March 19, 2001
Persistent Pain after Breast Surgery
Jim Barnett, MD
Just took care of one of my Pain patients today with an intrathecal drug pump trial. She has your diagnosis. Unfortunately as a Chronic pain interventional specialist, I didn't get to see her until she was 5 years out from her surgery, on and off narcotics (which don't work well in neuropathic pain syndromes), multiple but uncoordinated nerve blocks, on and off antiepileptic drugs and antidepressants.
Common problem, but tough to treat. Especially because nobody seems to know how to jump on this early.
In a perfect world, I would see a patient 2-3 months post op. They would have burning dysethetic pain, with allodynia (things normally not painful, i.e., clothing touching or sheets on skin) and I would do the following:
- immediate sympathectomy (Stellate block, possibly T2-3 block)
- start neurontin, slow leading up to 1200 to 2000 mg,/day
- start antidepressants, like Elavil in increasing doses. If that doesn't do it, one of the later SSRI types like Effexor or Remeron.
- Possibly use Clonidine,
- Another approach is an intravenous lidocaine trial followed by Mexilitine (oral lidocaine like drug).
- if everything else has failed, or I don't get the patient for years, use an intrathecal drug pump or (preferably) spinal cord stimulator.
- If EVERYTHING failed, I would resort to neurolytic procedures and figure out which nerves I could sacrifice or modify to reduce the pain.
- And of course, all the while I would use adjunctive care like PT, biofeedback, etc
Some points to consider.... I need to verify that the pain is sympathetically maintained pain. That's why the blocks are first. If it's not that, then I look for neuroma formation, and other etiologies of pain. Sympathectomies should be stellate, and in refractory cases, T2-T3. Radiofrequency and endoscopic sympathectomy are promising in up to 60 percent of cases. Due to Centralization or Plasticity, the pain may become ingrained in the patient's central nervous system (brain and cord and their respective pathways).
New things are coming out all the time. Research into new receptor theory is providing new therapies all the time.
Hang in there. See somebody that is an interventional pain specialist, Board certified by one or both of the ONLY boards out there, the American Board of Anesthesiology--Added Pain Qualification, or the American Board of Pain Medicine.
Hope this helps. Don't give up. There are people who will take a little time and help you.
Jim Barnett, MD
Pacific Regional Neurosurgery
Interventional Pain Center
Clinical practice guidelines for the care and treatment of breast cancer, Canadian consensus document from the Canadian Medical Association. ---------------------------------------------------------------------------- 10. The management of chronic pain in patients with breast cancer
The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer:
The postmastectomy syndrome is a fairly common sequel of breast surgery. All patients should be warned that it may occur, and that if it does, it does not signify a recurrence of cancer.
Between 10% and 30% of patients will suffer persistent pain after breast surgery; it is more common after axillary dissection or total mastectomy than after breast-conserving surgery (BCS). 16,17 Postmastectomy syndrome is usually due to injury to the intercostobrachial nerve (a cutaneous branch of T1-2) in the course of surgery, and the subsequent pain and paresthesias occur in the nerve distribution. Although pain may be present immediately after surgery, more commonly the characteristic pain syndrome will develop 30 to 60 days postoperatively. The patient will complain of a burning pain in the chest wall, axilla and arm, with a sense of constriction in the axilla. Involved skin may be irritated by clothing, and the pain may be exacerbated by movement. In over half of affected patients the pain may be experienced in the arm and in 40% it may be related to movement.17 This may cause the patient to restrict arm activity, with subsequent development of a frozen shoulder.
Intraoperative damage to other peripheral nerves may cause comparable chronic pain syndromes. These nonmalignant causes of pain must be distinguished from similar tumour-related brachial plexopathy. Since patients with postoperative pain will understandably worry about the possibility of recurrent cancer, all patients should be informed at the time of surgery that pain may occur. Therapy includes reassurance and counselling, physical therapy to prevent a frozen shoulder and pharmacologic measures common to other neuropathic pain disorders.