Post-Mastectomy Pain Syndrome: An Up-to-Date Review of Treatment Outcomes

The Role of Rehabilitation for Women with Cancer

As the prevalence of female cancer survivors increases, their quality of life (QOL) and function have become key areas of focus in the context of survivorship and rehabilitation needs. Although behavioral modifications may help to decrease the development of malignancy, women are still at increased risk of developing a cancer diagnosis in their lifetime. Cancer and its treatment can lead to significant functional impairments and symptomatic challenges. However, rehabilitation interventions and medical management provide options to address these issues throughout the oncological continuum of care. With appropriate treatment, women are enabled to experience improved QOL and performance status.

Post-mastectomy wound care - need for an empathetic approach

Mastectomy, a surgical procedure involving the removal of breast tissue, is a common treatment option for breast cancer. Post treatment, survivors often experience both physical and psychological symptoms, which in turn delay the recovery phase. Post-mastectomy wound complications, such as infection, pain, delayed healing, seroma formation, persistent discomfort and limited mobility often lead to prolonged hospital stays and reduced quality of life. Proper wound care, including dressing changes and wound management, is crucial for optimal healing. However, mastectomy also has a significant emotional and psychological impact on patients, leading to depression, anxiety, and poor body image due to significant changes in the body such as loss of hair, unsightly scars and weight changes. Patients also feel uncomfortable when medical professionals concentrate solely on survival, rather than empathizing with them. While these emotional reactions are often expected and considered normal during breast cancer treatment, what comes as a surprise is the additional harm caused by healthcare providers' communication and behaviour when treating breast cancer patients. Despite advances in medical technology, there remains a significant gap in providing psychosocial support for breast cancer survivors. Undergoing a mastectomy is an emotionally challenging experience, and healthcare providers play a vital role in establishing the groundwork for psychological recuperation. By incorporating empathetic practices into daily patient care, healthcare providers can be trained to create an unbiased, informative, and compassionate environment, to improve patient outcomes and satisfaction. The use of compassionate communication when interacting with the patient and their care givers can foster a more nurturing atmosphere for all parties involved. By prioritizing empathy in post-mastectomy wound care, healthcare providers can enhance the overall well-being of breast cancer survivors. This review explores the physical and emotional impact of mastectomy on patients, the healing process, and the importance of integrating empathy into post-mastectomy wound care.

Improving Fat Graft Survival Using Soluble Molecule Preconditioning

Fat grafting is widely used in plastic surgery to correct soft tissue deformities. A major limitation of this technique is the poor long-term volume retention of the injected fat due to tissue remodeling and adipocyte death. To address this issue, various optimizations of the grafting process have been proposed. This scoping review focuses on preclinical and clinical studies that investigated the impact of various classes of soluble molecules on fat grafting outcomes. Globally, we describe that these molecules can be classified as acting through three main mechanisms to improve graft retention: supporting adipogenesis, improving vascularization, and reducing oxidative stress. A variety of 18 molecules are discussed, including insulin, VEGF, deferoxamine, botulinum toxin A, apocynin, N-acetylcysteine, and melatonin. Many biomolecules have shown the potential to improve long-term outcomes of fat grafts through enhanced cell survival and higher volume retention. However, the variability between experimental protocols, as well as the scarcity of clinical studies, remain obstacles to clinical translation. In order to determine the best preconditioning method for fat grafts, future studies should focus on dosage optimization, more sustained delivery of the molecules, and the design of homogenous experimental protocols and specific clinical trials.

Effect of Intercostal Nerve Coaptation on Postoperative Pain in Implant-Based Breast Reconstruction: A Double-Blind, Randomized Controlled Pilot Study

PURPOSE

Patients undergoing breast surgery may experience chronic postoperative pain in the breasts, upper extremities, and axillary regions, and no established methods for preventing this pain are available at present. This study aimed to investigate whether coaptation of the transected intercostal nerve can prevent the development of neuropathic and chronic breast pain after mastectomy in implant-based breast reconstruction.

