The Post‐mastectomy Pain Syndrome—A Systematic Review of the Treatment Modalities

Post‐mastectomy pain syndrome (PMPS) is a chronic neuropathic pain condition, affecting many women who have undergone breast cancer surgery. The development of PMPS is complex and the treatment options are limited. In this systematic review, we have analyzed the existing treatment modalities of PMPS. Six studies on five treatments were carefully selected, critically evaluated, and presented. The treatments were: antidepressants, anti‐epileptics, topical capsaicin, and autologous fat grafting. Four of these treatments had a significant effect on PMPS. However, most of the studies had several flaws and therefore larger studies of high quality should be performed in the future.     

Greffe de tissu adipeux autologue dans la prise en charge chirurgicale des cicatrices douloureuses : résultats préliminaires

The purpose of this study was to report our experience about the effectiveness of autologous fat injections in the management of painful scars. Between 2010 and 2012, all patients with persistent incisional pain despite a well-conduced 6 months medical treatment received an autologous fat graft according to the technique originally described by Coleman. Results interpretation was based on pain improvement thanks to a Visual Analogic Scale (VAS), postoperative patient satisfaction, reduction on analgesics intake and quality of life improvement. Eleven patients were included, the mean quantity of fat injected was 11 cm³. Nine patients (1.5%) benefited from a complete or significant pain decrease, 74.5% reported being very satisfied or satisfied with the result. The mean reduction of VAS was 3.5 points. We did not observe any complication. Autologous fat grafting is an innovative therapeutic approach and appears to be an attractive concept in the management of scar neuromas resistant to drug treatment, by providing an easy effective and safe surgical treatment.     

Neuropathy After Herniorrhaphy: Indication for Surgical Treatment and Outcome

Background  Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. Methods  In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel’s sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. Results  Forty-three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45–95 min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12 months (preoperative 74 [range: 53–87] months versus 0 [range: 0–34] months; p < 0.0001). Conclusions  The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.     

Fat grafting for chronic heel pain following surgery for adult flatfoot deformity: Pilot study

IntroductionAutologous fat grafting is now a highly popular technique in plastic and reconstructive surgery, with broad applicability for various surgical procedures. Fat grafting can impart contours and augmentation, nourish tissue, modulate scar tissue, and produce regeneration at the recipient site. In this pilot study, the authors suggest that fat grafting may be useful therapeutic adjunct for cases of chronic heel pain following surgery for adult flatfoot deformity.Materials and methodsEight patients with chronic heel pain following surgery for adult flatfoot deformity underwent autologous subcutaneous heel fat grafting and recorded their levels of pain relief for 6 months postoperatively.ResultsThe authors recorded a statistically significant difference (p < 0.001) between pain scale values recorded before (t0) and six months postoperatively (t6). From t0 to t6, mean pain scale values changed from 8.125 to 2.413.ConclusionsVolumetric enhancement of the subcutaneous heel fat pad significantly ameliorated weight-bearing pain in these patients.     

Plate fixation adds stability to two-level anterior fusion in the cervical spine: a randomized study using radiostereometry

This study evaluated whether addition of a cervical spine locking plate (CSLP) in two-level disc fusions improved the postoperative stability and reduced the time to healing. Radiostereometric analysis was used to obtain precise recordings of the three-dimensional motion between the fused vertebrae. Eighteen consecutive patients were operated on with excision of two adjacent cervical discs and anterior horseshoe grafting with autologous bone (Smith Robinson technique). Nine patients were randomized to stabilization with autologous bone grafting and CSLP plate fixation and nine patients to grafting without fixation. Clinical symptoms in terms of pain in the neck and the arm were analysed preoperatively and after 1 year using a visual analogue scale (VAS). The patients operated without a plate displayed increased rotations around the transverse axis, corresponding to the development of a kyphosis [mean value no plate/plate 14.4°/0.8° (repeated measure ANOVA: P < 0.01)]. The mean compression was 3.2 mm larger in patients operated without a plate (repeated measure ANOVA: P < 0.01). Patients operated without a plate had more arm pain at the 1-year follow up (P < 0.05, Mann-Whitney U test). The VAS score for neck pain did not differ significantly between the two groups. Plate fixation could not be demonstrated to increase the healing rate, promote more rapid fusion or influence the frequency of graft complications. Received: 17 September 1997 Revised: 21 February 1998 Accepted: 2 March 1998     

Immediate Breast Reconstruction Does Not Increase Postmastectomy Pain

Background

Postmastectomy pain syndrome (PMPS) is a recognized complication of breast surgery, with a reported prevalence of 20–52 %. We investigated whether patients having immediate reconstruction (IR) reported more long-term pain compared to those having mastectomy alone (MA). We also investigated treatment factors influencing PMPS.

