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The aim of this study was to assess the impact of the preservation of the intercostobrachial nerve on the quality of life of patients operated for breast cancer.This study was ancillary to cost comparison study of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. It was a prospective multicenter, observational, non-randomized study. The quality of life was assessed using two questionnaires: QLQ-C30 and specific module QLQ-BR23 Surveys have been performed before initiation of surgery, one week, and 1 month, 8 months and 12 months after discharge from hospitalization for the first surgical procedure.Five hundred and seventy-eight patients with preservation of intercostobrachial nerve without axillary lymph node dissection (C- P+), 85 without preservation of nerve and axillary lymph node dissection (C+P-) and 57 with preservation of nerve and axillary lymph node dissection (C+P+) have been included in the study. The changing arm symptoms score was significantly different during follow-up between the three groups (P0.001). This difference between the two groups C- P+ and C+P+ was significant clinically at one week [16.9, IC95%: 11.9 to 22 (P0.01)], and persisted for up to 12 months [9.9, IC95%: 3.2 à16.6 (P=0.022)]. There was no difference between the group C+P- and C+P+. Results for physical functioning score were similar.Preservation of the intercostobral nerve is not associated with better quality of life. Only axillary lymph node dissection has an impact on quality of life.

The intercostal nerves (ICN) transfer to the musculocutaneous nerve (MCN) can restore elbow flexion in complete brachial plexus palsy. The last cases our service dealt with, allowed our staff to observe two different situations. In the 2 first patients, we were able to proceed with an intraneurodissection of the MCN motor component up to the axillary cavity level, while on the third case such dissection could not be performed as high. The aim of this work is to assess the feasibility of a transfer on the MCN's motor component.We conducted a series of 5 cadaver dissections of the MCN and ICN on the anatomy laboratory. Using magnifying loupes to perform an intraneurodissection, we were able to split the motor and sensory fibers as they stood out. It would help motor recuperation avoiding directional error on sensitive component.The ICN can be sutured on the motor component of the MCN, provided the dissection is very minutious.The intraneurodissection of the MCN up to the axillary cavity level is possible as the interfascicular exchanges are scarce there. Publications already refer to the possibility of a nerve transfer between the ICN and the motor component of the MCN. Therefore, our researches suggest that such a procedure can be considered for routine procedures.The neurotization is one of the latest breakthroughs in terms of brachial plexus surgery. We are hopeful that anatomical researches could lead to optimization possibilities.

Many of the thoracic operations that previously required a thoracotomy incision can now be performed with several small incisions and video-assisted thoracic surgery (VATS). Although there have been reports of less pain and less impairment of pulmonary function with VATS compared with thoracotomy, 1 many VATS patients report significant acute and chronic postoperative pain. Treating thoracoscopic pain effectively and minimizing the later development of chronic pain requires familiarity with a wide spectrum of analgesic techniques. An important variable in the analgesic plan for VATS is the likelihood of converting to an open thoracotomy. Conversion may be due to technical difficulties, inadequate lung separation, or bleeding, and may be more likely when the surgeon has less experience with VATS. The likelihood of conversion to an open procedure must be assessed preoperatively. If a VATS procedure is converted to a thoracotomy and analgesia (such as an epidural) is not in place, the patient’s recovery may be impaired. If not wellcontrolled, postoperative thoracic pain can lead to splinting and may impair the patient’s ability to take deep breaths following thoracic surgery. It is difficult to state precisely the incidence of pain following thoracoscopy, as the extent and severity varies according to surgical technique, patient sensitivity, and anesthetic pain management. In a recent survey of Dutch thoracic surgery patients, 47% of the VATS patients reported chronic pain. 2 In an earlier study, the incidence of chronic pain was reported to be 36% in VATS patients undergoing wedge resection. 3 It might seem intuitive that performing the surgery by thoracoscopy, which utilizes small incisions, would lead to less postoperative pain. However, the introduction of trocars during thoracoscopy may injure intercostal nerves, and additional manipulation of these instruments during the surgery may traumatize these nerves further by compression against ribs. 4 If a lobectomy is being performed, an incision will need to be enlarged in order to extract the specimen, and a rib retractor may be required. Also, the duration of the surgery may be greater using VATS. Ipsilateral shoulder pain is a common complaint following VATS, and in one study, it was reported to be chronic in 10% of patients. 5