METHODS

A prospective, double-blind, randomized controlled trial was conducted by dividing patients who underwent implant-based breast reconstruction after mastectomy into a control group without nerve coaptation and an experimental group with nerve coaptation. Patient clinical information was collected, and a survey using the pain and quality of life scale was conducted at 6 and 12 months after surgery.

RESULTS

Fifteen patients completed the study, including seven in the control group and eight in the experimental group. The two groups showed no significant differences in terms of clinical factors. The experimental group exhibited lower Short-Form McGill Pain Questionnaire scores than the control group at 6 and 12 months postoperatively, with a statistically significant difference at 6 months. Numerical Rating Scale and Present Pain Intensity scores for both groups were in the "no to mild" range throughout the study period, with no statistically significant differences between the groups. Although the difference in the BREAST-Q™ results did not reach statistical significance, the experimental group showed an improvement in the quality of life.

CONCLUSION

Intercostal nerve coaptation after mastectomy in implant-based breast reconstruction may facilitate initial nerve recovery. Although trial results are needed to fully determine the clinical impact, our findings support the ongoing scientific and clinical efforts to use this technique.

Paravertebral Blocks in Implant-Based Breast Reconstruction Do Not Induce Increased Postoperative Blood or Drainage Fluid Loss

Background: Women undergoing a mastectomy often suffer severely from the sequelae of losing one or both breasts. Implant-based breast reconstruction restores female body integrity but can result in significant postoperative pain. The use of paravertebral catheters has been shown to aid significantly in pain management during the postoperative recovery. However, the vasodilation that is induced by paravertebral blocks may lead to prolonged drainage fluid secretion, blood loss and increased likelihood of revision surgery. Therefore, we analyzed the effects of paravertebral blocks after combined mastectomy and immediate breast reconstruction. Methods: We analyzed 115 breast surgeries at the department of Plastic Surgery at the University clinic of St. Poelten between 1 August 2018 and 31 December 2022. Patients were analyzed regarding postoperative hemoglobin loss and drainage fluid volumes and their correlation with paravertebral blocks. Statistical analyses were performed using Levene's Test for Equality of Variances within our cohort. Results: The postoperative hemoglobin loss did not differ significantly between our groups (p = 0.295). Furthermore, a paravertebral block did not increase the amount of postoperative drainage fluid volumes (p = 0.508). Women receiving paravertebral blocks also did not stay longer in hospitals (p = 0.276). No paravertebral block-associated complication was seen. Conclusions: In this study, we demonstrated paravertebral blocks to be safe adjuncts in breast reconstruction to minimize pain without leading to increased blood loss or seroma formation. This indicated that vasodilatation induced by paravertebral blocks did not negatively influence the postoperative recovery. In conclusion, postoperative pain management using paravertebral blocks can be a beneficial therapeutic adjunct in surgical management of breast cancer patients.

Nonpharmacological Interventions for Postmastectomy Pain Syndrome-A Systematic Review of the Literature

OBJECTIVE

Literature regarding nonpharmacological interventions (NPI) for PMPS or CP after mastectomy is scarce and not fully appraised, therefore we conducted this systematic review to explore the current panorama of treatment options.

METHODS

A systematic review to assess the existing evidence regarding nonpharmacological approaches for PMPS. We reviewed the following databases: PubMed-MEDLINE, Embase, and Ovid (including the Cochrane Database for Clinical studies) using the following search terms: CP, mastectomy, and PMPS, and adjusted the terms depending on the database used. We included observational studies including case reports, cross sectional studies, cohort studies, and clinical trials (randomized or not) that included a NPI to treat PMPS.

RESULTS

Total 1061 records were identified. After duplicate elimination, 863 records were screened for eligibility. A total of 717 records were excluded using our criteria, 138 records were sought for retrieval, and 117 full text records were assessed. Finally, 30 studies were included: seven case series, one cross-sectional study, two cohort studies, one case-control study, five nonrandomized clinical trials, ten randomized clinical trials (RCT), one qualitative study, and three systematic reviews of the literature, including two meta analyses, were included.