Methods

In a single center, all patients who underwent MA or IR between January 2009 and June 2011 and attended for follow-up between February 2012 and July 2012 were identified. Patients were invited to complete two questionnaires, a pain intensity visual analog scale (VAS, scored 0 to 10) and the PainDetect screening tool for neuropathic pain.

Results

Of 318 patients due to attend, 272 (86 %) submitted complete questionnaires. Of these, 134 (49 %) women had IR (implant based n = 93, pedicled flaps n = 33, free flaps n = 8). The overall point prevalence pain was low, with 221 (81 %) reporting VAS current pain as zero. Only 8 (3 %) patients reported a VAS score above 4. Six (2 %) patients had a positive PainDetect score. The percentage of patients reporting VAS scores greater than zero and positive or borderline PainDetect scores was similar for MA and IR (VAS: 13 and 14 %, respectively; PainDetect: 6 and 11 %, respectively). Radiotherapy was the strongest predictor of neuropathic pain.

Conclusions

In this cohort, the prevalence of PMPS was lower than historic reports. We find no evidence of increased overall pain intensity or chronic neuropathic pain after IR compared to MA despite additional tissue dissection and potential donor site morbidity. This adds support to the positive benefits of breast reconstruction.     

Correction of breast asymmetry by autologous fat grafting with the aid of 3D laser-scanning technology

BackgroundCurrently, the lack of clinically accurate measurement and evaluation methods for breast asymmetry has considerably limited the use of autologous fat grafting in the correction of breast asymmetry.ObjectiveThis study calculated the volume difference in the bilateral breasts by three-dimensional (3D) laser scanning technology, established a bridge between digitalization and surgery to guide the correction of breast asymmetry by autologous fat grafting, and evaluated the surgical effect.MethodsIn the experimental group (3D group), the measurement range was defined by standardized methods, the algorithm to calculate the volume difference in the bilateral breasts was determined by the established software instructions, and the volume of intraoperative autologous fat grafting was guided by personalized data. In the control group, the volume of intraoperative autologous fat grafting was determined based on the surgeon's visual assessment and surgical experience.ResultsThe volume difference in the bilateral breasts was less at 12 months after surgery (P < 0.05), the satisfaction of patients was higher (P < 0.05), and the reoperation rate was lower (P < 0.05). The incidence of postoperative complications was low in both groups (P > 0.05).Conclusions3D laser scanning technology can be used as a bridge between digitalization and surgery to significantly improve the surgical effect of autologous fat grafting in the correction of breast asymmetry, with high patient satisfaction and high clinical application value.     

Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis

Background  The aim of the study was to compare the efficacies of steroid injections guided by scintigraphy, ultrasonography, and palpation in plantar fasciitis. Methods  A total of 35 heels of 27 patients were randomly assigned to three steroid injection groups: palpation-guided (pg), ultrasound-guided (ug), and scintigraphy-guided (sg). Patients were evaluated for pain intensity before the injections and at the last follow-up of 25.3 months with a 100-mm visual analog scale (VAS). Results  There were significant improvements in plantar fascia thickness, fat pad thickness, and VAS. Among the three groups of ug–pg, ug–sg, and pg–sg there were no statistically significant differences after treatment (P = 0.017, MWU = 36.5; P = 0.023, MWU = 29.5; and P = 0.006, MWU = 13, respectively). Conclusions  The ug, pg, and sg injections were effective in the conservative treatment of plantar fasciitis. We are of the opinion that steroid injections should be performed, preferably with palpation or ultrasonographic guidance.     

Pregabalin in the treatment of postmastectomy chronic pain: Results of an open label,single‐arm clinical study

Postmastectomy chronic pain (PMCP) is one of the important survivorship issues faced by breast cancer patients. It is a chronic pain which persists for more than 3 months after mastectomy or quadrantectomy and is considered to be neuropathic in nature. An open label, single‐arm, prospective study was conducted to evaluate the efficacy of Pregabalin in relieving clinically significant PMCP (pain score ≥3 on visual analogue scale). Pregabalin brought about significant reductions in pain (visual analogue scale [VAS] Scores; baseline 5.50 ± 1.197, end of 1 month 2.40 ± 1.430, end of 2 months 2.10 ± 1.370) and significant improvement in quality of life.     