Le shwannome thoracique solitaire est une tumeur nerveuse bénigne. La localisation est le plus souvent intra-thoracique au niveau du médiastin postérieur. Nous rapportons l'observation d'un schwannome solitaire du nerf intercostal de développement extra-thoracique imitant une tumeur sous-cutanée du thorax. La biopsie-exérèse nous a permis d’établir le diagnostic histologique. Après un recul de 14 mois aucune récidive n'a été notée. Le diagnostic de schwannome doit être suspecté devant toute tumeur sous cutanée du thorax. La certitude diagnostique est histologique. L'exérèse totale est le seul garant d'une guérison sans récidive.

Computed Tomography fluoroscopy for blocks and neurolysis provides a minimally-invasive, accurate and rapid alternative to surgery. Spinal and peri-spinal ultrasound-guided procedures, excluding peripheral procedures, will be discussed as well. The imaging-guided procedures discussed are performed using small needles. These percutaneous procedures must be performed with maximum patient comfort and cause as little complications as possible. These procedures should be performed by an experienced radiologist after discussion with the treating clinician.

Interpleural analgesia, a recently devised method for postoperative analgesia, consists of the injection of a local anaesthetic into the pleural space. The technique of the catheter insertion is simple and derived from the threadening of an epidural catheter, using the same equipment. An unilateral analgesia is obtained with a rapid onset but not efficient enough for a surgical procedure. The area covered by analgesia includes the thorax and the upper part of the abdomen. No haemodynamic adverse effects occur and ventilatory function is rather improved. The main mechanism of analgesia is probably a retrograde intercostal nerve blockade. Although the exact dose and volume of local anaesthetic is still controversial, 20 to 30 mL of 0.5% bupivacaine is very likely the most convenient. Lidocaine may also be administered at the dose of 2 mg.kg-1 of a 2% solution. Main indications of interpleural analgesia are cholecystectomies and thorax trauma patients. Adverse effects and hazards are uncommon and include mainly pneumothorax and toxic effects of a local anaesthetic overdose.

Pain is a major factor of respiratory decompensation after chest trauma. General and/or regional analgesia improve alveolar ventilation, make physiotherapy easier and often avoid mechanical ventilation. Concerning regional techniques, epidural, intercostal and interpleural routes have their respective indications and contraindications, benefits and risks. When suitable, epidural analgesia appears to be the preferable technique.

This study was aimed to assess the efficiency and the side effects of a continuous administration of bupivacaine into the paravertebral space. Twenty patients, ranked ASA 2 or 3, with a mean age of 57.9 years, and having had a posterolateral thoracotomy for resection of lung tissue, were randomly assigned to one of two groups, B or C. At the end of the surgical procedure, a 22 gauge catheter was inserted into the paravertebral extrapleural space, at T4 levels As soon as pain occurred during recovery (T0), the patients were given two-hourly intravenous boluses of buprenorphine. The patients in group B were also given, through the paravertebral catheter, a 20 ml bolus of 0.25% bupivacaine, followed by a continuous steady rate infusion (10 ml.h-1). Group C patients were given normal saline in the same way. All patients could improve their analgesia with 0.05 ml boluses of buprenorphine given by an auto-analgesia pump (Pharmacia). The following parameters were assessed during the 72 h which followed the first injection: pain with a visual analogic scale, quality of sedation (5 grades), heart and breathing rate, systolic and diastolic blood pressure, arterial blood gases. In group B, plasma bupivacaine concentrations were measured throughout the infusion, and for an 8-hour period after its end. The statistical analysis included 15 patients only, as the catheter had moved into the chest cavity in the other 5. Analgesia was qualified to be adequate by all patients, but there was no statistically significant difference in the amounts of self-administered buprenorphine between groups B and C.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report one case of posterior mediastinal neurinoma with a Adamkiewicz artery arising at an atypical site. They stress the spinal cord complications following thoracic surgery. The value of spinal cord arteriography during preoperative examinations and for prevention of complications is discussed.

