|Year : 2022 | Volume
| Issue : 2 | Page : 97-99
A technical report of postmastectomy axillary web syndrome symptom management using ultrasound-guided trigger point injections
Mohammad H Bawany1, Rachna Subramony2, Joel Castellanos3, Jessica Oswald4
1 Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
2 Department of Emergency Medicine, Division of Pain Management, University of California, San Diego, CA, USA
3 Department of Anesthesia, Division of Pain Management, University of California, San Diego, CA, USA
4 Department of Emergency Medicine; Department of Anesthesia, Division of Pain Management, University of California, San Diego, CA, USA
|Date of Submission||18-Dec-2021|
|Date of Decision||09-Feb-2022|
|Date of Acceptance||01-Mar-2022|
|Date of Web Publication||25-Aug-2022|
Dr. Jessica Oswald
Department of Anesthesiology, University of California, 200 W Harbor Dr, #8770, San Diego, CA 92103
Source of Support: None, Conflict of Interest: None
Axillary web syndrome (AWS) is a painful and difficult-to-manage complication of breast surgery with axillary lymph node dissection. Patients may believe that symptoms, including the presence of palpable axillary cords and reduced shoulder mobility, are a normal part of postoperative recovery. Both physician and patient education regarding this quality-of-life impairing condition is needed. In this report, we describe treating AWS using ultrasound-guided trigger point injections to avoid inadvertent damage to the neighboring lung, nerve, lymph nodes, and/or vasculature. There is limited information on their utility in treating AWS. At 4-month follow-up, our patient reported 70% improvement in her pain and discontinuation of her opioid medications, along with increased functionality. Ultrasound played a critical role in enhancing procedure accuracy and safety in zones that contain important nerve and vascular tissue and decreasing the risk of iatrogenic injury. While ultrasound was used historically for diagnostic purposes, we show why its use for interventions is on the rise.
Keywords: Axillary web syndrome, trigger point injection, ultrasound
|How to cite this article:|
Bawany MH, Subramony R, Castellanos J, Oswald J. A technical report of postmastectomy axillary web syndrome symptom management using ultrasound-guided trigger point injections. Indian J Pain 2022;36:97-9
|How to cite this URL:|
Bawany MH, Subramony R, Castellanos J, Oswald J. A technical report of postmastectomy axillary web syndrome symptom management using ultrasound-guided trigger point injections. Indian J Pain [serial online] 2022 [cited 2022 Sep 29];36:97-9. Available from: https://www.indianjpain.org/text.asp?2022/36/2/97/354717
| Introduction|| |
Axillary lymph node dissection is important for staging breast cancer. This procedure, however, can increase the occurrence of a difficult-to-manage postoperative complication known as axillary web syndrome (AWS). AWS is an underrecognized complication of mastectomy, thus explaining why studies show an incidence ranging from 6% to 86%. Identifying its characteristic tense, nonerythematous axillary cords poses a challenge to clinicians. Manipulation of the axilla in mastectomy involving axillary lymph node dissection causes localized inflammation and proliferation, leading to fibrosis of tissue, vessels, lymphatics, and ensuing cord formation. Cords are usually described in numbers of 2 or 3, starting at the armpit, and running along the medial aspect of the arm to the antecubital fossa, or toward the chest along the lateral border of the pectoralis major. Patients may believe that symptoms, including the presence of palpable axillary cords and reduced and painful arm and shoulder mobility, are a normal part of postoperative recovery. Both physician and patient education regarding this quality-of-life impairing complication of breast surgery is needed.
Physical therapy focusing on scar tissue breakdown is a mainstay in treatment once AWS is identified. It may not, however, resolve the condition in all patients, leading to chronic immobility and altered movement patterns. More recent investigations into alternative therapies, such as cord release through percutaneous needling with collagenase injection, have yielded encouraging initial results.
In this case report, we describe treating AWS using ultrasound-guided trigger point injections (TPIs) to avoid inadvertent damage to the neighboring lung, nerve, lymph nodes, and/or vasculature. TPIs have been used successfully for myofascial pain, but there is limited information on their utility in treating AWS. We present a case report where TPIs directly into an axillary cord resulted in improved arm range of motion, pain, and quality of life.
| Methods|| |
Written Health Insurance Portability and Accountability Act (HIPAA) authorization was obtained for this case report.