DISCUSSION

Findings suggest that there is a great response of patients to some NPI. Regarding surgical interventions, autologous fat grafting and lymph node transplantation showed to have the greatest benefit for patients in terms of quality of life and reduced pain scores. Pulsed radiofrequency demonstrated the highest quality of evidence for energy related procedures. Within the physical therapy interventions, transcutaneous electric nerve stimulation and dry needling showed the greatest benefit. Finally, virtual reality demonstrated the greatest benefit in educational interventions.

Cryoneurolysis for management of post-mastectomy pain: a systematic review

AIMS

Post-mastectomy pain syndrome is a common postoperative complication that can impact patient quality of life and function. The aim of this systematic review is to evaluate the effectiveness of cryoneurolysis as an intervention for the management of post-mastectomy pain.

METHODS

A prospero-registered systematic review was performed following PRISMA 2020 guidelines. An initial screening consisted of 53 articles imported from the following databases: PubMed, Embase, Web of Science, Cochrane, and Scopus. Google Scholar and WorldCat were also searched to pull any further articles.

RESULTS

Three clinical trials, one case series, and one case report were included. Primary outcome measure of patient reported pain score (VAS or NRS) showed clinically significant reduction in pain in all five studies. Three of the studies also reported reduction in opioid use with cryoneurolysis intervention. A pooled effect size of Hedges g = -0.963, (95% CI [-1.55, -0.373]), with heterogeneity (I2 = 0.70).

CONCLUSION

Cryoneurolysis intervention shows promising and clinically significant relief in post-mastectomy pain in patients and further studies are encouraged.

Evaluation and Management of Shoulder Dysfunction in Cancer Survivors

Purpose of Review

Shoulder dysfunction widely affects function and quality of life of cancer survivors. This paper discusses the etiology, identification, evaluation, and management of the common shoulder impairments seen in cancer survivors, particularly those with breast cancer, head and neck cancer, and Hodgkin lymphoma.

Recent Findings

Shoulder dysfunction can be caused by a wide range of sources, often as a sequelae of cancer treatments including surgery, systemic therapy, and radiation therapy. These can change the shoulder biomechanics leading to musculoskeletal disorders such as rotator cuff disease and adhesive capsulitis. Other etiologies include neuromuscular complications, such as post-breast surgery pain syndrome and radiation fibrosis syndrome, and lymphovascular disorders such as lymphedema and axillary web syndrome. Metastatic bone disease and primary bone cancer should be considered for those with intense shoulder pain. Detailed history and physical exam, and in some cases, imaging can assist with evaluation of shoulder issues. Exercise, physical and occupation therapy are essential in managing shoulder dysfunction.

Summary

Shoulder dysfunction can limit function and quality of life for cancer survivors. It is important to consider the possible etiologies as accurate diagnosis is critical for optimal treatment.

The Efficacy of Fat Grafting on Treating Post-Mastectomy Pain with and without Breast Reconstruction: A Systematic Review and Meta-Analysis

Post-mastectomy pain syndrome (PMPS), characterized by persistent pain lasting at least three months following mastectomy, affects 20-50% of breast surgery patients, lacking effective treatment options. A review was conducted utilizing EMBASE, MEDLINE, and all evidence-based medicine reviews to evaluate the effect of fat grafting as a treatment option for PMPS from database inception to 29 April 2023 (PROSPERO ID: CRD42023422627). Nine studies and 812 patients in total were included in the review. The overall mean change in visual analog scale (VAS) was -3.6 in 285 patients following fat grafting and 0.5 in 147 control group patients. There was a significant reduction in VAS from baseline in the fat grafting group compared to the control group, n = 395, mean difference = -2.17 (95% CI, -2.95 to -1.39). This significant improvement was also noted in patients who underwent mastectomy without reconstruction. Common complications related to fat grafting include capsular contracture, seroma, hematoma, and infection. Surgeons should consider fat grafting as a treatment option for PMPS. However, future research is needed to substantiate this evidence and to identify timing, volume of fat grafting, and which patient cohort will benefit the most.

