Page 285 Acute Pain Management

Postmastectomy pain syndrome
Chronic pain after mastectomy is common. In one epidemiological study the incidence was
24% at 18 months (Vilholm et al, 2008a Level IV); another study looking at patients more than
5 years after surgery (with no recurrence of cancer) reported an incidence of 29% (Peuckmann
et al, 2009 Level IV). Phantom breast pain has also been described, however, the incidence was
low in the range of 7% at 6 weeks and 1% at 2 years (Dijkstra et al, 2007 Level III‐3); phantom
sensations are more common — reported in 19% of patients more than 5 years after surgery
(Peuckmann et al, 2009 Level IV). Significant predictors for the development of postmastectomy
chronic pain were radiotherapy and younger age (Peuckmann et al, 2009 Level IV). Other risk
factors were higher postoperative pain scores and inclusion of major reconstructive surgery
(Chang, Mehta et al, 2009 Level IV).
Sensory testing (thermal thresholds, cold allodynia, and temporal summation on repetitive
stimulation) showed that postmastectomy pain is a neuropathic pain condition (Vilholm et al,
2009 Level III‐2).
Preincisional paravertebral block reduced prevalence and intensity of pain 12 months after
breast surgery (Kairaluoma et al, 2006 Level II). Perioperative use of gabapentin or mexiletine
after mastectomy reduced the incidence of neuropathic pain at 6 months postoperatively,
from 25% in the placebo to 5% in both treatment groups (Fassoulaki et al, 2002 Level II). Similar
protective results were achieved by the same group by the use of a eutectic mixture of local
anaesthetics alone (Fassoulaki et al, 2000 Level II) or in combination with gabapentin (Fassoulaki
et al, 2005 Level II).
Levetiracetam was ineffective in the treatment of postmastectomy syndrome (Vilholm et al,
2008b Level II).
Postherniotomy pain syndrome
This syndrome is thought to be mainly neuropathic pain as a result of nerve injury.
This assumption was confirmed in a study that showed that all patients with chronic
postherniotomy pain had features of neuropathic pain (Aasvang et al, 2008 Level IV).
Ejaculatory pain is a feature of this syndrome and occurs in around 2.5% of patients
(Aasvang et al, 2007 Level IV).
Very young age may be a protective factor as hernia repair in children under 3 months age
did not lead to chronic pain in adulthood (Aasvang & Kehlet, 2007 Level IV).
Mesh removal and selective neurectomy of macroscopically injured nerves reduced CHAPTER 9
impairment in patients with postherniorrhaphy pain syndrome (Aasvang & Kehlet, 2009
Level III‐3).
Posthysterectomy pain syndrome
Chronic pain is reported by 5% to 32% of women after hysterectomy (Brandsborg et al, 2008).
In most women the pain was present preoperatively; at a 1 to 2 year follow‐up, pain was
reported as a new symptom in 1% to 15% of patients (Brandsborg et al, 2008). The origin and risk
factors for persisting pain after hysterectomy are not clear. However, in a small prospective
survey, postoperative pain intensity as well as preoperative non‐pelvic pain were associated
with the presence of pain 4 months after surgery (Brandsborg et al, 2009 Level III‐3). For pain
reported 1 year after surgery, risk factors were preoperative pelvic and non‐pelvic pain and
previous Caesarean section; there was no difference found between vaginal or abdominal
hysterectomy (Brandsborg et al, 2007 Level IV).
Patients given perioperative gabapentin and a postoperative ropivacaine wound infusion had
lower opioid requirements after surgery and less pain one month later compared with patients
given placebo, although there was no difference in pain scores for the first 7 postoperative
Acute pain management: scientific evidence 237