Clinical Anatomy 19:106–111 (2006)

ORIGINAL COMMUNICATION

The Gross Anatomy of the Extrathoracic Course

of the Intercostobrachial Nerve
MARIOS LOUKAS,1,2* JOEL HULLETT,3 ROBERT G. LOUIS JR,3
SHELLY HOLDMAN,3 AND DANNY HOLDMAN3
1
Department of Anatomical Sciences, St. George’s University, Grenada
2
Department of Education and Development, Harvard Medical School, Boston, Massachusetts
3
American University of the Caribbean, Sint Maarten, Netherlands Antilles

Recent reports emphasize the importance of preserving the intercostobrachial nerve

(ICBN) during surgical procedures (i.e., mastectomy, axillary clearance). However, a lim-
ited number of scientific reports explore the surgical anatomy of this nerve. We dissected
100 adult human formalin-fixed cadavers (200 axillae). In all the cadavers the ICBN was
present with variant contributions from intercostal nerves T1, T2, T3, and T4. The arrange-
ments of the ICBN were typed as I through VIII. The components of Type I (45% or 90
of our specimens) included a branch to the posterior antebrachial cutaneous nerve, a
branch to the anterior and lateral parts of the axilla, a branch to the medial side of the
arm, and a branch to the medial antebrachial cutaneous nerve. Type II (25%) describes the
ICBN arising from T2 and giving off a branch to the brachial plexus. In Type III (10%),
lateral cutaneous branches of T2 and T3 fuse as a common trunk and then split immedi-
ately after exiting the intercostal space to form an ICBN. In type IV (5%), T2 and T3 join
distally to form an ICBN that ends as its terminal branches. Type V (5%): T3 joins T2
from the same intercostal space proximally, with Type VI (3%) showing a very proximal
branching of the sensory terminal nerves. Type VII (5%) displayed a contribution from T3
and a branch to the brachial plexus with multiple terminating branches. A contribution
from T3 and T4 and a branch to the brachial plexus with multiple branches of termination
comprised Type VIII (2%). Clin. Anat. 19:106–111, 2006. VC 2006 Wiley-Liss, Inc.

Key words: intercostobrachial nerve; mastectomy; sensory innervation to the

axilla; sensory supply; upper extremity

INTRODUCTION Fischer, 2001). The ICBN also communicates with

Despite intensive research in the anatomical sci-
ences for the last 200 years, some structures of the
human body still remain controversial or incompletely
described. One of these structures is the intercosto-
brachial nerve (ICBN). Standard anatomy textbooks
(Clemente, 1985; McMinn, 1994; Williams et al.,
1999; Sinnatamby, 2001) describe the ICBN as aris-
ing from the lateral cutaneous branch of the second
intercostal nerve (T2). The ICBN then pierces the
intercostal muscles and the serratus anterior in the mid-
axillary line, and crosses the axilla where the poste-
rior axillary branch gives sensation to the poste-
rior axillary fold. Finally, the ICBN passes into the
upper arm along the posteromedial border, supply-
ing the skin of this region (Cave, 1932; Baker and
the posterior antebrachial cutaneous nerve and the
medial antebrachial cutaneous nerve (Cave, 1932;
Williams et al., 1999). An intercostobrachial branch
can sometimes arise from an anterior branch of the
third lateral cutaneous nerve to supply the axilla
and the medial side of the arm (Clemente, 1985).
Cunnick et al. (2001) and Murakami et al. (2002)
*Correspondence to: Dr. Marios Loukas, M.D., Ph.D., Depart-
ment of Anatomy, American University of the Caribbean, Jordan
Road, Cupecoy, Lowlands, Sint Maarten, Netherlands Antilles.
E-mail: edsg2000@yahoo.com
Received 19 April 2004; Revised 30 May 2005; Accepted 24 June
2005
Published online 8 February 2006 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20226

V
C 2006 Wiley-Liss, Inc.