Post-mastectomy Pain Syndrome: A Review Article and Emerging Treatment Modalities

Post-mastectomy pain syndrome (PMPS) is a syndrome broadly applied to the development of chronic pain after surgical breast intervention (i.e., lumpectomy and mastectomy). The incidence of PMPS is likely underreported, and this has contributed to a paucity of high-level evidence related to the treatment of the aforementioned condition. A drive to reduce the burden of opioid use has led to pain management physicians trialing a variety of strategies to help patients manage PMPS. This review discusses the latest evidence behind treatment options for PMPS, exploring medications as well as interventional techniques (e.g., nerve blocks, radiofrequency ablation, neuromodulation, and intrathecal drug delivery systems). Recent advances in neuromodulation technology are of particular interest here due to the well-localized nature of PMPS-related pain and the specificity with which modern neuromodulation techniques can generate an effect. Finally, the review proposes a framework with which to approach the care of patients with PMPS, with a specific emphasis on the early consideration of neuromodulation techniques along with functional and physical therapy to reduce patient medication burden and improve overall quality of life.

Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer: study protocol for a randomised controlled trial

BACKGROUND

A single injection of local anaesthetic (LA) in the erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy (MRM) surgery, but the duration of analgesia is affected by the duration of the LA. The aim of this study is to investigate the effect of continuous ESPB on acute and chronic pain and inflammatory response after MRM surgery.

METHODS

In this prospective, randomised, controlled trial, we will recruit 160 patients, aged 18-80 years, scheduled for elective MRM surgery under general anaesthesia. They will be randomly assigned to two groups: a continuous ESPB group (group E) and a sham block group (group C). Both groups of patients will have a nerve block (group C pretended to puncture) and an indwelling catheter fixed prior to surgery. Electronic pumps containing LA are shielded. The primary outcome is the total consumption of analgesic agents. The secondary outcomes include the levels of inflammation-related cytokines; the occurrence of chronic pain (post-mastectomy pain syndrome, PMPS); static and dynamic pain scores at 2, 6, 12, 24 and 48 h postoperatively; and post-operative and post-puncture adverse reactions.

DISCUSSION

Analgesia after MRM surgery is important and chronic pain can develop when acute pain is prolonged, but the analgesic effect of a nerve block with a single injection of LA is limited by the duration of drug action. The aim of this trial is to investigate whether continuous ESPB can reduce acute pain after MRM surgery and reduce the incidence of chronic pain (PMPS), with fewer postoperative analgesic drug-related complications and less inflammatory response. Continuous ESPB and up to 12 months of follow-up are two innovations of this trial.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( https://www.chictr.org.cn/ ) ChiCTR2200061935. Registered on 11 July 2022. This trial is a prospective registry with the following registry names: Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer.

[Influence of cardiorespiratory training program on the intercellular adhesion molecule level in patients with postmastectomy syndrome]

Postmastectomy syndrome (PMS) is a complex neurovascular set of symptoms that develops in most patients after breast cancer (BC) treatment and significantly reduces the quality of life. One of the potential mechanisms of its occurrence is considered to be an endothelial dysfunction. The possible method of reducing manifestation of endothelial dysfunction is systematic aerobic dynamic training.

OBJECTIVE

To evaluate the influence of 12-week aerobic dynamic training program of moderate intensity on the endothelial dysfunction laboratory markers and life quality in patients with PMS.

MATERIAL AND METHODS

Single-center prospective randomized trial included 40 patients with PMS divided into study (20 patients) and comparative (20 patients) groups, as well as 20 healthy female volunteers. The expression level of soluble intercellular adhesion molecule-1 (ICAM-1) and platelet endothelial cell adhesion molecule-1 (PECAM-1) were evaluated in all participants at baseline by enzyme-linked immunosorbent assay method, and additionally psychological and physical component of health by SF-36 questionnaire were assessed in patients with PMS.

