Female ; Fractures, Compression ; Humans ; Intercostal Nerves ; Leg ; Muscles ; Neuralgia ; Pain Clinics ; Physical Examination ; Ribs* ; Spine ; Thoracic Wall ; Thorax ; Triamcinolone

BACKGROUND: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. METHODS: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. RESULTS: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. CONCLUSIONS: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.
Anesthesia, Conduction ; Brachial Plexus Block* ; Brachial Plexus* ; Humans ; Incidence ; Phrenic Nerve ; Shoulder ; Superficial Back Muscles ; Thoracic Nerves* ; Ultrasonography