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Effects on Chronic Postoperative Pain
Aline Albi-Feldzer, M.D.,* Emmanuelle Mouret-Fourme E, M.D.,† Smail Hamouda, M.D.,‡ Cyrus Motamed, M.D.,§ Pierre-Yves Dubois, M.D.,‖ Ludivine Jouanneau, Ph.D.,† Christian Jayr M.D., Ph.D.*
ABSTRACT Background: The efficacy of local anesthetic wound infiltration for the treatment of acute and chronic postoperative pain is controversial and there are no detailed studies. The primary objective of this study was to evaluate the influence of ropivacaine wound infiltration on chronic pain after breast surgery. Methods: In this prospective, randomized, double-blind, parallel-group, placebo-controlled study, 236 patients scheduled for breast cancer surgery were randomized (1:1) to receive ropivacaine or placebo infiltration of the wound, the second and third intercostal spaces and the humeral insertion of major pectoralis. Acute pain, analgesic consumption, nausea and vomiting were assessed every 30 min for 2 h in the postanesthesia care unit and every 6 h for 48 h. Chronic pain was evaluated 3 months, 6 months, and 1 yr after surgery by the brief pain inventory,
What We Already Know about This Topic
• There is an association between severity of acute pain after surgery and likelihood of chronic pain, yet whether these are causally related is not known
What This Article Tells Us That Is New
• In 236 women undergoing breast surgery for cancer, wound infiltration with ropivacaine reduced postoperative pain for the first 90 min after surgery, but did not reduce the incidence or severity of pain 3–12 months later
* Professional Staff, Department of Anesthesia and Intensive Care, Institut Curie-Hôpital René Huguenin, Saint-Cloud, France. † Professional Staff, Clinical Epidemiology, Institut Curie-Hôpital René Huguenin. ‡ Professional Staff, Department of Anesthesia and Intensive Care, Paoli Calmette, Marseille, France. § Professional Staff, Department of Anesthesia and Intensive Care, Institut Gustave Roussy, Villejuif, France. ‖ Professional Staff, Department of Anesthesia and Intensive Care, Institut Godinot, Reims, France. Received from the Department of Anesthesia and Intensive Care, Institut Curie-Hôpital René Huguenin, Saint-Cloud, France. Submitted for publication December 30, 2011. Accepted for publication October 19, 2012. AstraZeneca (Rueil-Malmaison. France) provided the authors with all information on ropivacaine and paid €5,000 for the civil liability insurance for the study protocol, which is mandatory in France. Support was provided from institutional or departmental sources. Presented at the American Society of Anesthesiologists annual meeting, New Orleans, Louisiana, October 17–21, 2009, and at the Société Française d’Anesthésie et de Réanimation annual French meeting, Paris, France, September 23–26, 2009. Address correspondence to Dr. Jayr: Chairman, Department of Anesthesia and Intensive Care, Institut Curie-Hôpital René Huguenin, 35, rue Dailly, Saint-Cloud 92210 cedex – France. email@example.com. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiol ogy.org.
Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2013; 118:318-26
hospital anxiety and depression, and neuropathic pain questionnaires. Results: Ropivacaine wound infiltration significantly decreased immediate postoperative pain for the first 90 min, but did not decrease chronic pain at 3 months (primary endpoint), or at 6 and 12 months postoperatively. At 3 months, the incidence of chronic pain was 33% and 27% (P = 0.37) in the ropivacaine and placebo groups, respectively. During follow-up, brief pain inventory, neuropathic pain, and anxiety increased over time in both groups (P < 0.001) while depression remained stable. No complications occurred. Conclusion: This multicenter, prospective study shows that ropivacaine wound infiltration after breast cancer surgery decreased immediate postoperative pain but did not decrease chronic pain at 3, 6, and 12 months postoperatively. reast cancer affects nearly 10% of all women, and is the most common type of cancer identified in women in western countries. Early detection and treatment have led to increased survival. With the increasingly prolonged
◊ This article is featured in “This Month in Anesthesiology.” Please see this issue of Anesthesiology, page 9A. ◆ This article is accompanied by an Editorial View. Please see: Cohen SP, Raja SN: Prevention of chronic postsurgical pain: The ongoing search for the holy grail of anesthesiology. Anesthesiology 2013; 118:241–3.