Patients of study group received a course of 12-week partially controlled aerobic dynamic training of moderate intensity lasting 45 minutes with frequency equal 5 times per week. Patients with PMS were re-evaluated for ICAM-1 and PECAM-1, as well as for life quality.

RESULTS

The group of patients with PMS after BC treatment had increased level of ICAM-1 in long-term period, that may indicate endothelial dysfunction. Statistically significant decrease of endothelial dysfunction laboratory markers was revealed in patients with PMS, who underwent the course of cardiorespiratory training. In the same time, the dynamics of changes in ICAM-1 was higher in the study group than in comparative group. Further, improvement of physical and psychological components of health by SF-36 questionnaire was found.

CONCLUSIONS

The program of cardiorespiratory trainings of moderate intensity in patients, who had BC treatment a year ago, decreases intercellular adhesion molecules level that may show an improvement of endothelial dysfunction.

Combined treatment with basalt stone and placenta extract to improve the chronic pain and scar after breast cancer surgery: a case report

BACKGROUND

The changes in body image caused by breast deformities and postoperative pain have a detrimental influence on the physical and mental health of patients with breast cancer. The postoperative quality of life (QOL) of these patients reduces significantly owing to the changes in the breast, an organ unique to women, that occur following breast cancer surgery.

CASE PRESENTATION

This case report presents the case of a Asian woman in her early 40 s with postoperative hypertrophic scarring and contraction of the scar following mastectomy; the patient presented with decreased range of motion of the upper arm, hyperpigmentation from radiation burns, changes in breast shape, and chronic pain. The patient received a combination therapy comprising Basalt Stone Treatment and the application of horse placenta extract. As a result of a total of eight sessions conducted once every two weeks, the patient's pain and scar improved. No adverse events were observed after the therapy.

CONCLUSION

Combination therapy with Basalt Stone Treatment and horse placenta extract improved the chronic pain and scar after breast cancer surgery.

Postmastectomy Functional Impairments

PURPOSE OF REVIEW

This narrative review aims to offer a thorough summary of functional impairments commonly encountered by breast cancer survivors following mastectomy. Its objective is to discuss the factors influencing these impairments and explore diverse strategies for managing them.

RECENT FINDINGS

Postmastectomy functional impairments can be grouped into three categories: neuromuscular, musculoskeletal, and lymphovascular. Neuromuscular issues include postmastectomy pain syndrome (PMPS) and phantom breast syndrome (PBS). Musculoskeletal problems encompass myofascial pain syndrome and adhesive capsulitis. Lymphovascular dysfunctions include lymphedema and axillary web syndrome (AWS). Factors such as age, surgical techniques, and adjuvant therapies influence the development of these functional impairments. Managing functional impairments requires a comprehensive approach involving physical therapy, pharmacologic therapy, exercise, and surgical treatment when indicated. It is important to identify the risk factors associated with these conditions to tailor interventions accordingly. The impact of breast reconstruction on these impairments remains uncertain, with mixed results reported in the literature.

Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications

Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n=82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate.

Postmastectomy Pain Syndrome: A Narrative Review

Postmastectomy pain syndrome is a very common disorder in breast cancer survivors. The impact on the quality of patients' lives is significantly adverse. The precise pathophysiology has not been determined as yet though various risk factors have been identified that make the patient vulnerable. Required preoperative work includes the identification and possible elimination of risk factors. Treatment is multidisciplinary involving surgical and non-surgical modalities. There is a great scope of research in this field.

Further Studies are Still Needed to Test Whether Fat Grafting Reduce Postmastectomy Pain

BACKGROUND

To test the effects of autologous fat grafting for reducing postmastectomy pain is important since post-operative pain bothers many patients with postmastectomy pain syndrome (PMPS), and one session autologous fat grafting for this condition is also investigated in some studies. Most of them show the positive effect on pain control, but the most recent randomized controlled trial (RCT) does not. The relatively small sample size with incomplete follow-up in the RCT might limit the certainty of evidence, and cases for the final analysis is lesser than expected numbers by sample size determination. Besides, there is no futility analysis to show the non-significant finding could be conclusive evidence. To check the conclusiveness of comparative evidence on this topic becomes a critical task for guiding clinicians and further studies in the future, therefore the purpose of this letter is to test whether evidence on fat grafting for alleviating pain amongst patients with PMPS is conclusive using sequential analysis.