A 65-year-old female presents with pain and tightness in her right chest and axilla. Her symptoms began after she had undergone skin-sparing mastectomy with sentinel node dissection for ductal carcinoma of her breast, complicated by postoperative hematoma and cellulitis of her right chest, 1.5 years prior. She has two visible and palpable cords, both 2 centimeters in diameter, in her axillary region; the first starts in her axilla and extends toward her antecubital fossa, and the second starts in her axilla and extends to her pectoralis minor. Her range of motion in the right arm is limited by pain to 30° of abduction and forward flexion. In addition to her palpable axillary cords and limited right arm range of motion, her physical examination is also notable for allodynia of her right anterior chest wall.
Her pain has negatively impacted her ability to use her right arm, and adherence to monthly physical therapy visits, lidocaine patches, and gabapentin 600 mg three times daily, and 10-mg oxycodone daily, have only minimally improved her symptoms.
We diagnosed her with AWS, explaining her axillary cords and painful restricted arm range of motion. Her chest wall allodynia was likely secondary to a postoperative compressive neuropathy of the pectoralis nerves. To manage her chest wall allodynia, we performed a large volume right Pec I and Pec II block, described in a previous case report. To manage her AWS, we performed TPIs into her palpable axillary cords. For the purposes of this report, we focus on TPI of the patient's axillary web.
The patient was positioned supine with her arm in abduction and forward flexion to expose the axilla. Under sterile technique, a high-frequency linear ultrasound probe was placed vertically over the anterior chest wall's axillary cord to identify pleura and in the axilla to locate the axillary artery, lymph nodes, and median, ulnar, and radial nerves. The indicator faced cephalad. The cord was palpated using the index finger and thumb from the anterior chest wall into the axilla and medially down the arm toward the antecubital fossa. TPIs were first delivered to the chest wall into the palpable cord located in the pectoralis minor with ultrasound guidance using an in-plane approach. [Figure 1] shows the pectoralis minor is 1.5 cm from the skin, whereas the underlying pleura is identified at 3.5 cm. Five injections using a 25G 1.5-inch needle with 1 cc of 0.25% bupivacaine were delivered proximally to distally into the pectoralis minor at a depth of 1.5 cm starting medially over the anterior chest wall and working laterally toward the axilla. Next, the axilla was scanned to identify critical structures. The procedure was then repeated into the palpable cord located at 1cm depth that extended medially down the arm toward the antecubital fossa. [Figure 2] is a linear image obtained while scanning the vicinity of the axilla, the radial, median, and ulnar nerves, and the axillary vein and artery visualized at 1 cm. The musculocutaneous nerve is also seen within the coracobrachialis muscle. A total of ten injections were performed, and after each injection, the cord was needled until palpable improvement of tension was felt between the fingertips.
|Figure 1: Landmarks for safe chest wall cord trigger point injection Ultrasound was performed in-plane with the indicator pointing cephalad to determine the depth of the pleura line, which was found to be at 3.5 cm. The pleura was identified by first identifying two contiguous ribs which are hyperechoic with posterior shadowing on ultrasound. The pleura is also hyperechoic with movement during respiration. The cord was palpated 1.5 cm deep to the skin|
Click here to view
|Figure 2: Landmarks for safe axillary trigger point injection. The axillary crease is used as a landmark. The patient is supine with arm in abduction and forward flexion to expose the axilla. A linear high-frequency transducer is used with the indicator pointing cephalad. Important structures, including the brachial plexus and vessels, are shown|
Click here to view
| Results|| |
The patient reported 100% pain relief after the procedure. She was able to immediately participate in activities that she had not enjoyed in years, including playing tennis, as she could now swing a racket pain-free. Within 1 week of the procedure, she had stopped taking her home opioids and gabapentin and felt she no longer needed to attend physical therapy sessions. At her 4-month follow-up, she continued to have a 70% improvement in her pain, movement, and function. While she occasionally used lidocaine patches, she had discontinued her opioid medications and was able to extend her shoulder to 75° and abduct her arm to 120°, much improved from the 30° of abduction she presented to us with.
| Discussion and Conclusion|| |
Studies have concluded that ultrasound cannot successfully characterize AWS, as the underlying pathology may be microlymphatic stasis or fibrin binding or fascial abnormalities, all of which are difficult to identify on ultrasound. Regardless, ultrasound plays a critical role in enhancing the accuracy and safety of procedures performed in the axilla.