Anesthesiology, V 118 • No 2
5 mg/kg). Therefore. the consumption of analgesics.7–9 Other predictive factors include anxiety. and those unable to comply with the protocol for any reason were excluded. ClinicalTrials. or hepatic dysfunction. Several predictive factors. Anesthesia was maintained with 50% nitrous oxide in oxygen. Patients were enrolled and informed consent was obtained at least 1 day before surgery. and medial upper arm or shoulder. and patients were assigned to either the placebo group or the ropivacaine group. and 1 yr after surgery by the BPI. the efficacy of local anesthetic wound infiltration for the treatment of acute pain after breast surgery is controversial. All patients gave their written informed consent. General anesthesia was induced with propofol (2. preoperative analgesic use (12 h).18–20 However. the estimated prevalence of chronic pain in the literature is between 20 and 65%. pregnancy. breast. scar. An occurrence of any previous cancer other than breast cancer. intercostobrachial nerve damage. The envelope was opened in an isolated room on the day of surgery.25 The authors suggested that larger clinical trials were necessary. The primary objective of this study was to address the question: Does wound infiltration influence the incidence of chronic pain evaluated by a score of three or more on item five (average pain) of the brief pain inventory (BPI) at 3 months after breast surgery? The secondary objectives were to assess the following: acute postoperative pain at rest or during mobilization. Women between the ages of 18 and 85 yr with an American Society of Anesthesiologists physical status I. ranging from simple lumpectomy to mastectomy with axillary node dissection. No other physician or nursing staff member was aware of the contents of the solution administered to each patient. double-blind. and atracurium or cisatracurium to facilitate orotracheal intubation. chronic postoperative pain has therefore become an important issue. young age (< 40 yr). type of surgery. acute postoperative pain. II. Treatment On the morning of surgery and before induction of anesthesia. France) and the study ethics review committee (Hôpital Ambroise Paré. severe renal. Anesthesiology 2013. axilla. Materials and Methods Population Four hospitals (cancer centers) participated in this prospective.5. and analgesic consumption are strong predictors of persistent pain after surgery.PERIOPERATIVE MEDICINE survival of breast cancer patients. Patients were randomized in randomly permuted blocks of four or six patients in each stratum. sealed envelopes. placebo-controlled study to evaluate the effect of ropivacaine infiltration on postoperative pain in patients undergoing breast cancer surgery. we conducted an extensive study in a homogenous population on the effect of deep wound infiltration with ropivacaine on acute and chronic pain as well as on factors of comorbidity. and III and a minimum life expectancy of 2 yr.6. Saint-Cloud. the presence of pain before surgery. hospital anxiety and depression (HAD). psychosocial factors. active malignant disease. The study was performed under double-blind conditions. Boulogne. Stratification was performed on the basis of hospital and type of surgery (conservative or not). have been identified for chronic postoperative pain. 118:318-26 . treated by conservative breast surgery with axillary lymph node dissection or radical modified mastectomy with either sentinel lymph node dissection or axillary lymph node dissection or no axillary lymph node dissection were included. However. adjuvant radiation therapy. related to both the patient and surgical factors. to be infiltrated by the surgeon. Patients were premedicated with hydroxyzine (2 mg/kg) administered orally 1 h before surgery.21–24 The effect of local anesthetic instillation on chronic pain has been evaluated. The solution was prepared in an isolated room and the nurse did not have any further contact with the patient. ipsilateral breast surgery in the past 3 yr. parallel-group. France). Patients were recruited from a surgical ward during the preoperative visit. an operating room nurse read the results of randomization to prepare the solution of normal saline or ropivacaine in identical syringes. opaque. or chemotherapy. Randomization A balanced block stratified randomization scheme was used for patient allocation. Exclusion Criteria. Inclusion Criteria. pulmonary. reported history of substance abuse. allergy to local anesthetics and morphine.2 µg/kg).10–17 Adequate and effective pain relief during the perioperative period may prevent and reduce chronic pain. randomized (1:1). gov NCT N° NCT00370240) was approved by the institutional review board (Institut Curie. Preoperative pain sensitivity.1–6 Chronic pain has a neuropathic component and has been reported to occur in various areas: the chest wall. Chronic pain was evaluated 3 months. sufentanil (0. nausea and vomiting every 30 min for 2 h in the postanesthesia care unit (PACU) and every 6 h for 48 h after surgery. Acute pain after breast surgery is moderate and depends on the type of surgery. and neuropathic pain (DN4) questionnaires. 6 months. Assignments were computer-generated and maintained in sequentially numbered. such as anxiety and depression after breast cancer surgery. and seems to be significantly effective at 3 months but not at 6 months. and the protocol (Eudra CT N° 2005-005691-32. sevoflurane (1–2% end-tidal concentration) 319 Albi-Feldzer et al.18–20 Postoperative loco-regional analgesia is one of the multimodal pain relief strategies used to prevent chronic pain and reduce opioid consumption and side effects.
