A Targeted Approach to Post-Mastectomy Pain and Persistent Pain Following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Ultrasound-Guided Superficial Serratus Plane Block for Persistent Post-Mastectomy Pain: Four Case Reports

Background: Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including physical medicine, physical therapy and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain. Methods: We report four cases of patients with PPMP that were performed using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.Results: We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief, but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.Conclusion: These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of “tightness” relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Ultrasound to the Rescue: Axillary Clearance under Complete Regional Blockade

No single regional anaesthetic technique is capable of complete anaesthesia of the axillary region. Regional or interfascial nerve blockade could be an effective alternative where administering general anaesthesia is not feasible, with superior analgesia, favourable haemodynamics, and reduced opiate related adverse effects. Ultrasound guidance improves effectiveness and safety profile. We report a case of a successful axillary clearance conducted under combined regional blocks for an axillary nodal recurrence following mastectomy for a breast carcinoma, in a patient who was not fit for general anaesthesia due to a persistent lobar pneumonia and recurrent asthma exacerbations. Our experience and current evidence supersede the initial conceptions of difficult ultrasonic intercostobrachial nerve (ICBN) visualization.

SITE-SPECIFIC FASCIA TUNING PEGS AND PLACES OF PERILOUS PASSAGE MYOFASCIAL CONSIDERATIONS IN UPPER EXTREMITY ENTRAPMENT NEUROPATHIES: A CLINICAL ANATOMISTS VIEW

The objective of this study was to identify common anatomical locations of densified fascia associated with axillary, musculocutaneous, median, ulnar and radial nerve entrapment. Additionally, a proposal concerning a tensegrity based expansive decompressive protective role of muscles and ligaments as ‘site-specific fascia tuning pegs’ is offered for consideration. This observational report provides a means to stimulate research into the dynamics of force transfer via tensegral mechanotransductive pathways possibly decompressing neurovascular structures. Morphological changes to fascia profunda, septal tissues, epineurium, perineurium and endomysial tissue in continuity with neural structures were noted. Entrapment neuropathies involving the upper extremity are a growing and widespread phenomenon within modern society. Upper extremity neuropathies affect dentists, athletes (professional and recreational), pianists, grocery store employees, office workers, cab drivers and a host of other professional and non-professional individuals. Neurovascular insults can develop at multiple sites referred to by anatomists as the three P’s [i.e. Places of Perilous Passage]. The complexity of the inter-communicating nerve network, known as the brachial plexus, is well described as are the referred pain patterns of the contributing terminal branches. Sensory innervation to the upper extremity includes most of the axilla while excluding a specific region of the medial upper extremity and axilla which is supplied by the intercostobrachial nerve [i.e. T2]. This observational study identified specific anatomical locations where increased fascial densification lead to reduced gliding of the various facial laminae due to densified, fibrotic or adhered fascial tissues. A new hypothesis emerged concerning “site-specific fascia tuning pegs” described as biological instruments [i.e. muscle fibers and ligaments] that modify the length and width of the various specialist neural and vascular tubes [i.e. epineurium, tunica adventitia]. This author hopes that providing this information will assist in improving diagnosis, treatment and prognosis of upper extremity neurovascular insults that result in pain or unpleasant changes in sensation. KEY WORDS: Neuropathy, Fascia, Entrapment, Brachial Plexus, Tensegrity, Densification, Fibrotic, Site-Specific Fascia Tuning Pegs.