Ann Thorac Surg 2008;85:1766-1770. doi:10.1016/j.athoracsur.2007.11.058
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Neurectomy for Treatment of Intercostal Neuralgia
Eric H. Williams, MDa,b,*,
Christopher G. Williams, MDb,
Gedge D. Rosson, MDa,b,
Richard F. Heitmiller, MDc,
A. Lee Dellon, MD, PhDa,b
a Division of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
b Dellon Institute for Peripheral Nerve Surgery, Baltimore, Maryland
c Department of Surgery, Union Memorial Hospital, Baltimore, Maryland
Accepted for publication November 20, 2007.
* Address correspondence to Dr Eric H. Williams, Dellon Institute for Peripheral Nerve Surgery, Johnston Professional Bldg, 3333 N Calvert St, Suite 370, Baltimore, MD 21218 (Email: williamseb{at}gmail.com).
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Abstract
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Background: Intercostal neuralgia due to surgical injury of the intercostal nerve is difficult to treat. No treatment modality has given effective pain relief. Experience with other painful neuromas has demonstrated that neuroma resection and muscle implantation has been effective in the upper and lower extremities. This approach was applied to patients with intercostal neuralgia.
Methods: A retrospective review was done of 5 consecutive patients who have had neurectomy of one or more intercostal nerves. Preoperative and postoperative pain levels, patient demographics, length of follow-up, and surgical technique were reviewed.
Results: Average patient age was 51.0 years (range, 39.2 to 61.3). Patients presented an average of 42.8 months (range, 10 to 138) after the surgical procedure or trauma that created their painful intercostal neuromas. The mean maximum pain level was 10, and the mean average pain level was 8 (range, 7 to 9). Postoperatively, the mean maximum pain level was 3.4 (range, 0 to 9), and the mean average pain level was 2.2 (range, 0 to 7). The differences were significant: p less than 0.01 for maximum pain level and p less than 0.05 for average pain level. Average follow-up after surgery was 8.8 months (range, 6.5 to 10.9). The most common surgical technique used was intercostal nerve neurectomy proximal to the intercostal nerve neuroma and implantation of the cut nerve into the latissimus dorsi muscle.
Conclusions: Intercostal neurectomy and implantation of the cut nerve into the latissimus dorsi or into the rib for severe intercostal neuralgia was an efficacious treatment in this small consecutive patient series.
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Introduction
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Intercostal neuralgia is defined as an intense, sharp, shooting or burning pain consistent with a neuropathic origin located in the distribution of an intercostal nerve [1]. Intercostal neuralgia may be due to a nerve entrapment, a traumatic or iatrogenic neuroma, persistent nerve irritation, or herpes zoster [1]. Although it is most commonly seen and recognized in patients with chronic chest wall pain after thoracotomy [2–4], intercostal neuralgia has been reported in patients after breast and abdominal surgery, trauma, and infection [5–7]. Intercostal neuralgia due to surgical injury of the intercostal nerve has traditionally been difficult to treat. No single treatment modality has been curative [4, 5]. There are several treatment options available, including systemic medications [1, 4], topical or invasive nerve blocks [4, 8, 9], cryoablation [10–12], and radioablation [13]. However, little has been written about the surgical excision of the intercostal nerves for chronic refractory pain [5, 6].
We present a series of 5 consecutive patients with chronic intercostal neuralgia due to prior injury of the intercostal nerves who were treated with intercostal neurectomies for the relief of pain. Owing to the success of implanting a divided nerve into muscle for providing lasting relief of neuroma pain [14,15], the proximal end of the divided intercostal nerve was implanted into muscle where that option was available.
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Material and Methods
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With Institutional Review Board approval, a retrospective record review was performed on 5 consecutive patients who were treated surgically for the presenting complaints of chronic pain attributable to a lesion of an intercostal or subcostal nerve between July 1, 2006, and February 1, 2007. The Institutional Review Board committee waived the requirements for individual patient consent. Inclusion criteria were presence of pain in the distribution of one or more intercostal nerves that had not responded to at least 6 months of nonsteroidal anti-inflammatory drugs, opiods, neuropathic pain medication, or physical therapy including scar massage. Diagnosis of the intercostal nerve to be resected required both the presence of a tender nerve in the interspace corresponding to the symptoms, and relief of those symptoms with a local anesthetic block (1% xylocaine plus 0.5% bupivicaine, without epinephrine). Demographic data are given in Table 1.
Preoperative and postoperative pain levels were obtained by one of the authors (E.W. or C.W.) who was not the primary surgeon. The numerical rating scale was 0, representing no pain, to 10, representing the worst pain imaginable. The preoperative and postoperative pain scores were statistically analyzed using the Wilcoxon rank-sum test, with the assumption that the data were not parametric. No patient who was surgically treated by our group for intercostal nerve injury was excluded from this review.
