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Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 6 - No. 5 2018 

Anesthesia eJournal - Online
ISSN 2333-2611

Page 22

Discovery of a Pectoral Nerve Neuroma by Procedural Ultrasound Before Breast 
Reconstruction Surgery: Case Report
Jonathan P Kline, MSNA, CRNA
Affiliation:
Director of Education for Twin Oaks Anesthesia. Practices Independently in office-based plastic surgery and in care team models in southwest Florida. 
Adjunct faculty at the Simulation Based Academic Fellowship in Advanced Pain Management at the University of South Florida

Funding/Conflict of Interest Disclosure: 
None

KEYWORDS: breast reconstruction, chronic pain, neuroma, ultrasound

INTRODUCTION
Breast reconstructions with multiple variations are commonly performed in the United States. According to the American 
Society of Plastic Surgeons, breast reconstruction accounted for over 100,000 procedures in 2016 or nearly 2% of all 
reconstructive procedures.1 Steady growth of 39% in breast reconstruction has been reported since 2000 with a 3% increase 
since 2015. One complication from breast implant placement of nearly any kind is the development of chronic pain, defined 
as prolonged pain for more than 30 days after surgery. Ivica and colleagues reported the incidence of chronic pain after 
simple breast augmentation at 15%.2 Brummett reports that the prevalence of chronic pain after noncosmetic breast surgery 
is between 29% and 47%, with up to 13% of those patients experiencing severe pain.3 Ultrasound is being used in novel 
ways across the anesthesia community for needle-guided techniques, and increasingly, for bedside diagnosis and treatment. 
Multiple disciplines have produced articles inviting anesthesia providers to incorporate ultrasound for procedures such as the 
FAST (focused assessment with sonography in trauma) examination, bedside transthoracic echocardiography, diagnosis of 
pneumothorax, and other modalities.
This case report describes a patient in which preprocedural ultrasound was used to correctly identify a pectoral neuroma 
during the routine placement of regional blockade, with subsequent surgical exposure and debulking.

Abstract
Chronic pain from breast surgery seems to be commensurate with and increase the number of breast surgeries. Many 
improvements have been made in both surgery and anesthesia techniques. These novel techniques have shown promising 
results in decreasing postoperative pain and opioid use, along with the cascade of undesirable side effects, and even cancer 
recurrence. Ultrasound may have played an integral part in the development of these analgesic techniques and can further 
our understanding of relevant anatomy. In the present case, ultrasound was used during the preprocedural analgesia to 
correctly identify a chronic-pain-causing neuroma. The offending neuroma was subsequently reported to the surgeon be-
fore the procedure and was resected under direct vision during the surgical reconstruction. This finding altered the course 
of the surgery and yielded positive results postoperatively.

AEJ

Acknowledgment: Special thanks to Dr Wayne, MD, 
for his support with this article



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Volume 6 - No. 5 2018 Page 23

REVIEW OF LITERATURE
Ultrasound is gaining interest as an effective, noninvasive, 
cost-effective, and certainly convenient point-of-care imaging 
modality for a variety of purposes. The anesthesia community has 
embraced its value for needle procedures such as vascular access 
and regional nerve blocks; however, anesthesia providers are also 
beginning to appreciate its value for critical care diagnostics, as 
well as for incidental, but significant, findings. This is reflected in 
applications similar to the case we present. A PubMed (National 
Library of Medicine) search for subject similarity was conducted. 
Mostly case reports currently exist regarding the use of ultrasound 
for neuroma identification and injection for postamputation pain. 
Additionally, nearly all these articles were reported in journals 
outside the academic anesthesia community.
In 1999 Jones and colleagues investigated the feasibility of 
ultrasound for diagnosing Morton’s neuroma with good results.4 
In 2003 Ernberg and colleagues reported the use of ultrasound 
in the detection and treatment of a painful stump neuroma.5 In 
2011 Chen et al presented the use of linear transducer ultrasound 
for diagnosis and subsequent treatment for postamputation 
pain.6 A 40-year-old woman presented with postamputation 
pain and prosthetic intolerance for a below-elbow incident. They 
successfully identified the median, ulnar, and radial neuromas 
and injected each with a steroid solution with significant pain 
reduction. In 2012 Torres-Claramunt and colleagues reported on 
the accuracy of ultrasound and magnetic resonance imaging use 
for diagnosing a Morton’s neuroma.7 In 2012, Currier and team 
used ultrasound to detect and treat an ilioinguinal neuroma in a 
young female presenting with persistent pain in the ilioinguinal/
iliohypogastric nerve distribution.8 An ultrasound examination 
revealed a swelling of the Ilioinguinal nerve, likely from trauma 
secondary to a Pfannenstiel incision. They further used the 
same imaging to inject the neuroma with 2 mL bupivacaine 
and steroid on 2 separate occasions. They reported significant 
reduction in patient discomfort following both injections. In 
2016, Somashekar et al reported impressive findings related to the 
use of ultrasound for the diagnosis of brachial plexus neuromas in 
newborns with brachial plexus palsy.9 In their study, ultrasound 
imaging correctly identified 21 of 25 cases of upper trunk and 
middle trunk neuroma involvement with an 84% sensitivity for 
each. These articles seem to support the notion that ultrasound is 
being used in novel ways not only to identify and diagnose, but 
also to provide safe, reliable imaging to direct needle guidance for 
treatment.
CASE PRESENTATION
A 29-year-old woman presented to the office-based surgical suite, 
physical status (PS)) class 2, with significant surgical history, 
including multiple breast reconstructions and mastectomy. She 
was currently taking opioid pain medication and occasional 
muscle relaxant medication to manage lingering left-sided, dull, 
achy chest wall pain that developed shortly after her previous 
breast implant surgery and subsequent removal. The removal of 
the implant was at the patient’s behest owing to pain. However, 
the removal of the implants did not improve her pain.
The procedural plan included ultrasound-guided erector spinae 
blocks, and novel INTRAPEC injection, followed by general 
anesthesia with laryngeal mask airway (LMA). Following the 