The authors present their experiences in experimental micro-neuro-surgery referring to the last 2 years. In the field of vascular microsurgery, they explored: the possibility of performing end-to-side anastomoses reducing to few minutes the blood flow interruption in the receiving vessel; experimental reconstructive techniques of the arterial wall in case of giant aneurysm; micro-anastomoses between vessels with calibre smaller than 1 mm. The possibility of carrying out nervous anastomoses between intercostal and lumbar nerves to re-innervate these latter has been also examined on the basis of experimental trials.

After a very precise anatomical review, the authors report the results of an anatomo-radiological study involving 244 urography films. The usual length of the 12th rib is 11 cm, with a width of 1 cm in the female and 1.5 cm in the male. The costo-lumbar angle was 45 degrees in 3/4 of the films. The kidney was often lower in the female than in the male. The renal artery was almost always given off at the level of the 12th rib or below, whilst at the level of the hilum, the renal artery and 12th rib having crossed, the artery was always above the 12th rib. Study of 173 usable cases of patients operated upon by lumbotomy revealed the following data: --lumbotomies on the 12th rib never opened the pleura, and gave rise to transient wall pain (7%) and one single case of abdominal wall hypotonia (1.4%) with no incisional hernias; --lumbotomies over the 11th rib were associated with 13% of cases of damage to the pleura, 16% of spontaneously resolving wall pain, 7 cases of prolonged parietal hypotonia and one incisional hernia out of 60 lumbotomies; --lumbotomies sub-jacent to the 12th rib were associated with residual abdominal wall pain in 3 cases out of 16. Lumbotomies over the 11th rib are associated with the risk of section of the superficial and deep abdominal branch of the 12th nerve and are hence those exposing to the greatest risk of abdominal wall hypotonia and neuralgia. Incision over the 12th rib would thus appear to be that associated with the least abdominal wall complications.

10 The activity of 107 medullary inspiratory neurones has been recorded extracellularly in anesthetized cats (urethane-chloralose). According to their localization in the medulla and to their axonal pathways (tested by antidromic activation), these neurones were classified as: bulbo-spinal neurones (NBSI) which send their axons to the spinal cord; they are located in the dorsal or the ventral respiratory nucleus; propriobulbar neurons (NPBI) whose axons are probably entirely located within the medulla; they are found only in the ventral nucleus. 20 Summation of gross discharges from phrenic (C5 ventral root) or inspiratory intercostal (from T4 to T10) nerves was triggered by spikes from medullary respiratory neurones. If the studied neurone controls the activity of the recorded motor fibres, after sommation of a great number of sweeps (3,000 to 5,000), the summed nerve activity displays a short delay excitatory wave, indicating that the activity of the motoneurones is increased after the onset of the medullary potential. On the other hand, there is a flat summed nerve activity if the nerve discharge is not directly dependent on the medullary recorded activity. 30 The dorsal nucleus NBSIs send their axon to the contralateral phrenic motoneurones (as it is revealed by the excitatory wave noted on the summed phrenic nerve activity, fig. 1 and 4) and not to the intercostal motoneurones (fig. 4). 40 The ventral nucleus NBSIs control contralateral intercostal motoneurones (fig. 5). Some of them send their axons only to these motoneurones, but the majority also act on phrenic motoneurones (fig. 2 and 5). 50 Connections between NBSIs and phrenic motoneurones are monosynaptic and probably also those between NBSIs and intercostal motoneurones. 60 No excitatory wave has been observed on phrenic or intercostal summed activity when summation was triggered by NPBI spikes (fig. 3). This confirms the accuracy of the "antidromic stimulation test" used to classify medullary respiratory neurons.

The slipping rib syndrome is characterized by upper abdominal pain due to irritation of the intercostal nerve by incomplete dislocation of the costal cartilage of the 8th, 9th, or 10th ribs. Twenty-three new cases are reported and the literature is reviewed. Diagnosis is only clinical. The pain is precipitated by movement and certain postures; it is faithfully reproduced by pressure on one particular point of the costal margin and is relieved by local injection of an anaesthetic. Pain from a slipping rib is usually attributed to visceral causes, which is a source of diagnostic errors.

The anesthesic fluid is injected close to the intercostal nerve at the starting point of its course in the corresponding space. Its gives an easy analgesia for thoracic or upper abdominal areas.