Surgical Approach
The intercostal spaces proximal to the painful skin area were examined for tenderness along the intercostal nerves (Fig 1). Confirmation that these nerves were the source of the pain had been obtained by intercostal nerve block. An incision was located to permit identification of the lateral branch of the intercostal nerves in the mid-axillary line by locating either the anterior or posterior ramus of this lateral branch and then following this proximally into the intercostal space (Fig 2A, B, C). It is important to note that it is not necessary to actually visualize and resect the neuroma itself. One can interrupt the pain signals by resecting the nerve involved at a more proximal site in an unscarred bed for which exposure may be more straight forward. In some cases, depending on choice of exposure, one will can see and resect the neuroma itself (Fig 3).
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Fig 1. Preoperative photo of patient 2 in the lateral decubitous position with markings of the locations of positive Tinel signs of the 8th, 9th, and 10th right intercostal nerves after a thoracoscopic lung biopsy. The asterisks (*) mark the most tender locations that cause radiating pain into the anterior chest wall.
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Fig 2. Intraoperative photos of patient 2. (A) Anterior ramus of lateral cutaneous sensory branch of the intercostal nerve (nerve loop marked with **) and posterior ramus (nerve loop marked with *) lateral cutaneous sensory branch of the intercostal nerve as it exits the chest wall. Patient is in the lateral decubious position. (B) Isolation of the anterior and posterior rami of the lateral cutaneous branches of the 8th, 9th, and 10th intercostal nerves. The posterior rami are marked with the nerve loops and numbered. (C) The black arrow marks the lateral cutaneous branch of the intercostal nerve proximal to its division into the anterior and posterior rami as it is dissected through the chest wall. The epineurium of the freshly cut end of the intercostal nerve is held in the Crile clamp ready for intramuscular implantation. Nerves are injected with bupivicaine before division. (D) Intramuscular implantation of the lateral cutaneous branch of the intercostal nerve into the latissimus dorsi muscle. The anterior border of the latissimus dorsi muscle is marked with the two black arrows. The Crile clamp holds the implanted end of the nerve into the muscle.
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Fig 3. Left subcostal neuroma (12th intercostal nerve) after nephrectomy stuck in the incision, resulting in chronic, debilitating flank pain. The exposure was carried out through the original nephrectomy scar. In this case, the actual neuroma can be seen tethered to the scar. The neuroma was resected in this case, and the proximal nerve implanted into the latissimus. One could accomplish the same denervation by resecting the subcostal nerve more proximally as well.
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After dividing the intercostal nerve or nerves, a 3-cm length of nerve was dissected proximally, and the proximal end was implanted into the latissimus dorsi muscle (Fig 2D). No strip of intercostal muscle was taken. The artery was left in place. In 1 patient, the intercostal neurectomy was combined with posterior spinal fusion; therefore, owing to the local geometry, the intercostal nerve was surgically divided at the proximal origin of the rib and implanted through a burr hole into the medullary canal of the overlying 7th rib.
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Results
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Preoperatively, the mean maximum pain level was 10; the mean average pain level was 8 (see Table 1.). After a mean of 8.8 months of follow-up, the mean maximum pain level decreased to a 3.4 (p < 0.01); the mean average pain level was 2.2 (p < 0.05).
Each patient had some degree of postoperative discomfort related to collateral sprouting from the adjacent intact intercostal nerves. This pain was managed by a desensitization program that included water walking. These complaints lasted 3 to 12 weeks, and improved with time. In 1 patient, a deep venous thrombosis developed and required 6 months of anticoagulation therapy. The patient who failed to respond to nerve resection had an intercostal neuroma due to a previous thoracotomy but also had spinal pathology requiring a lengthy spinal fusion over the same interval. His intercostal was placed into the rib and not into muscle. It is difficult to ascertain with certainty the cause of his failure. A second patient who had a poor response was injured by blunt trauma to her flank. She reported a residual average pain level of 4, mostly due to pain at the implantation site in the latissimus dorsi muscle. Her referred pain in the intercostal distribution was gone.