Fig. 1. A diagrammatic description of all eight types of the
ICBN. Contributions to the ICBN invariably involve T2 and may
often include T3 and T4. Terminal branches may arise to communi-
cate with the brachial plexus, medial antebranchial cutaenous nerve
in their reports indicated that the ICBN can pene-
trate the pectoralis major and minor muscles, albeit,
without providing additional nerve supply to these
muscles.
Although the surgical anatomy of the axilla has
been well described, recent scientific reports concern-
ing axillary lymph node clearance for breast cancer
(Bratschi and Haller, 1990; Murakami et al., 2002), as
well as risk factors for pain and sensory loss following
mastectomy (Vecht et al., 1989; Paredes et al., 1990;
Carpenter et al., 1999; Sinnatamby, 2001) are reem-
phasizing the clinical importance of this nerve.
Through our experience from many axillary dissec-
tions, we have observed that great variation exists
regarding the origins of this nerve, its communication
with other nerves, and its final sensory distribution.
The aim of our study, therefore, was to explore and
describe the range of all the above-mentioned observa-
tions, and provide a comprehensive picture of the anat-
omy of the ICBN across a broad range of specimens.
Intercostobrachial Nerve 107
and always provide sensory innervation to the axillary region. [Color
figure can be viewed in the online issue, which is available at
www.interscience.wiley.com.]
MATERIALS AND METHODS
The anatomy of the ICBN was examined in 100
adult cadavers during gross anatomy courses at the
American University of the Caribbean and at the
Harvard Medical School. Of these, 60 were male
and 40 were female and ranged in age from 55 to
86 years; mean age of 69. All the cadavers were fixed
in formalin–phenol–alcohol solution and initially dis-
sected by first-year medical students, with strict
instruction, supervision, and more through dissections
provided by this research team. None of the cadav-
ers revealed any evidence of previous surgical proce-
dures or traumatic lesions to the axillary regions.
Following preliminary examination, images from
all dissected specimens were recorded with a Sony
digital camera (model: Sony Cyber-Shot DSC-f717)
and studied using a computer-assisted image analysis
system (all measurements were carried out with the
Lucia program [1998 edition for Windows], made by
Nikon [Laboratory Imaging Ltd., Precoptic Co.,
108 Loukas et al.
Fig. 2. An example of ICBN Type II, arising from T2 and giving off a branch to the medial
cord of the branchial plexus. [Color figure can be viewed in the online issue, which is available at
www.interscience.wiley.com.]
Medical and Optical Instruments, Poland]). The dig-
ital camera was connected to an image processor
(Nvidia Riva TNT model 64) with linkage to a
mainframe computer. Digitized images of the ICBN,
together with their surrounding structures, were
stored in the Lucia program (1152 3 864 pixels), and
converted to intensity gray levels from 0 (darkest) to
32 bit (lightest). After applying a standard 1-mm scale
to all pictures within the program, Lucia was able to
use this information to calculate pixel differences
between two selected points (e.g., origin–termination)
of the ICBN. The purpose of the software was to
allow easy and accurate translation of pixel differences
into metric measurements. Specifically, the distance
was measured from the point of exit of the ICBN
(from the second intercostal space) to its point of divi-
sion into the terminal branches.
RESULTS
There was a bilateral occurrence of the ICBN in
all 100 specimens, and as expected, the subsequent
topological patterns regarding this nerve’s branching
(and reception of the branches of other nerves) de-
monstrated wide ranges of variation. To facilitate
comparisons between specimens and to analyze the
various branching patterns, the results of the dis-
sections were classified into eight types, which are
illustrated in Figure 1 and designated by Roman
numerals ‘‘I’’ through ‘‘VIII.’’
The title, ‘‘Type I,’’ was applied to the following
observed distribution pattern, which comprised 45%
(90 axillae) of our specimens and originated from
T2: the main trunk of ICBN continued for greater
than 2 cm after its exit from the second intercostal
space, before giving rise to the terminal branches.
The ICBN provided a branch to the posterior cuta-
neous nerve (to the forearm), a branch to the ante-
rior and lateral parts of the axilla, a branch to the
medial side of the arm, and a branch to the medial
antebrachial cutaneous nerve. An intrathoracic con-
tribution from T3 was also present in 30 of the 90
axillae in this first group. Type II (25%, 50 axillae)
followed the same termination pattern as Type I,
however, it included the ICBN giving off a branch
proximally to the nearby medial cord of the brachial
plexus (Fig. 2). T2 and T3 arose as a common trunk
in Type III patterns (10%, 20 axillae) and split
immediately after exiting the second intercostal
space (>1 cm from the external surface of the exter-
nal intercostal muscle). T2 and T3 are both consid-
ered to be involved in this pattern because there are