METHODS

This supplementary analysis used the data from the comparative evidence on fat grafting for PMPS based on the most recent RCT and previous systematic reviews. Complete data of pain score of two comparative studies from Italy were presented in a pooled report, therefore, this letter used data of pooled report for the Italy studies. Pooled mean difference (MD) in pain score between fat grafting and control groups was based on random-effects model. Quantitative synthesis consisted of cumulative meta-analysis and leave-one out sensitivity analysis due to heterogeneity from clinical setting across the included studies. Then, sequential analysis was further done with a conservative effect size (standardized mean difference = 0.2), type I error (α = 0.05), and power of 0.80 based on O'Brien Flemming method. All analyses were carried out using R version 4.1 via RStudio for Microsoft Windows.

RESULTS

Sequential analysis exhibited a non-significant and inconclusive evidence on fat grafting for pain control in PMPS if this synthesis included the newest RCT. Although the pooled result with unmet expectation of z-score in sequential analysis, it might not fall in futility. If the newest RCT was removed from the synthesis, sequential analysis showed significant but inconclusive evidence on fat grafting for pain control in PMPS.

CONCLUSION

There is no conclusive evidence to support or refuse the use of fat grafting in postmastectomy pain control. This topic is worthy of further studies in investigating the effects of fat grafting on pain control amongst patients with PMPS.

LEVEL OF EVIDENCE V

This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Successful neurolytic thoracic sympathetic ganglion block using C-arm fluoroscopic cone-beam computed tomography in patients with postmastectomy pain syndrome: a report of 3 cases

BACKGROUND

Postmastectomy pain syndrome involves persistent neuropathic and sympathetically maintained neuropathic pain that can be improved using a thoracic sympathetic ganglion block. However, conventional fluoroscopic procedures pose technical difficulties and are associated with potential severe complications. We report the use of C-arm fluoroscopic cone-beam computed tomography to enhance procedural success and treatment safety.

CASE PRESENTATION

Three women diagnosed with postmastectomy pain syndrome and experiencing persistent pain underwent C-arm fluoroscopic cone-beam computed tomography-assisted ethanol neurolytic thoracic sympathetic ganglion block. Pain severity decreased substantially after the procedure. The therapeutic effects were sustained for 12 months in cases 1 and 2 and for 5 months in case 3. All patients experienced a remarkable decrease in allodynia and hyperalgesia intensities.

CONCLUSION

C-arm fluoroscopic cone-beam computed tomography-assisted neurolytic thoracic sympathetic ganglion block offers a valuable alternative for managing otherwise intractable postmastectomy pain syndrome before considering more invasive techniques.

A Randomized, Double-Blind, Placebo-Controlled Trial to Evaluate the Therapeutic Effect of Magnesium-L-Threonate Supplementation for Persistent Pain After Breast Cancer Surgery

Purpose

Post-mastectomy pain syndrome is a common yet debilitating neuropathic complication after breast cancer procedures, resulting in significantly reduced quality of life. Recently, emerging evidence has supported the therapeutic effect of magnesium administration in chronic pain. However, the role of magnesium supplementation in development of chronic pain after breast cancer surgery remains less known. The aim of this study was to evaluate therapeutic effect of magnesium supplementation on persistent pain after breast cancer procedure.

Patients and Methods

This was a randomized, double-blind, placebo-controlled clinical trial. A total of 109 patients who underwent breast cancer procedure received magnesium-L-threonate (n = 48) or placebo (n = 61) for 12 weeks. Chronic pain incidence, short form of the McGill Pain Questionnaire (SF-MPQ), Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and Telephone Interview for Cognitive Status (TICS) were evaluated at 3- and 6-month follow-up.