12. admitted for breast surgery were enrolled between September 2006 and July 2007. or III. Evaluation Patients were asked to fill in questionnaires at inclusion. BPI. All patients were administered oral analgesics for postoperative pain (paracetamol 1g and ketoprofen 50 mg) every 6 h and rescue morphine with a patient-controlled analgesia pump for 24 h (bolus dose 1 mg on demand. type of surgery. version 2. the estimated incidence of chronic pain was 40% in the control group. Ondansetron 4 mg was administered for nausea and vomiting ± droperidol 1. when all patients had a follow-up of at least 12 months (fig. All patients were transferred to the PACU for 2 h. The number of patients included was calculated to obtain a 20% difference between the two groups (50% reduction of the incidence of chronic pain from 40 to 20%). The time × group interaction was tested for each score. and HAD scores were analyzed with mixed models for repeated data with an unstructured variance-covariance matrix. Finally. Measurement of pain on the VAS showed lower scores at rest and during mobilization in the first 90 min after the end of surgery in the ropivacaine group than in the control group (P < 0. the wound was completely infiltrated under blind conditions with repeated injections of the solution (3–4 ml for each injection). A population of 216 patients were required to demonstrate a 20% difference between the two groups at 3 months. The ropivacaine group received 3 mg/kg of 0. It was decided to include 230 patients to take into account patients who could not be evaluated. and cancer status at follow-up. Infiltrations were also performed in the second and third intercostal spaces and in the humeral insertion of the major pectoralis. Final assessments had to be completed by July 2008.1 µg/kg as required. breast cancer site. All patients received the same per kilogram dose of ropivacaine regardless of the type of surgery. and finally the experience of pain which is the consequence of pain intensity and pain interference. All analyses were based on the intent-to-treat principle and used R. 1). and 1 yr after surgery evaluating chronic pain (BPI). The patient was extubated at the end of surgery after reversal of the neuromuscular block. Patient characteristics were compared by the Chi-square test or Fisher’s exact test. and comorbidities (lymphedema). DN4. II.27 neuropathic pain (DN4).26 anxiety-depression (HAD). Logistic regression tested the interaction between confounding factors which could influence the incidence of pain at 3 months among the two groups. Pain was scored by a visual analog scale (VAS) anchored by no pain at all (score 0 cm) and worst possible pain (score 10 cm).25 mg every 8 h. pain’s interference with functions (seven daily activities. and morphine). Austria). or preoperative VAS. the patient received an intravenous injection of 1 g of paracetamol and 100 mg of ketoprofen ± omeprazole. Two-tailed P values were calculated and significance was set at 5%. when necessary. and sleep). before skin suturing. The R “nlme” package was used for linear and nonlinear mixed effect models.0 for Windows software (R foundation for statistical computing. Pain was evaluated by a nurse who was blinded to the treatment group. including general activity. for qualitative variables. One hour before the end of surgery. Vienna. United Kingdom] mixed with saline). A higher percentage of pain-free patients was observed in the ropivacaine group than in the placebo group during the first postoperative 48 h at rest and during Albi-Feldzer et al. and at 3 months. Statistical Analysis At 3 months. walking. The Woolf test was used to evaluate the interaction between the incidence of chronic pain and the study centers among the two treatment groups. and nausea and vomiting were assessed at the time of transfer to the PACU. and boluses of sufentanil 0.Ropivacaine Wound Infiltration and Chronic Pain or desflurane (3–4%). Acute postoperative pain at rest and after movement (elevation of the arm on the operated side) was assessed every 30 min for 2 h in the PACU and every 6 h for 48 h. The two groups were not statistically different for demographic data (table 1). The placebo group received an equal volume of saline solution (0. every 30 min for 2 h in the PACU and every 6 h for the first 48 h postoperatively. body mass index. . 