Reducing Persistent Postoperative Pain and Disability 1 Year After Breast Cancer Surgery: A Randomized, Controlled Trial Comparing Thoracic Paravertebral Block to Local Anesthetic Infiltration

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Abstract

Background

The objective of this study was to compare the effect of thoracic paravertebral block (TPVB) and local anesthetic (LA) on persistent postoperative pain (PPP) 1 year following breast cancer surgery. Secondary objectives were to compare the effect on arm morbidity and quality of life.

Methods

Women scheduled for elective breast cancer surgery were randomly assigned to either TPVB or LA followed by general anesthesia. An NRS value of >3 at rest or with movement 1 year following surgery defined PPP. Blinded interim analysis suggested rates of PPP much lower than anticipated, making detection of the specified 20 % absolute reduction in the primary outcome impossible. Recruitment was stopped, and all enrolled patients were followed to 1 year.

Results

A total of 145 participants were recruited; 65 were randomized to TPVB and 64 to LA. Groups were similar with respect to demographic and treatment characteristics. Only 9 patients (8 %; 95 % CI 4–14 %) met criteria for PPP 1 year following surgery; 5 were in the TPVB and 4 in the LA group. Brief Pain Inventory severity and interference scores were low in both groups. Arm morbidity and quality of life were similar in both groups. The 9 patients with PPP reported shoulder-arm morbidity and reduced quality of life.

Conclusions

This study reports a low incidence of chronic pain 1 year following major breast cancer surgery. Although PPP was uncommon at 1 year, it had a large impact on the affected patients’ arm morbidity and quality of life.

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Most cited references 31

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A clinical method of functional assessment of the shoulder.

C. R. Constant, A H Murley (1987)

Several methods have been devised to estimate shoulder function, none of which is entirely satisfactory. The method described in this article is applicable irrespective of the details of the diagnostic or radiologic abnormalities caused by disease or injury. The method records individual parameters and provides an overall clinical functional assessment. It is accurately reproducible by different observers and is sufficiently sensitive to reveal even small changes in function. The method is easy to perform and requires a minimal amount of time for evaluation of large population groups.

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Thoracic paravertebral block for breast surgery.

Paul A. Bergh, Matthias S. Klein, Derek S. Steele … (2000)

Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. Paravertebral nerve block (PVB) has the potential to offer long-lasting pain relief and fewer postoperative side effects when used for breast surgery. We compared thoracic PVB with general anesthesia for cosmetic breast surgery in a single-blinded, prospective, randomized study of 60 women scheduled for unilateral or bilateral breast augmentation or reconstruction. Patients were assigned (n = 30 per group) to receive a standardized general anesthetic (GA) or thoracic PVB (levels T1-7). Procedural data were collected, as well as verbal and visual analog pain and nausea scores. Verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea to GA alone. Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.

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Pain after breast surgery: a survey of 282 women.

M Dobke, Brian J. Lee, B. A. Wallace (1996)

Breast surgery is a common procedure performed in women. Many women who undergo breast surgery suffer from ill-defined pain syndromes. Although there exists a few reports on the incidence of post mastectomy pain, there are no published reports on chronic pain after breast reconstruction. This investigation attempts to characterize the pain after four types of breast surgery: (1) mastectomy, (2) mastectomy with reconstruction, (3) cosmetic augmentation, and (4) breast reduction. A questionnaire was mailed to 479 women who underwent breast surgery at the University of California, San Diego Medical Center between January 1988 and December 1992. A second mailing was sent to women who did not respond to the first mailing. Women were divided into four groups; mastectomy, mastectomy with reconstruction, cosmetic augmentation, and breast reduction. In the mastectomy and mastectomy with reconstruction groups, only women who had a lumpectomy with axillary dissection, a modified radical mastectomy, or a radical mastectomy were used in the study. 59% of the women responded. The incidence of pain occurring at least one year after surgery in the mastectomy + reconstruction group (49%) was significantly higher than the mastectomy (31%) and breast reduction (22%) groups. Thirty-eight percent of the women with breast augmentation complained of pain. Women who had reconstruction using breast implants had a higher incidence of pain (53%) than those without (30%). The pain incidence in women who had reconstruction without implants was identical to women who had a mastectomy without reconstruction. There was no relationship between the use of silicone or saline implants and pain (22% and 33% respectively). However, the submuscular placement of the implants resulted in a significantly higher incidence of pain (50%) than the subglandular placement (21%). Of the women that reported pain, arm pain was significantly higher in the mastectomy and mastectomy + reconstruction group (56% and 42%, respectively) as compared to the breast reduction group (0%). Most patients reported intermittent pain in all groups. Of the women that reported pain, the mastectomy and mastectomy + reconstruction group had higher pain related to movement (41% and 42%, respectively) than the augmentation and breast reduction groups (15% and 9%, respectively). The peak pain intensity was significantly higher in the augmentation group as compared to the mastectomy group. Our incidence of post mastectomy pain is higher than most reports. The incidence of breast pain is highest in the mastectomy + reconstruction and augmentation groups which is assumed to be secondary to breast implants. Every effort should be made to achieve the best cosmetic result in breast reconstruction which in many cases justifies the use of breast implants. However, these women should be counseled on the possibility of developing chronic pain.

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Author and article information

Contributors

: mchiu@toh.on.ca

Journal

Journal ID (nlm-ta): Ann Surg Oncol

Journal ID (iso-abbrev): Ann. Surg. Oncol

Title: Annals of Surgical Oncology

Publisher: Springer US (Boston )

ISSN (Print): 1068-9265

ISSN (Electronic): 1534-4681

Publication date (Electronic): 29 October 2013

Publication date PMC-release: 29 October 2013

Publication date (Print): 2014

Volume: 21

Pages: 795-801

Affiliations

[ ]Department of Anesthesiology, University of Ottawa, Ottawa, ON Canada

[ ]Department of Surgery, University of Ottawa, Ottawa, ON Canada

[ ]Clinical Epidemiology Program, Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada

[ ]The Ottawa Hospital, Ottawa, ON Canada

Article

Publisher ID: 3334

DOI: 10.1245/s10434-013-3334-6

PMC ID: 3933756

PubMed ID: 24165901

SO-VID: d06e810b-599d-421d-893c-e27497588220

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

History

Date received : 25 June 2013

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ScienceOpen disciplines: Oncology & Radiotherapy

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ScienceOpen disciplines: Oncology & Radiotherapy

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Reducing Persistent Postoperative Pain and Disability 1 Year After Breast Cancer Surgery: A Randomized, Controlled Trial Comparing Thoracic Paravertebral Block to Local Anesthetic Infiltration

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Abstract

Background

Methods

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Conclusions

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Karger: Oncology

Most cited references 31

A clinical method of functional assessment of the shoulder.

Thoracic paravertebral block for breast surgery.

Pain after breast surgery: a survey of 282 women.

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Cited by 16

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