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Treatment of Chronic Postmastectomy Pain with Intercostal Neurectomy and Nerve Cap Application
Jacob Y. Katsnelson, MD
Ryan L. Shapiro, MD
University of Louisville Department of Surgery/Division of Plastic Surgery
2025-01-10
Presenter: Jacob Y. Katsnelson, MD
Affidavit:
I certify that Jacob Katsnelson contributed to the design, data collection, and analysis of this project and also drafted the final abstract.
Director Name: Bradon Wilhelmi, MD
Author Category: Fellow Plastic Surgery
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)
Background:
Chronic postmastectomy pain (cPMP) is a debilitating clinical condition reported in up to 60% of mastectomy patients. A subset of cPMP is related to injury or entrapment of the 3rd-5th intercostal nerves, and there have been limited studies of surgical treatment with traction neurectomy and muscle replantation of the nerve stump. A nerve cap device (AxoguardŽ, Axogen, Alachua, FL) has been shown to have potential in limiting neuroma formation from transected nerves in the lower extremity. We investigated the efficacy of combining neurectomy with application of this nerve cap in the treatment of cPMP.
Methods:
Patients with cPMP unamenable to medical therapy were referred to our practice. Those with reproducible Tinel's sign over the 3rd-5th lateral intercostal nerves and response to 1% lidocaine injection at the maximal trigger point were considered for operative intervention. We performed surgical exploration at the maximal trigger point to identify the involved nerve branch, which was then treated with proximal neurectomy and application of nerve cap with epineural suture and fibrin glue. Patients were clinically followed to compare preoperative and postoperative pain level.
Results:
Nine patients underwent operative intervention. Intraoperative findings included fibrosis of the fourth intercostal nerve in all patients and a neuroma in one patient. Six patients had complete resolution of symptoms (67%), and three patients (33%) had significant pain relief on follow-up (mean, 70 days).
Conclusion:
Intercostal neurectomy with nerve cap application potentially offers a viable, technically straightforward technique for surgical management of cPMP.