3 cm along the subcutaneous and deep layers of the breast and axilla surgical incisions. with 90% power and a 5% alpha risk. Anesthesiology 2013. Data on demographics and the history of cancer included age. ketoprofen. 236 patients were treated (fig. At the end of surgery. work. Results Two hundred sixty women aged 18–85 yr with an American Society of Anesthesiologists physical status of I. enjoyment of life. Consumption of analgesics (paracetamol. VAS. if necessary. adjuvant therapy. mood. Intercostal infiltrations were performed under visual control by the surgeon (3–4 ml for each injection) on the anterior edge of the serratus anterior muscle and the upper edge of the second and third rib.75% ropivacaine [Astra Zeneca. relations with others. Ropivacaine wound infiltration decreased immediate postoperative pain in the PACU and increased the percentage of pain-free patients (VAS = 0) for the first 48 h.28 consumption of analgesics. London. lockout interval of 5 min). patient satisfaction. The BPI is a multidimensional pain assessment tool which includes. 1). pain intensity. A and B). and the independent Student t-test or Wilcoxon rank sum test for quantitative variables.8 ml/kg).375% ropivacaine (0. 118:318-26 320 Because toxicity was not expected with ropivacaine in this study (Phase 4 study with safe doses of ropivacaine).001) (figs 2. 6 months. the trial was not assessed by an independent data safety monitoring board.
95 mg (median) (0–21) Table 1.3) 9 (7.33 (0.3) 11 (9.4) 0. The level of pain was lower than expected in the placebo group. In the ropivacaine group. respectively.77) 0 0–5 66 (56.9–45.34 (0.32 (0.2) 2 (1.7–37.3) 53 (45.17–0. mobilization.1) 48 (40. compared to 53 and 48% of patients in the placebo group (P < 0.0) 3 (2. SLND = sentinel lymph node dissection.83 Saline Group n = 119 57 (13) 48–68 67 (12) 45–109 25 (4) 17. Demographic Data and Characteristics of the 236 Patients Treated for the Study Ropivacaine Group n = 117 Age (yr) Mean (SD) Range Body weight (kg) Mean (SD) Range BMI (kg/m2) Mean (SD) Range Visual analog scale (VAS) before surgery Mean (SD) Median Range ASA physical status (%) I II III Surgery (%) Breast-conserving surgery with ALND Mastectomy with ALND or SLND Mastectomy without ALND or SLND Sufentanil during surgery (µg/kg) Mean (SD) Range 56 (12) 47–65 67 (13) 40–105 25 (6) 16.7) 62 (52.4) 48 (41.11) 0.2 0. 1. BPI = Brief Pain Inventory.11) 0. ALND = axillary lymph node dissection.33 (0.07–0.93) 0 0–7 62 (52.6) 53 (45. Patient flow chart. ASA = American Society of Anesthesiologists. 118:318-26 321 Albi-Feldzer et al. 73 and 53% of patients reported no pain at all at rest or during movement.5 0. Anesthesiology 2013. respectively). BMI = body mass index.005 for each comparison.1) 55 (46. SLND = sentinel lymph node dissection. Morphine consumption with the controlled analgesia pump was very low in both groups: 2.83 ALND = axillary lymph node dissection. . n = 119 Tumorectomy with ALDN n = 62 n=9 n = 48 Allocation Mastectomy alone Mastectomy with either SLDN or ALDN Analyzed for chronic pain at 3 months Intent-to-treat Lost to follow-up Missing data (BPI) n = 111 n=3 n=3 Analyzed for chronic pain at 3 months Analysis Intent-to-treat Lost of follow-up Missing data (BPI) n = 108 n=3 n=8 Fig.PERIOPERATIVE MEDICINE Randomization n = 260 Excluded n = 24 Withdrawal of consent n=6 Failed to meet inclusion criteria n = 18 Patients included n = 236 Allocated to the Ropivacaine group.6) 0.001 and P = 0. n = number of patients. n = 117 Tumorectomy with ALDN Mastectomy alone Mastectomy with either SLDN or ALDN n = 53 n = 11 n = 53 Allocated to the Placebo group.
