An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review

Abstract

Objective Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. Design A retrospective study. Setting An academic cancer hospital. Subjects Adult females with PMPS diagnosis. Methods We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. Results Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). Conclusions Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.

Ultrasound‐guided fascial plane blocks for post‐breast surgery pain syndrome

“…10,11 A retrospective study found a median pain relief duration of 84 days, in postmastectomy patients who were submitted to a range of blocks including Serratus Anterior Plane, Interpectoral, Pectoserratus, and Intercostobrachial blocks, among others. 9 Another case series of patients complaining of pain in the axilla and medial arm, reported significant pain relief from 1 week to 3 months after ICBN block. 22 Repetition of the procedures in the majority of cases provided longerlasting pain relief.…”

“…In regards to PIPBs, we didn't include this technique because of the perceived low frequency of patients presenting with pain in the parasternal area. 8,9 Moreover, several technical issues deserve further consideration. First, the addition of an adjuvant to a local anesthetic to prolong block duration is a common practice.…”

“…7 Regarding the location of neuropathic symptoms, the most frequent painful area is perceived to be the lateral breast and lateral chest wall region. 8,9 First-line treatment of chronic post-breast surgery pain relies on conservative management including physical therapy, physical modalities (e.g., TENS), and oral medications (e.g., anticonvulsants, SNRIs, tricyclic antidepressants). For patients resistant to conservative treatment, ultrasound-guided neural blockade techniques are the next reasonable option.…”

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

“…More recently, a retrospective analysis demonstrated significant improvement in pain scores with various peripheral nerve blocks for post-mastectomy pain including ICBN blocks with durability of relief extending longer than 2 months in most cases. Notably, this review suggested that superficial serratus plane blocks at the 2nd or 3rd ribs could also be substituted in place of an ICBN block [47].…”

“…They found that a single injection achieved long-lasting relief of greater than 3 months in 72.3% of trigger points [55]. Pectoral nerve blocks, subcostal plane blocks, deep serratus plane blocks, erector spinae plane blocks, paravertebral nerve blocks and intercostal nerve blocks may also achieve similar effects and may be indicated when pain presents in a larger somatic distribution [47]. In cases of relief but recurring pain, surgical interventions may be considered.…”