Origin, Branching, and Communications of the Intercostobrachial Nerve: a Meta-Analysis with Implications for Mastectomy and Axillary Lymph Node Dissection in Breast Cancer

Abstract

The intercostobrachial nerve (ICBN), which usually originates from the lateral cutaneous branch of the second intercostal nerve, innervates areas of the axilla, lateral chest, and medial arm. It is at risk for injury during operative procedures that are often used in the management of breast cancer and such injury has been associated with postoperative sensory loss and neuropathic pain, decreasing the quality of life. PubMed, Excerpta Medica Database (EMBASE), ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), Scientific Electronic Library Online (SciELO), Biosciences Information Service (BIOSIS), and Web of Science were searched comprehensively. Data concerning the prevalence, branching, origin and communications of the ICBN were extracted and pooled into a meta-analysis. A total of 16 studies (1,567 axillas) reported data indicating that the ICBN was present in 98.4% of person. It most often (90.6%) originated from fibers at the T2 spinal level and commonly coursed in two branching patterns: as a single trunk in 47.0% of cases and as a bifurcating pattern in 42.2%. In the latter cases, the bifurcation was usually unequal (63.4%). Additionally, the ICBN presented with anastomosing communication to the brachial plexus in 41.3% of cases. The ICBN is a prevalent and variable structure at significant risk for injury during operative procedures of the axilla. In view of the postoperative pain and paresthesia experienced by patients following injury, surgeons need to exercise caution and aim to preserve the ICBN when possible. Ultimately, careful dissection and knowledge of ICBN anatomy could allow postoperative complications to be reduced and patient's quality of life increased.

Radiofrequency Thoracic Sympathectomy for Sympathetically Maintained Chronic Post‐Mastectomy Pain, a Preliminary Report: 6‐Month Results

“…In contrast, thoracic sympathectomy consistently interrupts the sympathetic supply to the upper limb and upper chest 26 . Chronic post‐mastectomy pain is primarily due to surgical injury of the intercostobrachial nerve that occurs during removal of breast tissue and axillary lymph nodes en bloc in modified radical mastectomy or during 21 quadrantectomy with axillary lymphadenectomy 27 . The intercostobrachial nerve is formed by the roots of T2, T3, and, uncommonly, T4, 5 so RF lesioning of T2, T3, and T4 sympathetic ganglia will interrupt sympathetic fibers carried through the intercostobrachial nerve; consequently, complete sympathetic denervation of the painful region (upper chest, axilla, and upper arm) occurs.…”

<p>Case Report Of Cryoneurolysis For The Treatment Of Refractory Intercostobrachial Neuralgia With Postherpetic Neuralgia</p>

“…The ICBN is often affected/injured postmastectomy and there is literature regarding postmastectomy altered sensitivity with intercostobrachial neuralgia 19. The ICBN is at significant risk for injury postoperatively after procedures involving the axillary region 20. The ICBN is a cutaneous nerve that stems from the second and occasionally third intercostal nerve anatomically 21.…”

AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery

“…This nerve injury is implicated in both persistent pain after breast surgery and permanent loss of sensory function in the region supplied. 44,78,89,104 In preclinical models, damaged nerves begin to spontaneously and repetitively fire without the presence of distal sensory input within the first hours to days after injury. 24,91 Tissue damage from surgical manipulation and the associated healing response leads to release of mediators including prostaglandins, bradykinins, cytokines (IL-1B and TNF), hydrogen ions, bacterial peptides, and miR-NAs, 30 many of which activate nociceptors directly and/ or enhance sensitivity.…”