In addition to wound infiltration. body mass index. increased the percentage of pain-free patients for the first 48 h postoperatively. The time × group interaction was tested. 118:318-26 322 Albi-Feldzer et al.4–35. respectively) (table 2). 3).96 mg (0–18) for the first 48 postoperative hours in the ropivacaine and placebo groups. placebo-controlled study shows that ropivacaine wound infiltration after breast surgery 1. 6.0001 and 0. 6. No treatment-related complication was observed. respectively) (fig. whereas depression scores remained stable compared to baseline in both groups (fig.3) 0–9 Saline Group n = 119 29/108 (26. No statistically significant difference was observed between the two groups for the primary outcome (BPI average pain) evaluated 3 months after breast surgery. 4). such as adjuvant therapy (chemotherapy or radiotherapy). type of surgery. age. The statistical difference was not tested because the incidence was low.0001 and P < 0.2 1. and 4. No statistically significant interaction was observed between the incidence of chronic pain and study centers in the two treatment groups (Woolf test).0001) in both groups. Pain severity and pain interference on the BPI were not statistically different between groups but increased significantly in both groups over time (P < 0. A statistically significant increase was observed in the mean BPI scores (severity and interference) compared to baseline during the study in both groups (P < 0. VAS = visual analog scale. VAS showed lower scores at rest and during mobilization in the first 90 min after the end of surgery in the ropivacaine group than those in the control group (P < 0.3%) 24.058). did not decrease chronic pain at 3 months (primary objective of the study). prospective. randomized. % = percentage of patients. No adverse effects were observed during or just after ropivacaine wound infiltration. Intention to Treat Analysis Primary Pain Outcome: BPI at 3 Months Score ≥ 3: n (%) CI 95% (Score ≥ 3. 2. (A) VAS at rest during the first 48 postoperative hours. double-blind. The maximum percentage of missing data for each point (0.9%) 18. the amount of paracetamol and ketoprofen consumed during the postoperative period was not different between the two groups.5–42 1. and 12 months) in both arms was less than 5% (range: 0–5%).001). n = number of patients. P value is associated with the test of group × time effect. Table 2. 5). 6 and 12 months postoperatively. Following the protocol. and 12 months postoperatively (P = 0.41 BPI = brief pain inventory.37 and 0.97 (2. (B) VAS on mobilization during the first 48 postoperative hours. variable (≥ 3 over 10) (P = 0. and 2. patients in the two treatment groups received the same quantities of intravenous analgesics. %) Mean score (SD) Range Ropivacaine Group n = 117 37/111 (33.001.2) 0–9 P Value 0. 3.Ropivacaine Wound Infiltration and Chronic Pain Fig. The incidence of nausea and vomiting (Apfel score > 2) was 4% in the ropivacaine and 6% in the control group. 3). The mean DN4 scores also increased over time (P < 0. did not decrease neuropathic pain at 3. A statistically significant improvement was observed in the anxiety score during the study (P < 0. decreased immediate postoperative pain for the first 90 min in the PACU. Anesthesiology 2013.001.058) (fig.001) and this increase was not statistically different between the two groups (P = 0. whether it was measured as a continuous score or as a categorical Discussion This multicenter. .42. respectively. respectively) (fig.37 0. 3. or anxiety and depression scores (table 3).7 (2. No statistically significant difference was observed between the two groups in relation to potential confounding factors. Chronic Pain: Primary Outcome 3 Months after Surgery. 2.