Using sonography, nerves appear hyperechoic; they have a characteristic “honeycomb” appearance and are often seen paired with vessels, which are identified as larger anechoic structures that demonstrate flow with the use of Doppler. Among vessels, veins can be differentiated from arteries in that they are compressible, while arteries are pulsatile [Figure 2]. Of critical importance when inserting needles into the axillary region is the identification of the lung pleura. The pleura is identified indirectly by two contiguous ribs which are hyperechoic with posterior shadowing [Figure 1]. The pleura is then seen as a hyperechoic line deep to the ribs that move with respiration.
While ultrasound was used historically for diagnostic purposes, its use for interventions, including injections for chronic pain, has recently increased in popularity. This is due to the advantages ultrasound offers over both blind approaches and other imaging modalities, such as the absence of harmful radiation exposure, the ability to visualize soft tissue and blood vessels, and the ability to visualize both the needle and injectate in real-time. Further, ultrasound eliminates the risk of an allergic reaction, as contrast agents are not used during imaging. Various chest wall blocks have been shown to be both feasible and safer with the use of ultrasound, affording practitioners an expanding repertoire with which to minimize complications while effectively treating acute and chronic pain conditions.
To our best knowledge, this is the first report of ultrasound-guided TPIs to cords seen in AWS. While the traditional approach to treatment can involve manually stretching and snapping the cords with the help of a physical therapist, this may be too painful or ineffective for some patients. The therapeutic mechanism behind TPIs is still mechanical adhesiolysis of the fibrous tissue causing the muscle “tethering,” albeit with a needle. Including anesthetic use and ultrasound guidance, however, makes our treatment precise, well-tolerated, and safe. While adding a local anesthetic does not change the long-term outcome, the addition of an anesthetic decrease the duration of posttreatment soreness, likely by blocking the discomfort following muscle manipulation from a needle. With ultrasound guidance, we exclude the possibility of injection into neighboring nerves or blood vessels. AWS is still an underrecognized yet debilitating complication of radical mastectomies, and current treatment remains limited. Here, we highlight the use of ubiquitously available ultrasound to perform a minimally invasive, safe, cost-effective, and efficacious therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Piper M, Guajardo I, Denkler K, Sbitany H. Axillary web syndrome: Current understanding and new directions for treatment. Ann Plast Surg 2016;76 Suppl 3:S227-31.
Figueira PV, Haddad CA, de Almeida Rizzi SK, Facina G, Nazario AC. Diagnosis of axillary web syndrome in patients after breast cancer surgery: Epidemiology, risk factors, and clinical aspects: A prospective study. Am J Clin Oncol 2018;41:992-6.
Johansson K, Ingvar C, Albertsson M, Ekdahl C. Arm lymphoedema, shoulder mobility and muscle strength after breast cancer treatment? A prospective 2-year study. Adv Physiother 2001;3:55-66.
O'Toole J, Miller CL, Specht MC, Skolny MN, Jammallo LS, Horick N, et al.
Cording following treatment for breast cancer. Breast Cancer Res Treat 2013;140:105-11.
Shin HJ, Shin JC, Kim WS, Chang WH, Lee SC. Application of ultrasound-guided trigger point injection for myofascial trigger points in the subscapularis and pectoralis muscles to post-mastectomy patients: A pilot study. Yonsei Med J 2014;55:792-9.
Bawany MH, Oswald J. Pecs blocks for chronic pain: A case report of successful postmastectomy pain syndrome management. A A Pract 2020;14:e01299.
Koehler LA, Hunter DW, Haddad TC, Blaes AH, Hirsch AT, Ludewig PM. Characterizing axillary web syndrome: Ultrasonographic efficacy. Lymphology 2014;47:156-63.
Parthasarathy S, John Charles SA. Analgesic efficacy of ultrasound identified trigger point injection in myofascial pain syndrome: A pilot study in Indian patients. Indian journal of pain. 2016:30:162-5.
Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery. Egypt J Anaesth 2014;30:129-35.
Koehler LA, Haddad TC, Hunter DW, Tuttle TM. Axillary web syndrome following breast cancer surgery: Symptoms, complications, and management strategies. Breast Cancer (Dove Med Press) 2019;11:13-9.
Roldan CJ, Hu N. Myofascial pain syndromes in the emergency department: What are we missing? J Emerg Med 2015;49:1004-10.
Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994;73:256-63.
[Figure 1], [Figure 2]