Long-term reduction in pain and disability after surgery with the interspinous device for intervertebral assisted motion (DIAM) spinal stabilization system in patients with low back pain: 4-year follow-up from a longitudinal prospective case series

Patients with low back pain (LBP) suffer chronic disability. In 40% of LBP patients degenerative disc disease (DDD) seems to be the cause. This prospective case series assessed the efficacy of the interspinous device for intervertebral assisted motion (DIAM™) in patients with LBP resulting from DDD. All patients were initially assessed by physical examinations, magnetic resonance imaging, dynamic X-rays and provocative discography. Eligible patients (n = 52) had LBP for a minimum of 4 months, and received surgery with the DIAM™ system 2–4 weeks after diagnosis. Patients were evaluated pre-/post-operatively for pain severity using a visual analogue scale (VAS), and for dysfunction and disability with the Roland–Morris Disability Questionnaire (RMDQ). VAS and RMDQ score changes were assessed using the appropriate contrasts and Bonferroni-corrected P values. As a result, significant (P < 0.0001) pain score reductions were observed between baseline values, and 2 (3.7, 95% CI 3.1; 4.2) and 48 (3.1, 95% CI 2.5; 3.6) months follow-up (intent-to-treat population). Disability scores were significantly (P < 0.0001) reduced between baseline and 2 (8.6, 95% CI 7.4; 9.9) and 48 (7.5, 95% CI 6.1; 8.9) months. Disability scores were similar from months 2 to 48. At 48 months, 67.3% of patients reached the minimum clinically important difference (MCID; ≥1.5-unit improvement) in VAS score and 78.9% of patients reached the MCID (≥30% improvement) in RMDQ score. No complications were associated with surgery. In conclusion, patients with LBP treated with the interspinous DIAM™ system showed significant and clinically meaningful improvements in pain and disability for up to 4 years.     

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient’s and observers’ scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.     

椎管次全环状减压术治疗陈旧性胸腰段骨折伴顽固性神经病理性疼痛

目的:探讨椎管次全环状减压术治疗陈旧性胸腰段骨折伴顽固性神经病理性疼痛患者的临床疗效。方法:2009年9月至2013年9月,采用椎管次全环状减压术治疗陈旧性胸腰段爆裂骨折伴顽固性神经病理性疼痛21例。所有患者初次手术均为后路椎弓根钉系统内固定伴或不伴相应节段椎板切除术。患者均为男性,年龄20~28岁,平均(25.00±2.38)岁;椎体残留骨块椎管内占位>50%;均为完全性脊髓损伤(ASIA级)或马尾神经损伤;VAS评分6~10分,平均(7.14±0.91)分。手术前后对患者进行MRI、CT、X线检查,记录止痛药使用种类及用量,并对患者手术前后的神经功能(ASIA分级)及疼痛状况(VAS评分)进行评估。结果:所有病例获得随访,时间8~32个月,平均(17.29±6.02)个月。21例患者均经后路手术去除椎管内占位骨块,解除其对脊髓、神经根压迫;12例患者感觉平面下移,但ASIA分级没有变化;术后VAS评分0~8分,平均(2.43±2.46)分,与术前比较差异有统计学意义(P<0.05)。其中11例停用镇痛剂,7例镇痛剂减量,3例无改善。结论:陈旧性胸腰椎骨折术后伴严重神经病理性疼痛患者,应尽早行MRI、CT、X线等影像学检查,如果椎管内存在明显占位骨块,椎管次全环状减压术可有效缓解疼痛症状并有利于神经功能的进一步恢复。     

A comparative study of full-thickness skin grafting with and without subcutaneous fat preservation