Results

About 31% (15 out of 48) of patients reported chronic pain after magnesium supplementation, and 26% (16 out of 61) of the control group at 6-month follow-up respectively. Total scores of SF-MPQ were significantly increased in the control group 6 months after surgical intervention (mean difference, 1.475; 95% CI, -2.730 to -0.2211), but NOT in the magnesium treated group (mean difference, 1.250; 95% CI, -2.775 to 0.2748). No significant differences were found between two cohorts on SF-MPQ, GAD-7, PHQ-9, PSQI, or TICS at each timepoint.

Conclusion

Oral supplementation of magnesium-L-threonate did not effectively prevent the development of persistent pain in breast cancer survivors, nor provide sufficient pain relief over placebo. We did not observe improvement of pain, mood, sleep disorder, or cognitive function after 12-week magnesium supplementation. Future study may focus on magnesium combined with other effective anti-neuropathic pain treatment.

Chronic Unilateral Headache Related to Scar Neuromas

Postcraniotomy and posttraumatic headaches can result in scars generating local pain or referred pain following a neuropathic pattern. One hypothesis is that the pain can be caused and maintained by scar neuromas, developed after the nerve injury during the surgical process or trauma. This study reports two patients with chronic unilateral headaches: the first one with a posttraumatic scar in the parietal region and the other with a postsurgical scar in the mastoid region. In both patients, the headache was ipsilateral to the scar, suggesting primary headaches (trigeminal autonomic cephalalgia (TAC), as hemicrania continua and chronic cluster headache). Pharmacological treatment for these conditions failed. Instead, there was complete remission of the headache with anesthetic blockade of scar neuromas (demonstrated by clinical examination in both patients). An active search for traumatic or nontraumatic scars is recommended in all patients with refractory unilateral headaches, and anesthetic blocks for scar neuromas can be effective in treating this pain.

Neurotrophin-3 (NT-3) as a Potential Biomarker of the Peripheral Nervous System Damage Following Breast Cancer Treatment

Damage to the peripheral nervous system (PNS) is a common complication of breast cancer (BC) treatment, with 60 to 80% of breast cancer survivors experiencing symptoms of PNS damage. In the current study, the levels of brain-derived neurotrophic factor (BDNF), galectin-3 (Gal-3), and neurotrophin-3 (NT-3) were measured in the blood serum of BC patients by ELISA as potential biomarkers that might indicate the PNS damage. Sixty-seven patients were enrolled in this multi-center trial and compared to the aged-matched healthy female volunteers (control group) (n = 25). Intergroup comparison of biomarker levels (i.e., Gal-3 and BDNF) did not show significant differences in any of the studied subgroups. However, intriguingly, NT-3 levels were significantly higher in BC patients as compared to healthy volunteers, constituting 14.85 [10.3; 18.0] and 5.74 [4.56; 13.7] pg/mL, respectively (p < 0.001). In conclusion, NT-3 might be employed as a potential biomarker in BC patients with clinical manifestations of PNS damage. However, further studies to validate its correlation to the degree of peripheral nervous system lesions are of high value.

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Effects of Physical Exercise and Motor Activity on Oxidative Stress and Inflammation in Post-Mastectomy Pain Syndrome

It is estimated that 10–50% of interventions can generate persistent post-surgical pain. Chronic post-mastectomy pain is a condition persisting for at least three months after surgery. It has been shown that physical activity in the cancer patient allows the improvement of the pain symptom. The aim of this study was to evaluate the effects of physical activity on the intensity and interference of chronic pain in the quality of life of women underwent mastectomy needed for breast cancer removal. The secondary objective was to measure the effects of physical activity on inflammatory and oxidative markers in the same population. A Numeric Rating Scale (NRS) was used to assess pain intensity, and Brief Inventory Pain (BIP) was used for assessing interference of pain in quality of life. Physical activity was measured with the International Physical Activity Questionnaire (IPAQ). Inflammatory mediators such as interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, c-reactive protein (CRP), and biomarkers of oxidative stress malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) were evaluated in the blood of patients. All the evaluations were performed after three and six months after surgery. Results showed that adequate physical activity can diminish intensity and interference of pain and that these effects are associated with a reduction of blood biomarkers of inflammation.

