Postmastectomy Pain Research Articles

Ultrasound-guided superficial serratus plane block for persistent post-mastectomy pain: four case reports

Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including medications, physical therapy, exercise interventions, cognitive-behavioral psychology, psychosocial interventions, and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain.We report four cases of patients with PPMP that were treated using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of "tightness" relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Perception of music and its cultural elements on acute post-mastectomy pain management among Nigerian women: an exploratory qualitative study.

This study aimed to explore the cultural elements of music in relation to pain management among women who have undergone mastectomy. An exploratory qualitative study with in-depth interviews. Using the purposive sampling technique, 20 participants were recruited for the study. The interviews were conducted face to face at the surgical out-patient clinic and female surgical ward. Data collection continued until data saturation was reached. The inductive approach was used to analyse the data, and the concepts were organised into themes. The consolidated criteria for reporting qualitative research guidelines (COREQ) were used to report this study. The participants were between 28 and 83years old and mostly diagnosed with stage III breast cancer. Three main themes emerged from the data analysis, including pain experienced after mastectomy, culture and music, and the perception of music for postoperative pain management after mastectomy. In this study, the knowledge of participants and the utilisation of music for pain management remains inadequate, but the participants perceived that music could be useful for pain control after mastectomy when the language and religion of the patient and the meaningfulness of the music were considered when introducing and selecting the music. This study will help open and extend the conversation about the utilisation and cultural elements of music that can be used clinically for pain management after mastectomy.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment.

Simple SummaryThere are many causes of pain following treatment of breast cancer. Pain may be due to nerve damage, problems of the musculoskeletal system, or both. Frequently, multiple different problems may be present at the same time which can make it difficult to determine the exact cause(s) of pain. Identifying the anatomic pain generators is essential to direct appropriate treatment. The purpose of this review is to outline different sources of post-mastectomy pain and to provide recommendations for the treatment of each one. Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Efficacy of serratus anterior plane block versus thoracic paravertebral block for postoperative analgesia after breast cancer surgery - a randomized trial

BackgroundBreast cancer surgery is associated with considerable acute post-surgical pain and restricted mobility. Various regional and neuraxial anesthesia techniques have been used to alleviate post-mastectomy pain. Ultrasound-guided serratus anterior plane block (SAPB) has been considered a simple and safe technique. This randomized control study was performed to compare the efficacy of SAPB with the thoracic paravertebral block (TPVB) for postoperative analgesia after breast cancer surgery. MethodsA total of 40 adult ASA physical status I - II female patients undergoing radical mastectomy were randomly allocated into two groups to receive either ultrasound-guided TPVB or SAPB with 0.4 mL.kg-1 0.5% ropivacaine, 30 min before surgery. All patients received standardized general anesthesia for surgery. Injection diclofenac and tramadol were used for postoperative rescue analgesia. The time to first rescue analgesia, total analgesic consumption in the first 24 hours, postoperative pain scores, and any adverse effects were recorded. ResultsThe time to first rescue analgesia was significantly longer in the SAPB group (255.3 ± 47.8 min) as compared with the TPVB group (146.8 ± 30.4 min) (p < 0.001). Total diclofenac consumption in 24 hours was also less in the SAPB group (138.8 ± 44.0 mg vs 210.0 ± 39.2 mg in SAPB and TPVB group respectively, p < 0.001). Postoperative pain scores were significantly lower in the SAPB group as compared with TPVB group (p < 0.05). The incidence of PONV was also less in the SAPB group (p = 0.028). No block-related adverse effects were reported. ConclusionWe found that the serratus anterior plane block was more effective than the thoracic paravertebral block for postoperative analgesia after breast cancer surgery.

Intraoperative infusion of esmolol reduces the incidence and intensity of post-mastectomy pain syndrome.

Intraoperative infusion of esmolol reduces the incidence and intensity of post-mastectomy pain syndrome.

Post-Mastectomy Pain: An Updated Overview on Risk Factors, Predictors, and Markers.

After breast surgery, women frequently develop chronic post-mastectomy pain (PMP). PMP refers to the occurrence of pain in and around the area of the mastectomy lasting beyond three months after surgery. The nature of factors leading to PMP is not well known. When PMP is refractory to analgesic treatment, it negatively impacts the lives of patients, increasing emotional stress and disability. For this reason, optimizing the quality of life of patients treated for this pathology has gained more importance. On the basis of the findings and opinions above, we present an overview of risk factors and predictors to be used as potential biomarkers in the personalized management of individual PMP. For this overview, we discuss scientific articles published in peer-reviewed journals written in the English language describing risk factors, predictors, and potential biomarkers associated with chronic pain after breast surgery. Our overview confirms that the identification of women at risk for PMP is fundamental to setting up the best treatment to prevent this outcome. Clinical practice can be planned through the interpretation of genotyping data, choosing drugs, and tailoring doses for each patient with the aim to provide safer and more effective individual analgesic treatment.

Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief

Post-mastectomy pain syndrome (PMPS) is a common and often debilitating condition. The syndrome is defined by chest wall pain unresponsive to standard pain medications and the presence of exquisite point tenderness along the inframammary fold at the site of the T4 and T5 cutaneous intercostal nerve branches as they exit from the chest wall. Pressure at the site triggers and reproduces the patient’s spontaneous or motion-evoked pain. The likely pathogenesis is neuroma formation after injury to the T4 and T5 intercostal nerves during breast surgery. We assessed the rate of long-term resolution of post-mastectomy pain after trigger point injections (2 mL of 1:1 mixture of 0.5% bupivacaine and 4 mg/mL dexamethasone) to relieve neuropathic pain in a prospective single-arm cohort study. Fifty-two women (aged 31–92) who underwent partial mastectomy with reduction mammoplasty or mastectomy with or without reconstruction, and who presented with PMPS were enrolled at the University of California San Francisco Breast Care Center from August 2010 through April 2018. The primary outcome was a long-term resolution of pain, defined as significant or complete relief of pain for greater than 3 months. A total of 91 trigger points were treated with mean follow-up 43.9 months with a 91.2% (83/91) success rate. Among those with a long-term resolution of pain, 60 trigger points (72.3%) required a single injection to achieve long-lasting relief. Perineural infiltration with bupivacaine and dexamethasone is a safe, simple, and effective treatment for PMPS presenting as trigger point pain along the inframammary fold.

Role of ultralow dose of naloxone as an adjuvant to fentanyl-bupivacaine in thoracic paravertebral block analgesia after modified radical mastectomy: Randomized controlled trial.

We evaluated the effect of the addition of 100 ng of naloxone to fentanyl-bupivacaine mixture used in thoracic paravertebral block (PVB) on the duration and the quality of post-mastectomy analgesia. A randomized double-blinded trial. Oncology surgery unit. This study included 135 patients, aged 40-60 years of either sex presented for elective unilateral-modified radical mastectomy. Patients were divided randomly into three groups: group I, received 0.3 mL/kg of 0.25 percent bupivacaine; group II, received 0.3 mL/kg of 0.25 percent bupivacaine, fentanyl 50 µg, and naloxone 100 ng; group III, received 0.3 mL/kg of 0.25 percent bupivacaine and fentanyl 50 µg. The visual analog scale was assessed immediately post-operative, every 2 hours till 12 hours, and then every 6 hours for 24 hours; the time of first and total amount of rescue analgesia and side effects during the first 24 hours were recorded. Group II showed a significant prolonged analgesia with a delayed first request of rescue analgesia and lower amount of morphine (592.1 ± 14.9 minutes and 7.28 ± 7.81 mg, respectively) than groups I (127.7 ± 35.1 minutes and 19.84 ± 2.56 mg, respectively) and III (232.2 ± 9.27 minutes and 13.52 ± 1.74 mg, respectively) as p < 0.001. Using naloxone as additives in PVB has been promising and effective in controlling post-mastectomy pain.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm

Summary:Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Transcutaneous electrical acupoint stimulation before surgery reduces chronic pain after mastectomy: A randomized clinical trial

Study objectiveDespite multiple interventions, the incidence of chronic pain after mastectomy could be as high as 50% after surgery. This study aimed to determine the efficacy of transcutaneous electrical acupoint stimulation (TEAS) before anesthesia induction in reducing chronic pain and to compare the effect of combined acupoint TEAS with that of single acupoint TEAS. DesignA multicenter randomized clinical trial. SettingThe study was conducted at six medical centers in China from May 2016 to April 2018. Final follow-up was on October 26, 2018. ParticipantsEligible patients were women scheduled for radical mastectomy under general anesthesia. InterventionsPatients were randomly and equally grouped into sham control (n = 188), single acupoint (PC6, n = 198), or combined acupoints (PC6 and CV17, n = 190) TEAS groups using a centralized computer-generated randomization system. TEAS was applied for 30 min before anesthesia induction. The sham-operated control group received electrode attachment but without stimulation. Anesthesiologists, surgeons, and outcome assessors were blinded to the interventions. MeasuresThe primary endpoint was the incidence of chronic pain 6 months after surgery. Incidences were compared among the groups using the unadjusted χ2 test. ResultsOf the 576 randomized patients, 568 completed the trial. In the intention-to-treat analysis, post-mastectomy pain at 6 months was reported in 42 of 190 patients (22.1%) in the combined acupoints group, 65 of 188 patients (34.6%) in the sham-operated group (P = 0.007; relative risk [RR], 95% confidence interval [CI]: 0.68, 0.52–0.89), and 72 of 198 patients (36.4%) in the single acupoint group (P = 0.002; RR, 95% CI: 0.72, 0.55–0.93). Remifentanil consumption during surgery and postoperative nausea and vomiting at 24 h after surgery were lower in the combined acupoint group than that in the sham-operated group. ConclusionTEAS at combined acupoints before surgery was associated with reduced chronic pain 6 months after surgery.Trial registration:Clinicaltrials.gov identifier: NCT02741726. Registered on April 13, 2016.

