Postmastectomy pain syndrome after preoperative stellate ganglion block: a randomized controlled trial.

BACKGROUND: This study investigated the effect of preoperative ultrasound (US) guided stellate ganglion block (SGB) with bupivacaine on the frequency of post mastectomy pain syndrome (PMPS). METHODS: Eighty patients scheduled for mastectomy with axillary dissection for breast cancer were included in this randomized controlled trial. Patients were randomized into two equal groups: Group A received US guided SGB one hour before surgery using five mL of 0.5% bupivacaine and multimodal systemic analgesia, Group B (control) received multimodal systemic analgesia only. Patients were followed up for six months. PMPS was assessed using the grading system for neuropathic pain (GSNP). Postoperative opioid consumption in the first 24 hours and numeric rating scale (NRS) were documented. Patient daily activity and functional capacity were evaluated using the Eastern Cooperative Oncology Group (ECOG) score. RESULTS: PMPS proportion was significantly lower in group A than group B (30% vs. 62.5%, P=0.004; 52% decrease [95% CI: 18.4%-71.8%]). Postoperative opioid consumption and NRS were significantly lower in group A as compared to group B. ECOG score was significantly higher in Group A than Group B. CONCLUSIONS: Following mastectomy with axillary dissection, preoperative US guided SGB is associated with less PMPS proportion, postoperative pain and opioid consumption and better patient daily activity and functional capacity.

The impact of ultrasound-guided continuous serratus anterior plane block versus intravenous patient-controlled analgesia on the incidence and severity of post-thoracotomy pain syndrome: A randomized, controlled study.

OBJECTIVE: The aim of this randomized controlled trial was to evaluate U/S guided serratus anterior plane catheter block (SAPB) versus patient-controlled analgesia (PCA) on the emergence of post-thoracotomy pain syndrome (PTPS) after thoracotomies for thoracic tumours. METHODS: This trial included 89 patients with chest malignancies, scheduled for thoracotomy were randomly allocated into two groups: Group A "PCA-group N=44" receiving patient-controlled analgesia and group B "SAPB group N=45" where analgesia was provided by SAPB. The primary outcome measure was the assessment for the possible emergence of PTPS at 12 weeks. The secondary outcome measures were pain relief measured using visual analog scale (VAS) score, Quality of life was assessed using Flanagan Quality of Life Scale (QOLS) and Activity level was assessed using Barthel Activity of daily living (ADL) score. RESULTS: At week 8, PTPS incidence was significantly (p = .037) higher in the PCA group (45%) than in the SAPB group (24%) with a relative risk of 1.38 and 95% CI (1.01-1.9) while the incidence of PTPS at week 12 was significantly (p = .035) higher in the PCA group (43%) than in the SAPB group (22%) with a relative risk of 2.38 and 95% CI (1.23-4.57). The need for pain therapy in PTPS patients was significantly lower in the SAPB group (17.7%) than the PCA group (38.6%) (p = .028) at week 12. Pain intensity: VAS-R and VAS-D (pain scores at rest and with activity, respectively) was comparable (p > .05) between both groups at 6, 12, 18 and 24 hr, however VAS was significantly higher in the PCA group at week 8 (p = .046) and week 12 (p = .032) . Both groups were comparable regarding ADL and QOL scores (p > .05). CONCLUSION: Serratus anterior plane block is assumed to be a good alternative for post-thoracotomy analgesia following thoracotomies. The current work hypothesized that SAPB for a week postoperatively, may reduce the emergence of PTPS and may reduce the demand for pain therapy in those patients. SIGNIFICANCE STATEMENT: The current work hypothesized that SAPB for a week postoperatively, is a good loco-regional alternative for post-thoracotomy analgesia following thoracotomies for chest malignancies, it may reduce the emergence of PTPS and the demand for pain therapy in these patients.

