An estimated 11-57% of patients will develop persistent pain after major breast surgery, it will be moderate to severe in 5-10% of patients. ANZCA chapter 1, Table 1.2, p 11. Risk factors include radiotherapy, younger age, higher postoperative pain scores and major reconstructive surgery. Early and aggressive treatment of pain may be beneficial in reducing the likelihood of developing chronic pain after breast surgery. ANZCA chapter 9, %u2018Post mastectomy pain syndrome%u2019, p 237.

Evidence-based treatment recommendations specific to the condition

For an overview of recommendations see: PROSPECT/ non-cosmetic breast surgery/Overall Prospect recommendations

For an overview of treatments that are NOT recommended see PROSPECT /non-cosmetic breast surgery/NOT recommended

Pre-and intraoperative

Systemic-based options

Gabapentinoids given in the peri-operative period can reduce postoperative pain and pain on movement ANZCA ,chapter 9, %u2018Post mastectomy pain syndrome%u2019, p 237. PROSPECT/non-cosmetic breast surgery/overall recommendations/pre-operative recommendations

COX-2-selective inhibitors or paracetamol in short breast surgery procedures to provide sufficient analgesia in the early recovery period.

Local, regional analgesia-based techniques

Paravertebral block (PVB) as injection or infusion may be employed as the sole anesthetic technique for major breast surgery. PROSPECT/non-cosmetic breast surgery/overall recommendations/pre-operative recommendations

PVB reduced postoperative opioid requirements, with minimal side effects and a shorter hospital stay ANZCA chapter 9, %u2018Post mastectomy pain syndrome%u2019, p 237.

PVB may reduce the incidence of chronic pain after major breast surgery French section 8.2, p 407, and has been shown to reduce nausea at 24 hours following cosmetic breast surgery but not in patients after breast cancer surgery ANZCA chapter 7, %u2018Paravertebral blocks%u2019, page 198.

NOT recommended

• PVB is not recommended for routine pain relief following minor breast surgery, in a day care surgery setting, as the risks may outweigh the benefits ANZCA chapter 9, %u2018Paravertebral blocks%u2019, p 239, PROSPECT / non-cosmetic surgery/summary recommendations/not recommended.

Postoperative

Systemic analgesia

Whenever possible, patients should be given multimodal pain management.

• COX-2 selective NSAIDs, non-selective NSAIDs, and calcium channel %u03B1-2-%u03B4 antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
• Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or paracetamol. ASA section V Multimodal techniques for Pain Management, p 253-254.

Paracetamol and nsNSAIDs or cox-2 selective inhibitors combined with strong opioids for severe pain or weak opioids for moderate to weak pain PROSPECT /non-cosmetic breast surgery/summary recommendations/postoperative

Continuous wound infiltration may be used after major breast surgery, although paravertebral blockade is preferred French section 9.2 p 407.

Summary

A targeted multimodal approach to pain relief, incorporating paravertebral local anesthetic nerve blockade, can reduce postoperative pain and analgesic requirements following major breast surgery, with minimal adverse effects.

Supplementary reading

1. Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: a critical review of risk factors and strategies for prevention. J Pain. 2011 Jul;12(7):725-46.
2. Vadivelu N, Schreck M, Lopez J, Kodumudi G, Narayan D. Pain after mastectomy and breast reconstruction. Am Surg. 2008 Apr;74(4):285-96.