Efficacy of physical therapy interventions on quality of life and upper quadrant pain severity in women with post-mastectomy pain syndrome: a systematic review and meta-analysis

PurposeTo determine the efficacy of physical therapy interventions on quality of life (QoL) and pain severity in post-mastectomy pain syndrome (PMPS).MethodsMultiple databases were searched from database inception to October 2020. Searches were limited to human studies published in either English or Chinese in peer-reviewed journals with full text available for randomized controlled trials conducted on females. Trials comparing the effectiveness of physical therapy interventions against control conditions on QoL and pain were included.ResultsEighteen trials were included in the review. The pooled analysis of the four exercise trials revealed a significant effect of the intervention on general [standardized mean difference [SMD]: 0.87 (95%CI: 0.36, 1.37); p = 0.001], physical [SMD: 0.34 (95%CI: 0.01, 0.66); p = 0.044], and mental health components [SMD: 0.27 (95%CI: 0.03, 0.51); p = 0.027] of QoL compared with the control condition. Meta-analyses of six exercise trials, two myofascial release trials, and two acupuncture trials revealed a significant improvement in pain severity in the treatment group than in the control group. However, meta-analyses of two studies revealed a non-significant effect of compression therapy compared to control on pain severity.ConclusionOur meta-analyses found that exercise is beneficial for improving the QoL and pain severity of women with PMPS. Future studies are needed to determine the optimal parameters for exercise interventions designed to improve QoL and pain severity in women with PMPS. The effect of acupuncture, myofascial release, and compression therapy remains inconclusive, and future research is required to validate the effect of these interventions on PMPS.

A study to evaluate the efficacy of instillation of ropivacaine with tramadol through surgical drains for post-operative analgesia in patients undergoing mastectomy

Background: Post mastectomy pain is common and distressing complication seen in large number of women following mastectomy. Variety of modalities have been proposed to combat post mastectomy pain but are associated with disadvantages so simple technique like local infiltration though surgical drains avoid unnecessary complications and provide good analgesia to a standard general anesthetic opioid based technique.&#x0D; Aims and Objectives: To evaluate the efficacy of instillation of ropivacaine with tramadol through surgical drains for postoperative analgesia in patients undergoing mastectomy with respect to pain score, duration of analgesia and need for rescue analgesia.&#x0D; Materials and Methods: Seventy-five female patients aged between 30-70 years belonging to ASA physical status I &amp; II scheduled for mastectomy with axillary clearance were enrolled in the study. Patient were randomly allocated into three groups of 25 each. Group I- 40ml saline was instilled through the surgical drain, group II- 40ml 0.25% ropivacaine was instilled through the surgical drain and group III- 40ml 0.25% ropivacaine with 100mg tramadol was instilled through the surgical drain. Pain score was assessed using VAS (0-10) at rest and at movement and hemodynamic monitoring like pulse rate, noninvasive BP, respiratory rate was recorded immediately after the surgery, every hourly up to 4hours, then four hourly for the next 24hours. Patient satisfaction regarding pain relief was assessed at 24hours post operatively.&#x0D; Results: VAS at rest was clinically and statistically significantly lower in group II and III at 1,3,4,8,12 and 16 hours postoperatively(p&lt;0.05) as compared to group I however was comparable in between groups II and III. Similarly, VAS at movement was clinically and statistically significantly lower in group II and III at 1,3,4,8,12 and 16 hours postoperatively(p&lt;0.05) as compared to group I but comparable in between groups II and III. Patient satisfaction when compared was statistically more significant in group II and III as compared to group I but comparable in between group II and III.&#x0D; Conclusion: Instillation of ropivacaine or ropivacaine with tramadol through surgical drain is safe, effective and inexpensive technique for post-operative analgesia. It provides good relief of pain, prolonged analgesia, decreases analgesic requirement and increase patient’s satisfaction. However, addition of tramadol to ropivacaine serves no added advantage when compared to ropivacaine alone.

