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Cirocchi R, Matteucci M, Randolph J, Duro F, Properzi L, Avenia S, Amato B, Iandoli R, Tebala G, Boselli C, Covarelli P, Sapienza P. Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis. World J Surg Oncol 2024; 22:92. [PMID: 38605346 PMCID: PMC11007944 DOI: 10.1186/s12957-024-03374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023. MATERIALS AND METHODS The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google. RESULTS We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%). CONCLUSIONS The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy.
| | - Matteo Matteucci
- Department of Medicine and Surgery, University of Milan, Milan, 20122, Italy
| | - Justus Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, 30341, USA
| | - Francesca Duro
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Luca Properzi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Bruno Amato
- Department of Public Health, University of Naples "Federico II", Naples, 80131, Italy
| | - Ruggiero Iandoli
- Department of General Surgery, P.O Frangipane Ariano Irpino, Avellino, 83031, Italy
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, AOSP of Terni, Terni, 05100, Italy
| | - Carlo Boselli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Piero Covarelli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Paolo Sapienza
- Department of Surgery, "Sapienza" University of Rome, Roma, 00161, Italy
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Olivencia-Delgado MN, Jusino-Álamo JF, De Miranda-Sánchez E, Quiñones-Rodríguez JI. From Cadaveric Dissection to the Operating Room: A Unilateral Double Intercostobrachial Nerve and the Implications in Axillary Lymph Node Dissection. Cureus 2023; 15:e36647. [PMID: 37102027 PMCID: PMC10123002 DOI: 10.7759/cureus.36647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
There are multiple treatment options for breast cancer (BC), including lumpectomy, chemo- and radiotherapy, complete mastectomy, and, when indicated, an axillary lymph node dissection. Such node dissections commonly lead the surgeon to encounter the intercostobrachial nerve (ICBN), which, if injured, leads to significant postoperative numbness of the upper arm. To assist in identifying the ICBN, we report a unilateral variation of a dual ICBN. The first ICBN (ICBN I) originates from the second intercostal space, as classically described in human anatomy. On the contrary, the second ICBN (ICBN II) originates from the second and third intercostal spaces. The anatomical knowledge of ICBN origin and its variations are crucial for axillary lymph node dissection in BC and other surgical interventions that involve the axillary region (e.g., regional nerve blocks). An iatrogenic injury of the ICBN has been associated with postoperative pain, paresthesia, and loss of upper extremity sensation in the dermatome supplied by this nerve. Therefore, maintaining the integrity of the ICBN is a worthy goal during axillary dissections in BC patients. Increasing the awareness of ICBN variants among surgeons reduces potential injuries, which would contribute to the BC patient's quality of life.
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Affiliation(s)
| | - Javier F Jusino-Álamo
- Department of Anatomy and Cell Biology, Universidad Central del Caribe School of Medicine, Bayamon, PRI
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Estrada RG, Bacca J, Socolovsky M. A novel dual nerve transfer for restoration of shoulder function and sensory recovery of the hand, in patients with C567 traumatic root avulsion of the brachial plexus. Clin Neurol Neurosurg 2021; 210:107005. [PMID: 34741973 DOI: 10.1016/j.clineuro.2021.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension. METHODS The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count. RESULTS The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively. CONCLUSION These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients.
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Affiliation(s)
- Ricardo González Estrada
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, Clinica Bolivariana, Universidad Pontificia Bolivariana School of Medicine, Medellin, Colombia.
| | - Juliana Bacca
- Department of Pathology, University of Antioquia, Medellin, Colombia.
| | - Mariano Socolovsky
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.
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Siddiqui AU, Gurudiwan R, Siddiqui AT, Satapathy BC, Gupta P. Aberrant bifurcation of intercostobrachial nerve in the axilla: A case report. Morphologie 2020; 104:70-72. [PMID: 31473078 DOI: 10.1016/j.morpho.2019.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 06/10/2023]
Abstract
Intercostobrachial nerve (ICBN) studies have been undertaken by many authors as it is a highly variable structure with numerous patterns reported worldwide. ICBN is a frequently damaged structure in Axillary Lymph Node Dissection (ALND) or mastectomy. Compression of this nerve, due to the enlargement of axillary lymph nodes from cancer breast may be presented as referred pain along the medial side of arm. Different patterns on the course and distribution of the ICBN have been described in literature. We encountered a lesser known variation of the ICBN where it pierced the second intercostal space as a single trunk and immediately divided into two branches. The putative clinical implications of this aberrant bifurcation are of value in significantly diminishing complications such as pain and sensory disturbances presenting after mastectomy and ALND. The findings of the presentation may be of use by surgeons and interventionists in approaching the area in a more precautious manner.