while the increase in pain severity from the sixth to twelfth months was not statistically significant. P value is associated with the test of group × time effect.33 * P value for logistic regression to test the interaction between confounding factors which may influence the incidence of pain at 3 months. No statistically significant difference in the incidence of chronic pain was observed on the BPI 3.9 mg/48 h). the overall incidence of chronic pain at 3 months on the BPI (27 and 33% in the ropivacaine and placebo groups.93 0. mastectomy with or without axillary lymph node dissection.31 A statistically significant difference between the two groups was only observed for the first 90 min.98 0. and mastectomy with sentinel lymph node dissection. Potential Confounding Factors which May Interact with the Incidence of Chronic Pain at 3 Months among the Two Groups Factors Breast-conserving surgery with ALND Mastectomy without ALND or SLND Mastectomy with ALND or SLND Age BMI Axillary lymphedema: yes/no Radiation therapy: yes/no Chemotherapy: yes/no Hormonal treatment: yes/no Postoperative nausea and vomiting score > 2 Patient satisfaction HAD score at 3 mo Anxiety score at 3 mo Anxiety score ≥ 11 at 3 mo Depression score at 3 mo Depression score ≥ 11 at 3 mo P Value* 0.54 0. In this study. 3. and the estimated prevalence of sensory disturbances ranges between 20 and 80%.87 0. The incidence of chronic pain was low in this Fig. Patients received optimal postoperative treatment with nonsteroidal antiinflammatory drug. BPI = brief pain inventory.29.PERIOPERATIVE MEDICINE Table 3.18. BMI = body mass index. No difference in anxiety and depression (HAD scores) was observed between the two groups.001. and 12 months after surgery. 118:318-26 323 Albi-Feldzer et al.62 0. and finally the type of analgesia. time to surgery.13. which is also in line with the literature and shows that local anesthetic infiltration is a potent adjuvant as part of the multimodal management of pain after breast surgery.92 0. However. and then from the third to sixth months.19. Multivariate analysis failed to identify any risk factors for chronic pain in this study.001 and P < 0. the methods used to measure pain.45 0. ALND = axillary lymph node dissection. both at rest and during mobilization. SLND = sentinel lymph node dissection. acetaminophen and rescue morphine (Patient-controlled Analgesia). Anesthesiology 2013. Morphine consumption was also very low for the first 48 h in both groups (2. the frequency and period of monitoring. 6. number of patients studied.30 The intensity of acute postoperative pain was always less than 25 mm on the VAS. The time × group interaction was tested.24 0. The increase in pain severity was statistically significant from the preoperative period until the third month. types of surgery.62 0. HAD = hospital anxiety and depression.80 0.42 0. respectively) was low compared to certain other published studies (20–65%). respectively) in our patients was in the middle range compared to that reported in other studies (17–50%). and 12 months after surgery. BPI scores before surgery and 3. No significant difference was observed between the two groups. Because the management of acute postoperative pain was optimal in the two groups. the incidence of neuropathic pain on the DN4 (24 and 30% in the ropivacaine and placebo groups. . adjuvant therapy. ropivacaine infiltration could not decrease the pain score further after the first 90 min and the pharmacokinetics of ropivacaine do not allow a sustained effect for more than 90 min. The increase in pain interference was statistically significant from the preoperative period until the third month only. The various types of surgery included breast tumor resection with axillary lymph node dissection. 6.37 0. respectively).94 0. Pain severity and pain interference (BPI scores) increased significantly over time in both groups (P < 0. which is similar to the results reported in the literature. but anxiety decreased significantly with time.77 0. and the two treatment groups.3 This wide range of prevalence of pain reported in the literature is probably because of differences in the definitions of persistent pain.99 0.