Magnesium Sulfate as an Adjuvant in Ultrasound Guided Stellate Ganglion Block for Post Mastectomy Pain Syndrome

Abstract Background: Cancer breast is the most common cancer in women and 2nd most common cancer overall. Post-Mastectomy Pain Syndrome (PMPS) is a term used to describe chronic pain following both partial mastectomy or mastectomy. It is one of many post-surgical persistent pain syndromes. Studies estimate that PMPS develops in about 25% to 60% of women leading to disability, psychological distress, and diminished quality of life. Aim of Study: The aim of the study was to compare analgesic efficacy and duration of stellate ganglion block when using both dexamethasone and magnesium sulfate with the local anesthetic lidocaine in comparison to using dexam-ethasone alone with lidocaine in cases of post mastectomy pain syndrome. Patients and Methods: Current double-blind study was conducted from September 2019 to September 2020 at outpa-tient pain clinic in Oncology Center Mansoura University (OCMU). Fifty female patients between age of 20 and 60 years, ASA physical status I and II underwent breast surgery. The patients were randomly assigned by computer generated sequence of random numbers method according to the drugs used into 2 equal groups, each group consisted of 25 patients, one group had received Dexamethasone and Lidocaine (group D) and the other group had received Magnesium, Dexameth-asone, and Lidocaine (group DM). After block, pain score was obtained using Visual Analog Scale (VAS). The shoulder movements were measured using goniometry. The skin tem-perature of the ipsilateral arm to the block was also measured. Results: After block, pain score was obtained using Visual Analog Scale (VAS). The shoulder movements were measured using goniometry. The skin temperature of the ipsilateral arm to the block was measured, the different types of shoulder movements were significantly better after injection of SGB in both groups compared to before injection. DM group showed longer analgesic duration and lower VAS score with less analgesia needed compared to D group. Conclusion: Adding magnesium sulfate to lidocaine and dexamethasone for ultrasound guided stellate ganglion block in cases of post mastectomy pain syndrome increases the time to first request of analgesia, decreases VAS values and the total amount of analgesia needed in the follow-up.

Postmastectomy pain syndrome after preoperative stellate ganglion block: a randomized controlled trial.

This study investigated the effect of preoperative ultrasound (US) guided stellate ganglion block (SGB) with bupivacaine on the frequency of post mastectomy pain syndrome (PMPS). Eighty patients scheduled for mastectomy with axillary dissection for breast cancer were included in this randomized controlled trial. Patients were randomized into two equal groups: Group A received US guided SGB one hour before surgery using five mL of 0.5% bupivacaine and multimodal systemic analgesia, Group B (control) received multimodal systemic analgesia only. Patients were followed up for six months. PMPS was assessed using the grading system for neuropathic pain (GSNP). Postoperative opioid consumption in the first 24 hours and numeric rating scale (NRS) were documented. Patient daily activity and functional capacity were evaluated using the Eastern Cooperative Oncology Group (ECOG) score. PMPS proportion was significantly lower in group A than group B (30% vs. 62.5%, P=0.004; 52% decrease [95% CI: 18.4%-71.8%]). Postoperative opioid consumption and NRS were significantly lower in group A as compared to group B. ECOG score was significantly higher in Group A than Group B. Following mastectomy with axillary dissection, preoperative US guided SGB is associated with less PMPS proportion, postoperative pain and opioid consumption and better patient daily activity and functional capacity.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background: Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete. Objectives: This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research. Methods: A PubMed search with the relevant keywords was done for articles published in the last 10 years. Results: The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy. Conclusions: PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

A pilot study to evaluate the efficacy of PEC blocks in minimising chronic post-mastectomy pain

This small prospective pilot study of 17 patients evaluated the efficacy of PECS block in preventing both immediate and long term post-operative pain after mastectomy. It describes the technique for performing a PECS blockade and demonstrated very low pain scores in both the peri-operative period and at 6 months.

Effect of perioperative pain neuroscience education in patients with post-mastectomy persistent pain: a retrospective, propensity score-matched study.