Ultrasound-guided continuous serratus anterior plane block: dexmedetomidine as an adjunctive analgesic with levobupivacaine for post-thoracotomy pain. A prospective randomized controlled study.

Purpose: The study aimed to evaluate the analgesic efficiency of dexmedetomidine (DEX) when added to levobupivacaine in continuous ultrasound-guided serratus anterior plane block (SAPB) performed at the end of major thoracic surgery. Methods: This randomized, double-blind trial included 50 adults undergoing thoracic surgery. Continuous SAPB was performed at the end of surgery. Patients were randomized into two groups. Group L (n=25) received levobupivacaine only while Group DL (n=25) received a mixture of levobupivacaine and DEX. All patients received intravenous (IV) paracetamol every 8 hrs. Morphine IV was given according to VAS score of pain as a 5 mg loading dose. The primary outcome measure was postoperative pain intensity. Secondary outcome measures were postoperative morphine consumption and adverse effects. Results: Analgesia was satisfactory in the two groups up to 24 hrs. VAS score was significantly lower in group DL compared to group L between 6 and 24 hrs postoperatively. Total morphine consumption was significantly lower in group DL compared to group L (p<0.001). Up to 12 hrs postoperatively, sedation score was significantly lower in group DL compared to group L. Afterwards, all patients were fully alert. All values of mean arterial pressure and heart rate were within the clinically accepted ranges. There were no recorded cases of hypotension or bradycardia in the whole studied group. Conclusions: Continuous SAPB with levobupivacaine plus DEX seems to be a promising analgesic alternative following thoracotomy. Combined with IV paracetamol, this approach provided adequate analgesia and proper sedation. Trial registration: ISRCTN registry; study ID: ISRCTN35517318.

The Possible Preventive Role of Pregabalin in Postmastectomy Pain Syndrome: A Double-Blinded Randomized Controlled Trial.

CONTEXT: Chronic postmastectomy pain syndrome (PMPS) has a considerable negative impact on the quality of life of breast cancer patients. OBJECTIVE: The objective of this study was to assess the possible preventive role of perioperative pregabalin in PMPS. METHODS: This randomized controlled study included 200 patients with breast cancer scheduled for elective breast cancer surgery. They were randomly assigned to one of two treatment groups. The pregabalin group received 75 mg of pregabalin twice daily for seven days and the control group received oral equivalent placebo capsules. The primary outcome was development of neuropathic PMPS. Neuropathic pain was assessed using the Grading System for Neuropathic Pain. Secondary outcome measures were safety and Visual Analogue Scale scores. RESULTS: Neuropathic pain was significantly less frequent in the pregabalin group compared to the control group at four weeks (P = 0.005), 12 weeks (P = 0.002), and 24 weeks (P < 0.001) postoperatively. PMPS was diagnosed in 11 patients (11%) of the pregabalin group and 29 patients (29%) of the control group (P < 0.001, relative risk: 0.26, 95% CI: 0.12-0.56). At the three follow-up time points, Visual Analogue Scale scores during the first three postoperative weeks were comparable in both groups while they were significantly lower in the pregabalin group at 4, 12, and 24 weeks. These two groups were comparable in the frequency of adverse events (P = 0.552). CONCLUSION: Perioperative oral pregabalin 75 mg twice daily, starting at the morning of surgery and continued for one week, could reduce the frequency of postmastectomy pain syndrome.

The impact of intravenous dexamethasone on the efficacy and duration of analgesia of paravertebral block in breast cancer surgery: a randomized controlled trial.