Skin grafting is an important method of wound repair and reconstruction. Skin grafting can be classified using multiple classification criteria. We often perform full-thickness skin grafting (FTSG) for small wound areas; however, the traditional FTSG technique frequently causes postoperative scar depression at the donor site, especially in the abdomen. This study aimed to determine whether preserving the subcutaneous fat when performing FTSG can improve donor site prognosis. We reviewed 25 patients who underwent autologous FTSG in the last 3 years. Among them, subcutaneous fat was preserved in 11 patients (experimental group), whereas it was not preserved in 14 patients (control group). Using a 3D camera and the Patient and Observer Scar Assessment Scale (POSAS), we evaluated the donor site postoperatively. According to POSAS, vascularization was significantly more severe in the experimental group. The Antera 3D camera revealed more severe scar depression at the donor site in the control group. The processing time for graft take, subcutaneous fat trimming and donor site closure was less in the experimental group than in the control group. Preserving subcutaneous fat at the donor site improved patient outcomes by reducing donor site depression after FTSG.     

Sexual health of women with pelvic floor disorders

Preemptive analgesia in vaginal surgery has had conflicting efficacy reported in the existing literature. This study was designed to clarify the usefulness of preemptive local analgesia (PLA) in patients undergoing vaginal hysterectomy. A prospective, randomized, double-blinded trial of PLA in 90 women undergoing vaginal hysterectomy was conducted. PLA consisted of 20 ml of 0.5% bupivacaine with 1:200,000 epinephrine injected in a paracervical-type fashion. Total narcotic use and pain (using a visual analog scale (VAS)) was recorded at 30 min, 3, 12, and 24 h postoperatively. The mean total dose of narcotic was significantly less in the PLA group versus the placebo group (P = 0.009) at every time point postoperatively. Additionally, the mean pain VAS 30 min and 3 h postoperatively was 43% (P = 0.003) and 33% (P = 0.02) lower, respectively, in the PLA group. PLA with bupivacaine prior to vaginal hysterectomy is associated with significantly lower pain scores and a reduction in narcotic use postoperatively.     

Pain after Open Preperitoneal Repair versus Lichtenstein Repair: A Randomized Trial

Background The open preperitoneal approach in inguinal hernia repair might have the benefit of a mesh in the preferred space without the disadvantages of an endoscopic procedure. Methods A total of 172 patients with primary inguinal hernia were randomized to undergo the open preperitoneal Kugel or the standard open anterior Lichtenstein procedure in a teaching hospital. The main outcome measures were operating variables, visual analog scale (VAS) pain scores, and consumed analgesics during the first 2 weeks postoperatively and at 3 months, neurological examination, and complications. Results In the Lichtenstein group the operation took longer (54 min versus 41 min; p < .001). There were no clinically important differences in VAS pain score or number of analgesics during the first 2 weeks postoperatively. In the Kugel group the mean VAS pain score at 3 months was less (0.3 versus 0.9; p = .002), as was the proportion of patients reporting pain (21 versus 40%; p = .007). Pain was merely described as neuropathic, especially in the Lichtenstein group. With the anterior repair significantly more nerves were encountered, numbness reported, and cutaneous sensory changes found with neurological examination (all p < .001). Conclusions For those surgeons preferring an open approach, the Kugel procedure is a feasible alternative for the standard Lichtenstein procedure and is associated with less chronic pain at three months. Most likely the neuropathic pain and numbness with the Lichtenstein technique are results of more nerves at risk with the anterior approach.     

Jet-assisted fat transfer to the female breast: preliminary experiences

Background

Nowadays, autologous fat grafting is used as a versatile tool for distinct touch-ups after performed breast reconstruction or aesthetic augmentation. Different approaches of fat harvest, filtering, and reinjection have been described in last three decades. After the first report in 2010, the Berlin Autologous Lipotransfer (BEAULI) method became one of the latest popular techniques in the field of large volume fat grafting. Preliminary experiences with the rising jet-assisted fat transfer in a large case series of two specialized European centers are presented.

Methods

Retrospective analysis enrolled over 167 female nonsmokers with reconstructive or aesthetic indications treated with at least one procedure according to the standardized protocol of the BEAULI? technique from February 2010 to June 2012. Patients with weight changes >5 kg and endocrine or cardiovascular comorbidities have been excluded. Demographics and items of the treatment (i.e., grafted volumes per procedure) were enlisted for evaluation. The first outcome has been estimated based on complications rate, pain report (VAS score), and digital photographs after at least 6 months of follow-up.