Central sensitization (CS)-related symptoms and pain catastrophizing contribute to persistent post-mastectomy pain (PPMP). Pain neuroscience education (PNE) is effective in reducing CS-related symptoms and pain catastrophizing in patients with chronic pain. However, to date, no intervention study of PNE has been conducted to patients with PPMP. This study was aimed to examine whether PNE is more effective than biomedical education (BME) for PPMP. In this retrospective case-control study, 118 patients were included. We intervened different patients at different times as follows: (1) a BME group (n = 58) of patients who received BME combined with physiotherapy and (2) a PNE group (n = 60) of patients who received PNE combined with physiotherapy. One year after surgery, we assessed pain intensity and interference (brief pain inventory [BPI]), CS-related symptoms (central sensitization inventory [CSI]), and pain catastrophizing (pain catastrophizing scale [PCS]). Propensity score matching was used to reduce or minimize selection bias and confounding biases and to make the number of cases in both groups match 1:1. Propensity score matching generated the BME group (n = 51) and the PNE group (n = 51). The BPI score, CSI score, and PCS score were statistically significantly lower in the PNE group than in the BME group (all, p < 0.05). The effect sizes for the BPI intensity (r = 0.31) were moderate. PNE resulted in a better outcome of pain management with less functional disability and CS-related symptoms compared to BME after breast surgery.

Treatment of Postmastectomy Pain Syndrome with Spinal Cord Stimulation: A Case Series

Background: Postmastectomy pain syndrome (PMPS) is a chronic pain syndrome that can be refractory to treatment by pain specialists. Spinal cord stimulation is a technique that has been approved for neuropathic pain and shown promise as a modality for targeted treatment. In this study, we report the outcomes of spinal cord stimulation in patients with refractory PMPS. Case Report: A retrospective chart review was performed at The University of Texas MD Anderson Cancer Center to identify patients who underwent spinal cord stimulation during a 3-year period. Relevant outcomes for efficacy and safety were evaluated. The protocol was reviewed and approved by The University of Texas MD Anderson Cancer Center Institutional Review Board. Seven patients with refractory PMPS were treated with spinal cord stimulation at our institution. All patients initially underwent trial spinal cord stimulation, with a mean preoperative Numeric Rating Scale (0-10) (NRS-11) score of 8.29 ± 1.70. Six of 7 (85.7%) patients reported a successful trial stimulation (&gt; 50% pain reduction); however, only 5 received permanent implantation. Following implantation, the reported one-month postoperative NRS-11 score was 4.20 ± 1.79. The mean change in the pain score between pre- and postoperative intervention was 4.40 ± 1.34 (Cohen’s d = 3.28, P = .002). The mean decrease in the morphine equivalent daily dose (MEDD) following implantation was 55.80 (SD 82.21, Cohen’s d = 0.68, P = .125). Conclusion: Spinal cord stimulation may be an effective therapy for patients experiencing chronic PMPS and should be considered in medically refractory cases. Future prospective studies are warranted to confirm the positive outcomes we demonstrated pertaining to pain scores and opioid medication changes. Key words: Cancer pain, postmastectomy pain syndrome, neuromodulation, opioids

Persistent Post-Mastectomy Pain: The Impact of Regional Anesthesia Among Patients with High vs Low Baseline Catastrophizing

Persistent Post-Mastectomy Pain (PPMP) varies both in its severity and impact, with psychosocial factors such as catastrophizing conferring greater risk. Preoperative regional anesthesia (RA) is an important non-opioid therapy, but with variable success at preventing PPMP in previous reports. We previously reported that RA was associated with lower acute post-mastectomy pain and opioid use, but more prominently among patients with higher baseline catastrophizing. The current longitudinal investigation at 3, 6, and 12 months postop aimed to detect differential long-term impact of RA on PPMP among patients with high vs low catastrophizing. In this prospective observational study, patients (n=123) completed preoperative psychosocial assessment and underwent mastectomy either with (n=56) or without (n=67) preoperative RA. Generalized estimating equation (GEE) regression analysis assessed impact of baseline catastrophizing, RA, and their interaction, on the primary outcome of pain severity index, as well as secondary outcomes including cognitive and emotional impact of pain, and persistent opioid use. We observed a significant interaction between the effect of catastrophizing and RA on PPMP. Specifically, RA was associated with reduced pain severity and pain impact 3, 6, and 12 months postoperatively, but only among those with high baseline catastrophizing scores. In addition, both RA and lower catastrophizing scores were associated with lower incidence of persistent opioid use. The efficacy of therapies to prevent PPMP may be importantly influenced by pain-modulatory psychosocial characteristics. These findings underscore the importance of considering individual patient factors when applying preventive treatments, and of including their assessment in future trials.

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators.

Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence. This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12months. The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain. This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.