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Affiliation(s)
- A U Siddiqui
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India.
| | - R Gurudiwan
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India
| | - A T Siddiqui
- Department of Cardiothoracic and Vascular Surgery, Kind Saud Medical City, Riyadh, Saudi Arabia
| | - B C Satapathy
- Department of Anatomy, All India Institute of Medical Sciences, Mangalagiri, Vijayawada, Andhra Pradesh, India
| | - P Gupta
- Department of Anatomy, All India Institute of Medical Sciences, 492099 Raipur, Chhattisgarh, India
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Abstract
Nerve transfer surgery involves using a working, functional nerve with an expendable or duplicated function as a donor to supply axons and restore function to an injured recipient nerve. Nerve transfers were originally popularized for the restoration of motor function in patients with peripheral nerve injuries. However, more recently, novel uses of nerve transfers have been described, including nerve transfers for sensory reinnervation, nerve transfers for spinal cord injury and stroke patients, supercharge end-to-side nerve transfers, and targeted muscle reinnervation for the prevention and treatment of postamputation neuroma pain. The uses for nerve transfers and the patient populations that can benefit from nerve transfer surgery continue to expand. Awareness about these novel uses of nerve transfers among the medical community is important in order to facilitate evaluation and treatment of these patients by peripheral nerve specialists. A lack of knowledge of these techniques continues to be a major barrier to more widespread implementation.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, R293, Stanford, California, 94305, USA.
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Emamhadi M, Andalib S. Successful recovery of sensation loss in upper brachial plexus injuries. Acta Neurochir (Wien) 2018; 160:2019-2023. [PMID: 30094689 DOI: 10.1007/s00701-018-3648-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/31/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Injuries of the upper trunk of the brachial plexus may trigger motor and sensory deficits. There exists a growing body of literature with respect to the reconstruction of motor deficits in upper trunk brachial plexus injuries by using nerve transfers; albeit to date, very few old reports have focused on the reconstruction of sensory loss resulting from upper trunk injuries. In this case series, we review six cases (five males and one female) with upper trunk brachial plexus injuries undergoing sensory nerve transfers. METHODS Sensory reconstruction was carried out by using transfer of the ulnar to the median nerves, innervating adjacent aspects of the little and ring fingers (the fourth web space) and adjacent aspects of the thumb and the index finger (the first web space), respectively. RESULTS The mean age of our six patients was 30.5 ± 9 years old (range 20-45). The mean time interval between the injury and subsequent surgery was 6.6 ± 1.8 months (range 5-10). Five patients achieved S3 or S3+ in both the thumb and the index finger while the sixth one regained S2+ in the index finger while also achieving S3 in the thumb according to the Highet-Zachary system scoring scale. CONCLUSION These results suggest that nerve transfers can achieve satisfactory outcomes in patients having sensory reconstruction after upper brachial plexus injuries, and thus, we lay emphasis on reviving the use of sensory nerve transfer techniques in such patients.
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Foroni L, Siqueira MG, Martins RS, Heise CO, Sterman H, Imamura AY. Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:796-800. [PMID: 29236823 DOI: 10.1590/0004-282x20170148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/14/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. METHODS Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. RESULTS Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. CONCLUSION The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.
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Affiliation(s)
- Luciano Foroni
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurocirurgia Funcional, Grupo de Cirurgia de Nervos Periféricos. São Paulo SP, Brasil
| | - Mário Gilberto Siqueira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurocirurgia Funcional, Grupo de Cirurgia de Nervos Periféricos. São Paulo SP, Brasil
| | - Roberto Sérgio Martins
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurocirurgia Funcional, Grupo de Cirurgia de Nervos Periféricos. São Paulo SP, Brasil
| | - Carlos Otto Heise
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil.,Instituto Fleury, Departamento de Neurofisiologia, São Paulo SP Brasil
| | - Hugo Sterman
- Universidade de São Paulo, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brasil
| | - Adriana Yoriko Imamura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Terapia de Mão, São Paulo SP, Brasil
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