Fig. 3. An example of ICBN Type VI, arising from T2 and dividing proximally to give a contri-
bution to the medial antebrachial cutaneous nerve. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
two distinct main branches that diverge shortly after
leaving the second intercostal space to subsequently
provide smaller terminal branches. A superior distri-
bution, giving rise to a medial antebrachial cutane-
ous branch and a branch to the medial side of the
arm, and an inferior distribution, giving origin to
branches to the medial side of the arm, the anterior
and lateral aspects of the axilla, and to the posterior
cutaneous nerve to the forearm, were both present
in this type. It was observed in Type IV (5%, 10
axillae) that T2 and T3 joined distally (after exiting
their respective intercostal spaces) to form an ICBN
that after 2 cm of travel ended as the classic terminal
branches of Type I. In Type V (5%, 10 axillae), T3
exited the same intercostal space as T2 (the second
intercostal space) and united with T2 less than 2 cm
after their exit from the second intercostal space and
then predictably gave origin to the classic terminal
distribution. Type VI (3%, 6 axillae) displayed a
proximal branching of the typical sensory terminal
branches, with division of the main trunk occurring
less than 2 cm after its exit from the second inter-
costal space (Fig. 3). Type VII (5%, 10 axillae) dis-
played an origin from T2 as well as T3. Proximal to
the joining of T3, a branch to the medial cord of the
Intercostobrachial Nerve 109
brachial plexus diverged, and subsequently the clas-
sic distribution arose. Type VIII (2%, 4 axillae) con-
sisted of contributions from T3 and T4 to the typical
T2 component; and similar to Type VII, the classic
distribution was present along with a contribution to
the medial cord of the brachial plexus exiting proxi-
mal to the T3/T4 anastomoses (Fig. 4).
With regard to symmetry of the ICBN patterns, it
was noted that Types I, II, and III appeared to be sym-
metrical in 40% (36), 50% (25), and 20% (4) of the cases,
respectively. No differences were noticed in the preva-
lence of ICBN type with respect to race, age, or gender.
DISCUSSION
In the course of axillary dissections during seg-
mental mastectomy procedures, the ICBN is likely
to be encountered (Baker and Fischer, 2001). The
medial portion of the ICBN is encountered during
exposure of the long thoracic and thoracodorsal
nerves. Identification of this nerve here is essential
to its preservation (Bratschi and Haller, 1990; Abdullah
et al., 1998).
An explanation of the typical (textbook) sensory
distribution of the nerves involved in the variations
110 Loukas et al.
Fig. 4. An example of ICBN Type VII, arising from T2 and receiving an extrathoracic contribu-
tion from T3 and giving a branch to the brachial plexus. [Color figure can be viewed in the online
issue, which is available at www.interscience.wiley.com.]
of the ICBN is necessitated here, before further dis-
cussion. The ICBN supplies the floor of the axilla.
The medial brachial cutaneous nerve, along with the
ICBN, supplies the medial and anterior surfaces of
the arm. The posterior antebrachial cutaneous nerve,
a branch of the radial nerve, supplies a posterior
strip of the skin over the forearm (McMinn, 1994).
As can be seen in our results, there is wide variation
in the potential types of ICBN arrangements; however,
there is little variation in the ultimate distribution of
its end branches. In a few types, a branch traveled
from T2 (and variably T3) to meet the brachial plexus,
but this was the only variant from the classic branches
that were present in all other types. These results
seem to indicate that if damaged quite proximally in
the axilla, sensory deficits could be relatively constant
among patients. However, this assumption is limited,
because the ICBN also often receives contributions
from intercostal nerves other than T2, and variably
from the brachial plexus, consequently complicating
the potential predictability of any specific sensory loss
in a patient with damage to this nerve.
Our observations are confined to morphology.
Given the variable branching patterns and types of
ICBN, it might be difficult to account for the type or
degree of sensory deficit (or lack thereof) experienced
by postmastectomy/postlymphectomy patients. Exten-
sive studies have been performed in an attempt to elu-
cidate this information (Assa, 1974; Vecht et al., 1989;
Abdullah et al., 1998; Salmon et al., 1998; Freeman
et al., 2003); however, these have largely not taken
into consideration a patient’s individual type of ICBN
variation. This is understandable considering the
extensive surgical dissection required to uncover dis-
tributing branches of a nerve. Varying types of sensory
loss have been reported among patients with trauma
to the ICBN (Assa, 1974; Vecht et al., 1989; Abdullah
et al., 1998; Salmon et al., 1998; Wong, 2001; Freeman
et al., 2003). These include sensory impairment in the
upper posteromedial aspect of the arm, sensory deficits
below the elbow, and deficits in the posterior axillary
fold and chest wall. Although these descriptions of
sensory deficits are largely general, a more comprehen-
sive understanding of the origin and distribution of the
ICBN, as shown in our present study, could eventually
allow physicians and researchers to more accurately
localize the source of sensory deficits.
Cunnick et al. (2001), in a surgical study of 50
patients, elucidated and described six variations of the
ICBN. Although they gave an excellent description
of the intercostal origins of each of their variants,
they provided no information regarding distribution