High-rate breakthrough cancer pain and tumour characteristics - literature review and case series

Cancer pain requires careful comprehensive patient evaluation and an appropriate and personalized clinical approach by a trained multidisciplinary team. The proper assessment of breakthrough cancer pain (BTcP) is part of an all-inclusive multidimensional evaluation of the patient. The aim of this narrative review is to explore the relationship between high-rate BTcP, which strongly impacts health- related quality of life and tumour characteristics, in the face of novel approaches that should provide guidance for future clinical practice. The presentation of short, emblematic clinical reports also promotes knowledge of BTcP, which, despite the availability of numerous therapeutic approaches, remains underdiagnosed and undertreated. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.

Evidence Mapping Based on Systematic Reviews of Cognitive Behavioral Therapy for Neuropathic Pain

Objective

This evidence mapping is aimed at identifying, summarizing, and analyzing the available evidence on cognitive behavioral therapy (CBT) for neuropathic pain (NP).

Methods

This study was conducted following the methodology of Global Evidence Mapping (GEM). Searches were conducted in PubMed, Embase, the Cochrane Library, and PsycINFO to identify systematic reviews (SRs) with or without meta-analysis published before February 15, 2022. The authors independently assessed eligibility, extracted data, and evaluated the methodological quality of the included SRs using AMSTAR-2. The results were presented in the tables and a bubble plot based on the identified population-intervention-comparison-outcome (PICO) questions.

Results

A total of 34 SRs met the eligibility criteria. According to the AMSTAR-2, 2 SRs were rated "high," 2 SRs were rated "moderate," 6 SRs were rated "low," and 24 SRs were rated "critically low." The most common study design utilized to evaluate the efficacy of CBT for NP was the randomized controlled trial. In total, 24 PICOs were identified. Migraine was the most studied population. CBT for NP usually reaches the "potentially better" result at follow-up.

Conclusions

Evidence mapping is a useful way to present existing evidence. Currently, the existing evidence on CBT for NP is limited. Overall, the methodological quality of the included SRs was low. Further improvements in the methodological quality of SRs and more research on the most efficient CBT formats for NP are recommended in the future.

Percutaneous CT-Guided Cryoneurolysis of the Intercostobrachial Nerve for Management of Postmastectomy Pain Syndrome

PURPOSE

To evaluate the feasibility, safety, and efficacy of intercostobrachial nerve (ICBN) cryoneurolysis for pain control in patients with postmastectomy pain syndrome (PMPS).

MATERIALS AND METHODS

Fourteen patients with PMPS were prospectively enrolled into this clinical trial after a positive response to a diagnostic computed tomography (CT)-guided percutaneous block of the ICBN. Participants subsequently underwent CT-guided percutaneous cryoneurolysis of the same nerve and were observed on postprocedural Days 10, 90, and 180. Pain scores, quality-of-life measurements, and global impression of change values were recorded before the procedure and at each follow-up point using established validated outcome instruments.

RESULTS

Cryoneurolysis of the ICBN was technically successful in all 14 patients. The mean pain decreased significantly by 2.1 points at 10 days (P = .0451), by 2.4 points at 90 days (P = .0084), and by 2.9 points at 180 days (P = .0028) after cryoneurolysis. Pain interference with daily activities decreased significantly by 14.4 points after 10 days (P = .0161), by 16.2 points after 90 days (P = .0071), and by 20.7 points after 180 days (P = .0007). There were no procedure-related complications or adverse events.

CONCLUSIONS

Cryoneurolysis of the ICBN in patients with PMPS was technically feasible and safe and resulted in a significant decrease in postmastectomy pain for up to 6 months in this small cohort.

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.

Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial

Background

Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly.

Objectives

This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients.

Methods

In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed.

Results

Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups.

Conclusions

The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.