initial discussion, explanation, and approval, the patient gave 
informed consent for the anesthetic and surgical procedures, 
including total revision of the breast reconstruction.She was 
escorted to the operating room table, positioned comfortably 
prone, sedated with 2 mg intravenous (IV ) midazolam, had 
monitors placed, and received bilateral ultrasound-guided erector 
spinae blocks using a Terason 3300 paired with a linear probe 
(12L5; Terason-Teratech, Burlington, MA).The patient was 
then assisted into the supine position, preoxygenated, and had 
an uneventful general anesthesia induction and insertion of #3 
LMA. A linear probe (12L5; Terason-Teratech) was covered and 
placed transverse over the anterior lateral chest in preparation 
for INTRAPEC injection. The right side was performed 
according to the original description by Kline, void of abnormal 
structures.10 Upon obtaining required imaging for the left side, 
a notable separation between the pectoralis major and minor 
was seen. This separation was imaged using several orientations 
and determined not to be an artificial remnant from a previous 
surgery. The thoracoacromial artery was then identified by general 
characteristics and confirmed with the application of the color 
Doppler mode. The abnormality, which was identified as a separate 
and distinct entity, was then captured and stored digitally. This 
anomalous structure was identified as a possible neuroma of the 
pectoral nerve (Figure 1).  The irregular finding was reviewed and 
discussed with the surgeon before incision. The surgeon planned 
to visualize the region following dissection and creation of the 
implant pocket.

Figure 1. Ultrasound image of the pectoral neuroma (shown by 
arrow). 
During the dissection of the left pectoral intramuscular space 
between the pectoralis major and minor for implant pocket 
creation, the surgeon obtained direct exposure and visualized 
the suspected neuroma (Figure 2). The tissue anomaly was then 
carefully dissected to reveal a portion of the lateral and most of 
the medial pectoral nerve. The nerves were carefully stripped of 
tissue irregularities by the surgeon under direct visualization. The 
specimen was placed on a card and photographed along with 
the scar excision from previous left and right infra-mammary 
incisions, as was typical for this surgeon’s technical protocol 



Anesthesia eJournal          www.anesthesiaejournal.com
Volume 6 - No. 5 2018 Page 24

(Figure 3). The diagnosis was then confirmed to be neuroma by 
gross examination by the surgeon. During the case the patient 
received dexamethasone 10 mg in the block solutions and 
ketorolac 30 mg IV. Following an uneventful surgical completion 
of bilateral breast reconstruction and placement of bilateral breast 
implants, the patient emerged from general anesthesia and was 
brought to the recovery room where she stated that the chronic 
pain in her left upper chest wall region had significantly subsided.
DISCUSSION
This was, to our knowledge, the first reported preprocedural scan 
diagnosis of a pectoral neuroma by ultrasound that resulted in 
an alteration of the surgical plan and subsequent outcome. It is 
plausible that the surgical resection of the neuroma is responsible 
for the dramatic reduction in chronic pain, however there may 
factors that have influenced this outcome. It is possible, however, 
that the significant improvement in pain from this chronic 
irritation can be explained outside the reduction of the neuroma 
from the medial and lateral pectoral complex. The surgery itself 
could have disrupted a potential contracture caused by several 
surgical traumas and alterations in the subpectoral architecture. 
Alterations in the posterior breast capsule may also have played a 
role in pain reduction. The regional blockade itself was expected 
to play a role in postoperative as well as intraoperative pain 

control, contributing to the relief reported by the patient. The 
muscle spasm relief described with the INTRAPEC injection, 
and the IV ketorolac, as part of the multimodal treatment 
plan, could also have contributed to pain reduction. Although 
not noted during the injection, the local anesthetic could have 
contacted the medial and lateral pectoral nerves, also blocking 
pain from those nerves themselves, although the washing out of 
the pocket before implant placement would likely have reduced 
the clinical effect and certainly the duration of pain relief.
CONCLUSION
Ultrasound is a reliable, cost-effective, and safe imaging modality, 
embraced by many clinical professionals who aim to reduce 
pain. Its relevance to this case is unparalleled in utility as it 
provided the guidance required to safely place regional blockade 
and incidentally located a potential source of chronic pain. The 
painful neuroma located by this ultrasound scan, performed 
for an unrelated purpose, suggested that special attention be 
paid by the surgeon during the surgical course. In this case the 
abnormality identified by preprocedural ultrasound provided 
valuable insight to the cause of pain and was subsequently 
removed. This provided the patient with significant postoperative 
relief of a chronic pain condition.

Figure 2. Intraoperative location and confirmation of 
ultrasound findings of pectoral nerve neuroma. The 2 muscles 
visible are the dark maroon-colored pectoralis major at the 
top left portion of the image and the pectoralis minor at the 
image’s center. Note the circled region of tissue representing 
the large neuroma.

Figure 3. Photo of excised neuroma. The 2 large strings 
of tissue are from the scar revision caused by previous 
surgeries. The debulked neuroma tissue appears on the 
lower right of the card.



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Volume 6 - No. 5 2018 Page 25

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