PURPOSE: The study aimed at the evaluation of the impact of intravenous (IV) dexamethasone on efficacy and duration of analgesia of paravertebral block (PVB) in patients undergoing modified radical mastectomy (MRM). PATIENTS AND METHODS: This randomized, double-blind controlled trial included 50 patients with breast cancer scheduled for unilateral MRM. Ultrasound-guided PVB was performed in out-of-plane technique. The technique was repeated at each segment from C7 to T6. The participants were randomly allocated to one of two groups. Group BD (n=25) received IV 8 mg dexamethasone diluted with 8 mL of normal saline to reach 10 mL solution, while Group B received IV 10 mL normal saline. Top-up local infiltration analgesia into the surgical field was performed by the surgeon if needed using lidocaine 1% intraoperatively. Propofol infusion of 50-100 µg/kg/min was maintained throughout the surgery. The time to administration of the first postoperative analgesic dose, pain intensity as visual analog scale (VAS) score, number of patients who required rescue morphine analgesia, total morphine consumption, postoperative nausea and vomiting (PONV) impact scale, and the overall satisfaction of patients with pain management were measured. RESULTS: Fifty patients were randomized and analyzed. The time to first rescue analgesic dose was significantly longer in Group DB (P<0.001). The VAS scores were significantly lower in Group DB compared to Group B up to 12 hours postoperatively. Morphine consumption was lower in Group DB compared to Group B. PONV Impact Scale score was significantly higher in Group B. CONCLUSION: Systemic dexamethasone increased the efficacy and duration of the single-shot multilevel PVB in breast cancer surgery. TRIAL REGISTRATION: ISRCTN registry, study ID: ISRCTN15920148.

A Novel Technique of Saddle Rhizotomy Using Thermal Radiofrequency for Intractable Perineal Pain in Pelvic Malignancy: A Pilot Study.

BACKGROUND: The prevalence of pain in advanced pelvic cancer may reach up to 95%. Control of such pain is often difficult owing to a variety of neuroanatomical and functional peculiarities. Different modalities have been utilized to treat this pain including saddle chemical rhizolysis with the potential for jeopardizing the neural control of the sphincters. OBJECTIVE: The aim of this pilot study is to determine the feasibility of using selective thermal radiofrequency as an alternative to saddle chemical rhizolysis in patients with refractory perineal pain associated with pelvic malignancies. STUDY DESIGN: Pilot study. SETTING: Pain Relief Department of the National Cancer Institute, Cairo University. METHODS: Forty patients, 18 years of age or older, who had pelvic malignancy and were complaining of moderate or severe perineal pain not controlled with maximum tolerable doses of morphine sulfate for at least 4 weeks were randomly allocated to receive selective saddle rhizotomy using thermal radiofrequency ablation of S3 on one side and bilateral ablation of S4 and S5 (RF group, n = 20) or conventional chemical rhizotomy using hyperbaric 6% phenol in glycerin (Phenol group, n = 20). Patients were assessed for the intensity of pain, daily consumption of analgesics, functional improvement, overall patient satisfaction, degree of disability and occurrence of procedure-related side effects at 1,4, and 12 weeks. RESULT: The results were comparable in both groups regarding the control of pain and functional improvement. The incidence of specific procedure-related adverse outcomes was also equivalent for both interventions, although per-patient incidence of major complications was significantly higher in the phenol group. LIMITATION: Small sample size to demonstrate statistical significance of the relatively small frequency of events, and the patients could not be blinded to the intervention they received owing to the technical uniqueness of either intervention. CONCLUSION: Selective thermal radiofrequency ablation of the S3 root on one side, S4 root on both sides, and S5 roots could serve as a feasible alternative to conventional saddle rhizotomy using hyperbaric phenol. KEY WORDS: Perineal cancer pain, chemical rhizotomy, thermal radiofrequency.

Thermal Versus Super Voltage Pulsed Radiofrequency of Stellate Ganglion in Post-Mastectomy Neuropathic Pain Syndrome: A Prospective Randomized Trial.