Results

The included 132 patients (240 breasts) had a mean age of 39.7 years and underwent 487 autologous jet-assisted fat transfer procedures with minor complications (5.35 %) like tiny oil cysts formations or hematoma of the donor site. Low postoperative pain (88.6 % with VAS 1 to 4) has been reported during the first week, and final aesthetic evaluation showed good to excellent results. We observed a higher frequency of procedures, especially in irradiated patients (>3.62) compared to the rest of reconstructive cases (>2.78). The presented data helped us to differentiate the treatment according to the respective indications (reconstructive vs. aesthetic) and to optimize our intern protocol.

Conclusions

Water-jet-assisted liposuction with consecutive immediate mammary fat injection is a procedure with a short hospitalization and low complication rate. Based on the preliminary results in the use of the BEAULI? technique for breast reconstruction and aesthetic augmentation, the authors presume that it can be safely applied for these specific patient groups. Although further studies including long-term follow-up are certainly required to constantly control and compare the presented method to other autologous fat grafting techniques. Level of Evidence: Level III, therapeutic study.     

Effect of internal mammary vessels radiation dose on outcomes of free flap breast reconstruction

To assess the impact of internal mammary (IM) vessels radiation dose on autologous free‐flap based breast reconstruction outcomes. We retrospectively evaluated the medical records of breast cancer patients who underwent mastectomy and free‐flap breast reconstruction after postoperative radiation therapy (RT) to the breast/chest wall with (n = 9) or without (n = 11) electively including the IM lymph nodes. Twenty patients were included. Median age at diagnosis was 50 years (range, 33‐63). The median time interval between the start of RT and reconstructive surgery was 16 months (range, 6‐45). The maximal IM vessels dose was not associated with the risk of all complications (P = 0.44) or fat necrosis (P = 0.31). The mean IM vessels dose was not significant for the risk of all complications (P = 0.13) but was significant for fat necrosis (P = 0.04). A high mean IM vessels dose was related to the occurrence of fat necrosis.     

Autologous Cell-Enriched Fat Grafting for Breast Augmentation

Autologous fat grafting for breast augmentation has faced some historical hurdles. However, in recent years it has been gaining acceptance from the medical community. This prospective, nonrandomized open-label study of 20 Japanese women supports the use of autologous fat grafting in breast augmentation and explores enhancement of fat graft tissue with autologous adipose-derived regenerative cells (ADRCs). After adipose harvesting using syringe liposuction, the tissue is processed in the Celution 800 System^?, which washes the graft and isolates ADRCs. The average cells per gram of harvested adipose tissue was 3.42 × 10⁵, and the mean cell viability measured using an automated cell counting system before graft delivery was 85.3%. All patients demonstrated improvement in circumferential breast measurement (BRM) from their baseline state, and breast measurements were stable by 3 months after surgery. The mean BRM 9 months after surgery had increased 3.3 cm from preoperative measurements. Through 9 months, overall physician satisfaction was 69% and patient satisfaction was 75%. No serious or unexpected adverse events were reported, and the procedure was safe and well tolerated in all patients. Postoperative cyst formation was seen in two patients. These prospective results demonstrate that ADRC-enriched fat grafts processed with a closed automated system maintain high cell viability and that the procedure is safe and effective, with all patients showing improvement after a single treatment.     

Supraspinatus and infraspinatus weakness in overhead athletes with scapular dyskinesis: strength assessment before and after restoration of scapular musculature balance

A disturbance in scapulohumeral rhythm may cause negative biomechanic effects on rotator cuff (RC). Alteration in scapular motion and shoulder pain can influence RC strength. Purpose of this study was to assess supraspinatus and infraspinatus strength in 29 overhead athletes with scapular dyskinesis, before and after 3 and 6 months of rehabilitation aimed to restore scapular musculature balance. A passive posterior soft tissues stretching was prescribed to balance shoulder mobility. Scapular dyskinesis patterns were evaluated according to Kibler et al. Clinical assessment was performed with the empty can (EC) test and infraspinatus strength test (IST). Strength values were recorded by a dynamometer; scores for pain were assessed with VAS scale. Changes of shoulder IR were measured. The force values increased at 3 months (P < 0.01) and at 6 months (P < 0.01). Changes of glenohumeral IR and decrease in pain scores were found at both follow-up. Outcomes registered on pain and strength confirm the role of a proper scapular position for an optimal length–tension relationship of the RC muscles. These data should encourage those caring for athletes to consider restoring of scapular musculature balance as essential part of the athletic training.