37 Epidural analgesia with local anesthetics decreases chronic pain 3. 3 months after breast surgery. neuroma pain. anxiety scores decreased (P < 0. high anxiety scores were more frequent (70 vs. P value is associated with the test of group × time effect. respectively).6. 4. Postoperative morphine consumption was also low.3 Various types of pain may also coexist after breast surgery. DN = neuropathic pain. or 12 months after thoracotomy. 70% in each group. Fassoulaki failed to demonstrate a difference in the incidence of chronic pain with gabapentin or mexiletine.8. intercostobrachial neuralgia. . For instance. Jung proposed four distinct pain syndromes: phantom breast pain.35 In a review of neuropathic pain after breast surgery.31 Few published studies have evaluated the prevention of chronic pain after breast surgery. and 12 months after surgery.40–42 These results are in accordance with our results. and other nerve injury pain. Only a trend for decreasing was observed in the ropivacaine group compared to control group between the sixth and the twelfth postoperative month. partially related to intraoperative nerve injury. However. and 12 months after surgery over time. DN4 scores before surgery and 3.39 Better control of acute postoperative pain. Anesthesiology 2013. none of the patients in the treatment group developed chronic iliac crest dysesthesia (0 vs. 37%) in patients with chronic pain than in the other patients.001) and this increase was not statistically different between the two groups (P = 0. and socio-environmental factors are major comorbid and confounding factors. Neuropathic pain was also globally identical in the two groups.38 After posterior spinal arthrodesis. Similarly.001) but depression scores remained stable over time. Fasssoulaki25 randomized 50 patients who underwent breast cancer surgery to one of two groups.3 chronic pain after breast cancer surgery and adjuvant therapy is predominantly characterized by neuropathic pain. The time × group interaction was tested. P value is associated with the test of group × time effect. HAD = hospital anxiety and depression. In addition. local anesthetic infusion at the iliac crest bone graft donor site decreased donor site pain and increased patient satisfaction at a minimum of 4 yr after surgery. in the current study.058). be due to the effective control of acute postoperative pain in the two groups (30% of all patients were pain-free at rest for the first 48 h). 118:318-26 324 Albi-Feldzer et al. Nerve-sparing techniques may reduce the incidence of neuropathic pain without totally eliminating this complication.32 If severe acute postoperative pain is associated with a higher incidence of chronic pain. which is concordant with the absence of difference in terms of chronic pain.Ropivacaine Wound Infiltration and Chronic Pain Fig. with no significant differences between the two groups. 6. 5.29. therefore. and interruption of the nociceptive signal are the most frequent explanations proposed for this phenomenon. Recent data show that chronic pain and other surgical. study compared to the literature. 6. topical local anesthetic and intraoperative irrigation of the brachial plexus and several intercostal Fig. postthoracotomy pain correspond to neuropathic characteristics. HAD scores before surgery and 3. Patients in the multimodal treatment group received gabapentin. The time × group interaction was tested. Based on the results of previous studies.33. The mean DN4 scores increased over time (P < 0.34 the low incidence of chronic and neuropathic pain observed in our study could. the antiproinflammatory properties of local anesthetics. psychosocial. we did not detect any differences for the HAD scores between the two groups. but the incidence of burning pain was statistically lower in the two active treatments groups compared to the placebo group.36. 6.13 One hypothesis is that local or loco-regional analgesia decreased the incidence of neuropathic pain. associated with a low incidence of nausea and vomiting.
As a result other authors have used continuous wound infiltration after mastectomy to prolong analgesia. Buckley E. Patients in the multimodal treatment group had a lower incidence of axilla pain (14 vs. Miaskowski C: Prevalence. Shorten GD: The associations between severity of early postoperative pain. Studts JL. Andrykowski MA. Sloan P. and analgesic use (0 vs. O’Brien J. To test for a statistically significant difference between the two groups. Ip HY. this treatment seems to be more effective when used during minor surgery. an alpha risk less than 5% was accepted (type I error: inappropriately rejecting a true null hypothesis). Iohom G. but interestingly the incidence of chronic and neuropathic pain is similar as well in the published literature as in our study. Jensen TS. Kenady DE: Postmastectomy/postlumpectomy pain in breast cancer survivors. and impact of postmastectomy pain syndrome: An investigation of women’s experiences. J Clin Epidemiol 1998. Although previous studies have failed to demonstrate the analgesic effects of wound infiltration with local anesthetic solutions after abdominal surgery. . 