Post-surgical pain can lead to phantom limb pain, residual limb pain, or even Post-mastectomy pain syndrome (PMPS). PMPS can be defined as chronic pain that persists after breast surgery in the post-surgical area and area surrounding it. Typically after breast surgery, patients may experience PMPS. Patients expressing Post-mastectomy pain syndrome typically show effects after procedures such as mastectomy and reduction mammoplasty. People suffering from PMPS tend to be diagnosed infrequently and have limited treatment options including, opioid medications which tend to be ineffective. In, "Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief," Khoury et al. analyzed the effects of trigger point injections in individuals experiencing PMPS that underwent either a mastectomy or mammoplasty with/or without reconstruction. Previous research has been shown linking PMPS after breast surgeries to the formation of neuromas, specifically in the T4 and T5 cutaneous intercostal nerve branches. A neuroma can cause chronic pain and is the blunt and benign end of damaged nerve tissue. These researchers wanted to use injections of bupivacaine and dexamethasone to reduce pain in people with PMPS. The chest wall contains the T4 and T5 intercostal nerve branches where it is common for people with PMPS to experience pain in this region. These researchers predicted that trigger points, or focal points of the radiating pain, can be located through clinicals and can be used for injections sites to help relieve pain. In the article, "Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees" by Dumanian et al. they studied how the Targeted Muscle Reinnervation (TMR) technique can reduce pain in people with phantom limb pain and residual limb pain. Treatment for these types of pain includes nerve ablations and neurotoxin injections which have been ineffective in some cases. TMR allows surgeons to remove neuromas and connect the residual nerve to an adjacent motor neuron. The TMR technique was originally made for TMR prosthesis control, but studies have shown it to be effective for postamputation pain. TMR could be a potential treatment to reduce pain in people with PMPS that underwent a mastectomy or reduction mammoplasty.
In the study done by Dumanian and his colleagues, twenty-eight amputee participants underwent a randomized clinical trial splitting the group up into participants that receive TMR and participants that receive standard neuroma surgery to analyze which technique is the most effective to treat phantom limb pain. Participants rated their pain on two pain scales including the NRS and PROMIS scale. MRI scans were completed on patients to record any potential complications after the operation. Through the researchers' results, TMR showed evidence for decreasing phantom limb pain (PLP) in participants. There was also evidence showing a positive trend for participants that underwent TMR with residual limb pain compared to those who had standard neuroma surgery. The applications of TMR have been shown to improve PLP and can potentially be effective for PMPS. TMR being used to treat postamputation pain can lead to experimenting TMR as treatment for other chronic pain like PMPS that is associated with the formation of neuromas.
The article, "Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief," by Khoury et al. uses trigger point injections to help relieve pain in individuals with PMPS. These researchers had fifty-two women who underwent mammoplasty with or without reconstruction and mastectomy to participate in this experiment and proceeded to inject them with a combination mixture of bupivacaine and dexamethasone to reduce pain in individuals with PMPS. This combination of drugs has been known to help improve pain caused by neuromas. These researchers used trigger points to localize the point of injection. Khoury et al.'s results support that trigger point injections can lead to pain reduction in individuals with PMPS. Trigger point injection is a non-invasive technique that is safe and effective in treating PMPS. But this research is limited and without a long period of data collection researchers don't know how long pain reduction could last. Some people also require multiple injections to maintain pain regulation. TMR might be an effective one-time treatment to help manage and reduce pain in people with PMPS. Although TMR has been used to reduce PLP, it might potentially be useful for PMPS management.
It is apparent in both studies that people suffering from chronic pain due to PMPS live uncomfortable lives. Khoury et al. research emphasizes the need for better treatment for PMPS and uses trigger injection points to help create a more effective treatment. This research is beneficial for people who underwent breast surgery and want a variety of treatment options to help with potential pain symptoms after their procedure. These injections have limitations including the need of multiple injections over a persistent time period and possible research may find results showing that this method might be proven to be ineffective after a person's immune system builds tolerance to the injection. The Dumanian et al. stud talks about how TMR could be effective in reducing PLP. TMR works to target neuromas that also play a factor in PMPS which might be beneficial for future studies as another treatment option for people with PMPS.
Works Cited
Dumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, Ertl WJ, Tintle SM, Nanos GP, Valerio IL, Kuiken TA, Apkarian AV, Porter K, Jordan SW. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Ann Surg. 2019 Aug;270(2):238-246. doi: 10.1097/SLA.0000000000003088. PMID: 30371518.
Khoury, A.L., Keane, H., Varghese, F. et al. Trigger point injection for post-mastectomy pain: a simple intervention with high rate of long-term relief. npj Breast Cancer 7, 123 (2021). https://doi.org/10.1038/s41523-021-00321-w
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