Regional Anaesthesia for Breast Surgery

Vol 2 | Issue 1 | January-June 2021 | Page 40-46 | Anjolie Chhabra, Divya Sethi, Abhijit Nair


Authors: Anjolie Chhabra [1], Divya Sethi [2], Abhijit Nair [3]

[1] Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Employees’ State Insurance Cooperation Postgraduate Institute of Medical Sciences and Research, New Delhi, India.
[3] Department of Anaesthesia, Ibra Hospital, North Sharqiya Governorate, Ibra-414, Sultanate of Oman.

Address of Correspondence
Dr. Anjolie Chhabra,
Professor, Department of Anaesthesiology, AIIMS, New Delhi, India.
E-mail: anjolie5@hotmail.com


Introduction


Innervation of the breast:
The breast receives innervation mainly from the 2 to 6 thoracic (T2-6) spinal nerves. The thoracic spinal nerves after emerging from the intervertebral foramina divide into dorsal and ventral ramii [1]. The dorsal ramii provide innervation to the skin and the muscles of the medial back. Each ventral ramus continues anteriorly as an intercostal nerve, accompanied by an intercostal artery and vein lying between the innermost and the internal intercostal muscle along the inferior borders of the respective ribs. Near the midpoint of the hemithorax corresponding to the midaxillary line, each intercostal nerve gives a lateral cutaneous branch that further divides into an anterior and posterior branch. Sensory supply of lateral aspect of breast is provided by the anterior divisions of the lateral cutaneous branches of T2–T6 intercostal nerves with contributions from T1 and T7 nerves. The intercostal nerves interconnect providing overlapping nerve supply to the breast. The main intercostalnerve continues anteriorly and terminates as an anterior cutaneous branch that further divides into a medial and lateral divisions which provide cutaneous innervation over the sternum and medial part of the breast respectively [2-4] (Figure 1) [5].
The intercostobrachial nerve (T2) mainly provides cutaneous innervation to the axillary tail of the breast, the axilla, and the medial upper arm. The medial cutaneous nerve of the arm (branch of the brachial plexus) may also supply the roof of the axilla and may receive contributions from T1 and T3 nerves. The supraclavicular nerves of the cervical plexus provide sensory supply to the infraclavicular or supramammary area [6, 7], (Figure 1).
The muscles of chest wall underlying the breast, the pectoralis major (PMM) and pectoralis minor (PmM) are innervated by mixed motor and sensory nerves, the lateral pectoral nerves (LPN) (C5-7, lateral cord) and the medial pectoral nerves (MPN) (C7-T1, medial cord), branches of the brachial plexus. These nerves also possess proprioceptive and nociceptive fibres and thus traction, stretching or muscle spasm of these muscles can lead to dull, aching perioperative pain. In addition, the long thoracic nerve (LTN) (C5-7) and the thoracodorsal nerve (TDN) (C6-8, posterior cord) branches of the brachial plexus innervate the serratus anterior (SAM) and the latissimus dorsi (LD) muscles, that form part of the axilla [8].
Therefore, the breast, axilla and the surrounding tissues are supplied by interconnected network of T2-T6 intercostal nerves, branches of the brachial plexus and the lower branches of the cervical plexus (Figure 1) [5].


References


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3. Cheng GS, Ilfeld BM. An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery. Pain Med. 2017 Jul 1; 18:1344-65.
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5. Kim DH, Kim S, Kim CS, Lee S, Lee IG, Kim HJ, Lee JH, Jeong SM, Choi KT. Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study. Pain Res Manag. 2018 May 15;2018:4315931.
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33. George R, Dahl K, Blair DHJ. How I Do It: Transversus Thoracic Plane and Pecto-Intercostal Fascial Block. ASRA NEWS. Available at https://www.asra.com/asra-news/article/250/how-i-do-it-transversus-thoracic-plane-a and Pecto-Intercostal Fascial Block. Last accessed on December 15, 2020.
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How to Cite this Article: Chhabra A, Sethi D, Nair A | Regional Anaesthesia for Breast surgery | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 40-46.


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