4).19 In addition to providing acute postoperative pain relief. Cunningham L. 103:494. 92:795–801 2. Jung BF. Kehlet H: Chronic postoperative pain: The case of inguinal herniorrhaphy. Anesthesiology 2010. Pain 2003. Br J Anaesth 2001. Gärtner R. arm pain (23 vs. Szarvas S. Wicksell RK. and 12 months were statistically lower in the paravertebral block group. 113: 1260–1 17. Chan J. We did not conduct a post hoc power analysis for DN4 score comparison. Chambers WA: A retrospective cohort study of post mastectomy pain syndrome. 83:91–5 15. Oaklander AL. Kehlet H. 118:318-26 325 these techniques may be an area of future research in chronic pain and also in cancer free-recurrence survival. Lancet 2006. 59%). Perkins FM. JAMA 2009. Ahrendt GM. Ewertz M. References 1. 367:1618–25 9.18.19 Postoperative pain intensity and chronic pain at 3. Br J Anaesth 2008. such as inguinal hernia repair or breast surgery. Squair J. Kehlet H: Perioperative analgesia to prevent chronic postmastectomy pain. Anesth Analg 2006. Abrishami A. Bourne D. Anesthesiology 2011. and posttraumatic stress disorder. The absence of a statistically significant reduction in the severity and incidence of chronic pain despite the better control of acute pain in the current study could have been due to the short duration or to an insufficient analgesic potency of the local anesthetic compared to the potent prolonged multimodal analgesia given to both groups. Aasvang E. In fact. Stevens PE. After testing the difference between the DN4 scores of the two groups (fig.25 Two other studies compared a control group with multimodal analgesia or with multimodal analgesia plus paravertebral block. Jensen MB. Olsson GL: Predicting and preventing chronic postsurgical pain and disability.44 Also. 87:88–98 5. Pain 1999. 104:601–7 18. 93:1123–33 7. 95:69–76 3. Anesthesiology 2009. Nielsen J. Abrishami A. Butler M. Analgesia is probably obtained with paracetamol and ketoprofen in most patients making the combination with wound infiltration less effective. Smith WC. Our study has limitations. Br J Anaesth 2005. It is possible that the number of patients was not sufficient (type II error). Carpenter JS. author reply 494–5 10. Aasvang E. living with a diagnosis of cancer. Wong J. De Kock M: Expanding our horizons: Transition of acute postoperative pain to persistent pain and establishment of chronic postsurgical pain services. A review of predictive factors. thoracic paravertebral block provides better pain control than infiltration after breast surgery and comparisons of Anesthesiology 2013. Dworkin RH: Neuropathic pain following breast cancer surgery: Proposed classification and research update. The chronic pain and neuropathic pain increased significantly over time in both groups (fig.20. it still is not sufficient to consider the difference to be statistically significant. while the control group received a placebo instead of the three active agents. 61:61–8 16. Br J Surg 2005. 45%). Kroman N.PERIOPERATIVE MEDICINE spaces with ropivacaine. Anesthesiology 2000. Chung F. Kehlet H: Prevalence of and factors associated with persistent pain following breast cancer surgery. 101:77–86 6. therefore.45.058 which although close to 0. Cordova MJ. the P value was 0. Pain 1995. 51:1285–92 11. 4). Larney V. loco-regional analgesia reduces the incidence and intensity of chronic pain. 111:657–77 13. but not 6 months after surgery. chronic postsurgical pain and Albi-Feldzer et al. Dibble SL. The number of patients may. Kehlet H: Surgical management of chronic pain after inguinal hernia repair. Anesthesiology 2009. Macrae WA: Chronic pain after surgery. Abdalla H. Macrae WA: Chronic post-surgical pain: 10 years on. anxiety. Several confounding factors were probably present in the first year after surgery delaying the resolution of persistent postoperative pain and increasing neuropathic pain: adjuvant chemotherapy and radiotherapy. 302:1985–92 4. the number of patients for this study was calculated for the main outcome (BPI scores at 3 months) and does allow a robust conclusion concerning this outcome. 23%) 3 months. McGrath PC.18. Chung F: Predictors of postoperative pain and analgesic consumption: A qualitative systematic review. Although the incidence of chronic pain was lower than that reported in the literature. 104:1–13 14. Wong J: Preoperative pain sensitivity and its correlation with postoperative pain and analgesic consumption: A qualitative systematic review.43. Wilder-Smith OH. be sufficient for comparison of neuropathic pain allowing valid conclusions concerning this endpoint. 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