BACKGROUND: Breast cancer is the second most common cancer world-wide following lung cancer. Post-mastectomy pain syndrome (PMPS) is one of the chronic post-surgical pain disorders (CPSP) of neuropathic character; nearly 20-50% of patients may develop PMPS. Stellate ganglion blockade has been performed as a diagnostic, prognostic, or therapeutic intervention for different pain syndromes. OBJECTIVE: The aim of this study is to evaluate and compare the efficacy and safety of thermal versus super voltage pulsed radiofrequency (RF) application of stellate ganglion in neuropathic PMPS in cancer patients. STUDY DESIGN: A prospective, double-blind, randomized, and controlled trial. METHODS: Eighty patients with PMPS after surgery for breast cancer were recruited from the pain clinic of the National Cancer Institute with pain duration of more than 6 months and less than 2 years, visual analog scale (VAS) >/= 40 mm, and not responding to oxycodone and pregabalin for at least 4 weeks. The pain had to be of positive neuropathic character, as detected by the grading system for neuropathic pain (GSNP; score of 3 or 4). The patients were allocated into 2 equally sized groups: Group A: Pulsed RF; super voltage pulsed RF was applied with a time of 360 seconds at 42º C, with a pulse width of 20 m/sec and voltage of 60-70 v. Group B: Thermal RF; thermal RF neurolysis was applied with a time of 60 seconds at 80º C, and was then was repeated twice after needle-tip rotation. Stellate ganglion RF therapy was done under fluoroscopy, integrated by ultrasound guidance. The patients were assessed for pain relief by change in VAS score, functional improvement, and the analgesic concomitant medication (oxycodone and pregabalin) consumption prior to block and at 1, 4, 12, and 24 weeks thereafter. The impact of treatment on quality of life (assessed by short-form health survey questionnaire [SF-36]) and patient function capacity (assessed by the Eastern Cooperative Oncology Group [ECOG]) were also recorded. RESULTS: The percentage of patients who had successful response was significantly higher in the thermal RF group compared to the pulsed RF group at the first week and first, third, and sixth months, with significant difference in post-mastectomy pain intensity, functional improvement, and less rescue analgesia. There was no significant difference in quality of life or patient functional capacity. LIMITATIONS: A longer follow-up period may be needed for the evaluation of RF effect on PMPS. CONCLUSIONS: Thermal RF of the stellate ganglion is a safe and successful treatment for PMPS. It appears to be more effective than pulsed RF of the stellate ganglion in this pain syndrome. KEY WORDS: Cancer breast, post mastectomy pain syndrome, stellate ganglion block, radiofrequency therapy.

Comparative study on the analgesic effect of acute ipsilateral shoulder pain after open thoracotomy between preoperative ultrasound guided suprascapular nerve block (SNB) and intraoperative phrenic nerve infiltration (PNI) in cancer lung patients.

INTRODUCTION: Acute ipsilateral shoulder pain (ISP) is a common complaint in patients after thoracotomy. The incidence ranges from 21% to 97%. Unfortunately, clinical studies did not put enough focus on ISP post thoracic surgery. AIM OF THE WORK: This study was designed to compare the effectiveness of suprascapular nerve block (SNB) and phrenic nerve infiltration (PNI) for controlling ISP. PATIENTS AND METHODS: One hundred and thirty-five lung cancer patients (135) scheduled for open-lung surgery were randomly allocated into three equal groups; control group: received thoracic epidural with general anesthesia, suprascapular group: (SNB) one hour before the operation with 10 ml bupivacaine plus thoracic epidural with general anesthesia and phrenic nerve group: (PNI) was performed by the operating surgeon with 10 ml bupivacaine plus thoracic epidural with general anesthesia. The visual analogue score (VAS) of ISP, rescue of ketorolac for break through shoulder pain, peak expiratory flow rate (PEFR) and arterial blood gases were measured every 6 h postoperatively for 48 h. RESULTS: The VAS, rescue doses of ketorolc and PEFR were significantly lower in the phrenic nerve group (P-value <0.05). There was no statistically significant difference between the three groups postoperatively as regards arterial blood gases (P-value >0.05). CONCLUSION: PNI is more effective than SNB for ISP.