patterns and gave no mention of branches anastomos-
ing with the brachial plexus. O’Rourke et al. (1999)
performed an impressive analysis of the ICBN in 14
cadavers. They noted a contributing branch from the
first intercostal nerve (in one specimen), as well as the
third, whereas we observed no such contribution from
the first space, but observed a branch from the fourth
intercostal space in four axillae. Their study did eluci-
date communications with the brachial plexus in
10 axillae. This relationship was also observed in
64 axillae in our study. Whether these communica-
tions represent fibers from the brachial plexus entering
the ICBN or vice-versa is unknown at the present
time, though O’Rourke et al. (1999) indicated that all
branches were from the brachial plexus to the ICBN.
This description was based merely on the general
assumption that the angle of the connection between
the ICBN and the brachial plexus denoted fiber flow
from the brachial plexus. We propose two theories as
to the potential nature of the fiber direction in these
specimens. These theories hinge on the knowledge that
the T2 spinal nerve can contribute to the brachial
plexus. It seems possible that T2 could contribute
to the brachial plexus intrathoracically and then
branch downwards to the ICBN, extrathoracically.
Similarly, and equally plausible, there is the possibil-
ity of absence of intrathoracic contributions of T2 to
the brachial plexus, with the alternative that T2 may
ultimately contribute to the brachial plexus extra-
thoracically. Further research into the specifics of the
intrathoracic contribution (or lack thereof) of the T2
spinal nerve to the brachial plexus could potentially
elucidate whether this observed communication in
both our study and that of O’Rourke et al. (1999) is
a branching from the brachial plexus or to it.
With the current trend in axillary clearance proce-
dures (and associated mastectomy/lymphectomy pro-
cedures) to preserve rather than transect the ICBN
(Teicher et al., 1982; Temple and Ketcham, 1985;
Bratschi et al., 1990; Abdullah et al., 1998; Salmon
et al., 1998; Carpenter et al., 1999; Motomura et al.,
1999; Freeman et al., 2003), it is imperative that
physicians be careful not only in preserving the
proper ICBN root itself (from the second intercostal
space), but be aware of potential incoming anasto-
moses or exiting tracts (i.e., to the brachial plexus)
from the nerve, as well.
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