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Comment
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The small group of patients reported here confirm the two other reports [5, 6] of small series of patients demonstrating that chronic intercostal neuralgia can be relieved in patients by resecting the appropriate intercostal nerves. The two questions left to resolve are one, what to do with the cut end of the intercostal nerve, and two, at what level should the intercostal nerve be divided. In the 5 patients reported by Wong and colleagues [6], the intercostal nerve was left in the intercostal space, with excellent long-term results. However, theoretically at least, this site, during respiration, may create movement of the end of the nerve as it attempts to regenerate, and in thin patients, does not afford much protection for the nerve. In their 12 patients, Ducic and Larson [5] implanted the nerve into muscle, chosing the rectus abdominus or the serratus anterior. Their only failure was a patient who had a thoracotomy, and those authors believed they may not have divided the intercostal nerve posteriorly enough. In 4 of our 5 patients, the nerve was implanted into the latisimus dorsi muscle, affording a large muscle, away from abdominal and chest wall movement, and allowing, also, for a proximal site of resection of the intercostal nerve. In our fifth patient, where exposure was obtained by the surgeon doing spinal fusion surgery, this most proximal site of division of the intercostal nerve suggested a direct implantation of the intercostal nerve into the rib.
The series of patients reported by Wong and associates [6], Ducic and Larson [5], and ourselves are similar with the exception that all 5 of the patients in the Wong series and 7 of the 12 patients in the Ducic and Larson series had previous breast surgery, which suggests that the location of injury to the intercostal nerve was more anterior than in the 5 patients we report and in the 5 patients who Ducic and Larson report who had previous chest and abdominal surgery. However, if the results of these three studies are combined, 17 of 21 patients (81%) obtained a good to excellent result.
Chosing the site of resection along the course of the intercostal nerve depends upon the location of the patient's symptoms and the known anatomy of these nerves [16–18]. The clinical sequela of motor weakness will differ depending on which thoracic level the nerves are injured. The upper thoracic intercostal nerves innervate the intercostal muscles, and if lost, will have little clinical sequela as long as the patient's diaphragm is functioning [19–21]. Abdominal motor weakness may present in intercostal nerve injuries from T7 and below, as these are responsible for motor function of the transversalis, external and internal obliques, and rectus abdominus muscles [16–18]. Motor weakness was present already in 3 of our patients, including the patient who had T7 injury from thoracotomy. Immediately after the thoracotomy, the patient noticed a bulge in his right upper abdomen due to denervation of the upper abdominal wall that never resolved. Another patient in this series who had neuromas secondary to thoracoscopic surgery demonstrated a much larger abdominal bulge due to the loss of function of several intercostal nerves. Korencov and coworkers [22] present another case of a patient who presented with abdominal wall paresis after laparoscopic cholecystectomy.
Separate sensory branches perforate the thoracoabdominal wall at known intervals such as the posterior paramedian line, the mid-axillary line, and anterior rectus sheath [16–18]. If the patient has pain in a dermatomal pattern but no motor weakness, it may be possible to spare the motor portion of the intercostal nerve by resecting only the perforating lateral cutaneous branch. If the motor function is nonfunctional or is expendable, then the entire intercostal nerve may be resected proximal to the lesion. Both of these approaches were taken in this small series.
If the pain is located only anteriorly, then only the anterior cutaneous branch may be injured, as described by Rosson and Dellon [23]. That may help refine the surgical technique while minimizing the complications. However, if one has a difficult time determining the location of the injury to the intercostal nerve, such as in a postthoracotomy patient, it is wiser to take the more proximal approach, even though one will sacrifice more of the motor innervation of that distribution.
In our series, 1 patient reported good pain relief in the anterior chest wall after the resection of her intercostal nerve, but continued to have pain where the nerve was implanted to the latisimus muscle. We believe that pain was either due to the patient's small size and lack of bulky muscle, or that the nerve ending may have been pulled from the implant site. A second patient who had an intercostal neuroma owing to a thoracotomy had initially reported good pain relief with neurectomy, but the pain in the T7 dermatome had returned after 6 months to his preoperative level. This patient's outcome is difficult to interpret for several reasons. First, he had a simultaneous spinal fusion including the same spinal level. Second, the intercostal nerve was placed into bone, not muscle. We believe that the nerve was proximal to the intercostal nerve injury because it was divided at the most proximal portion of the rib, much more proximal to where a retractor would be placed. At this time, we are not advising placement of the nerve ending into bone.
For a patient who fails to improve after resection of the intercostal nerve, there is still the possibility of doing a dorsal ganglionectomy.
In conclusion, early experience with resection of the intercostal nerves with implantation of the proximal end into the latissimus dorsi muscle demonstrates that intercostal neurectomy may be a curative option to consider in the management of patients with severe refractory chest or abdominal pain due to intercostal neuromas. Preoperative localization and diagnostic nerve blocks help direct the surgeon's operative plan. Using this approach, we have achieved excellent resolution of pain in 3 of 5 patients and good relief in 1 other patient. We had 1 patient who did not respond to resection of the intercostal nerve. Larger numbers of patients and a prospective longitudinal study would help further define the usefulness of this approach.
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Acknowledgments
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The authors would like to thank Willis H. Williams, MD, for his assistance with the manuscript review and preparation, and for assistance with statistical analysis.
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Top
Abstract
Introduction
