title: A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy.
abstract: BACKGROUND
  Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain.
  
  
  METHODS
  A systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy.
  
  
  RESULTS
  Thirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another.
  
  
  CONCLUSIONS
  Appropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear.
authors.affiliation: Department of Anaesthetics and Pain Management, Charing Cross Hospital, London, UK; Peripheral Neuropathy Unit, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London, UK.
authors.forename: S R
authors.initials: SR
authors.lastname: Humble
authors.forename: A J
authors.initials: AJ
authors.lastname: Dalton
authors.forename: L
authors.initials: L
authors.lastname: Li
mesh_terms: D059787:Acute Pain / Q000628:therapy*; D000779:Anesthetics, Local; D059350:Chronic Pain / Q000628:therapy*; D006801:Humans; D008408:Mastectomy; D010149:Postoperative Pain / Q000628:therapy*; D013908:Thoracotomy; D016896:Treatment Outcome
chemical_list: D000779:Anesthetics, Local
references.citation: Anesth Analg. 2002 Jan;94(1):11-5, table of contents
references.pmid: 11772793
references.citation: Science. 2000 Jun 9;288(5472):1765-9
references.pmid: 10846153
references.citation: J Cardiothorac Vasc Anesth. 2010 Aug;24(4):608-16
references.pmid: 20005744
references.citation: Anesth Analg. 2005 Nov;101(5):1427-1432
references.pmid: 16244006
references.citation: Anesthesiology. 2002 Nov;97(5):1234-44
references.pmid: 12411810
references.citation: Br J Anaesth. 2006 Mar;96(3):353-60
references.pmid: 16415310
references.citation: Pain. 2003 Oct;105(3):415-423
references.pmid: 14527702
references.citation: Paediatr Anaesth. 2008 Apr;18(4):335-7
references.pmid: 18315645
references.citation: Anesthesiology. 2003 May;98(5):1214-22
references.pmid: 12717144
references.citation: Curr Opin Support Palliat Care. 2008 Jun;2(2):133-9
references.pmid: 18685411
references.citation: Pain. 1992 Jan;48(1):21-27
references.pmid: 1738570
references.citation: Pain. 2007 Dec 5;132(3):237-251
references.pmid: 17920770
references.citation: Pain Pract. 2012 Mar;12(3):175-83
references.pmid: 21676165
references.citation: J Postgrad Med. 2009 Oct-Dec;55(4):257-60
references.pmid: 20083871
references.citation: Anaesth Intensive Care. 2004 Jun;32(3):330-8
references.pmid: 15264726
references.citation: Can J Anaesth. 1999 Dec;46(12):1127-32
references.pmid: 10608205
references.citation: Br J Anaesth. 2012 Jan;108(1):126-33
references.pmid: 21980121
references.citation: Minerva Anestesiol. 2012 Jul;78(7):757-66
references.pmid: 22441361
references.citation: Clin J Pain. 2010 Jun;26(5):381-5
references.pmid: 20473044
references.citation: Lancet. 1997 Nov 8;350(9088):1353-7
references.pmid: 9365449
references.citation: Lancet. 2006 May 13;367(9522):1618-25
references.pmid: 16698416
references.citation: Anesthesiology. 2011 May;114(5):1144-54
references.pmid: 21368651
references.citation: Anesthesiology. 2006 Mar;104(3):570-87
references.pmid: 16508405
references.citation: Clin J Pain. 2012 Sep;28(7):567-72
references.pmid: 22699129
references.citation: Clin J Pain. 2011 May;27(4):304-8
references.pmid: 21178605
references.citation: Ann Fr Anesth Reanim. 2008 Dec;27(12):979-86
references.pmid: 19013751
references.citation: Anesthesiology. 2013 Feb;118(2):318-26
references.pmid: 23340351
references.citation: Eur J Cardiothorac Surg. 2012 May;41(5):1078-82
references.pmid: 22290901
references.citation: Eur J Pain. 2009 May;13(5):497-505
references.pmid: 18783971
references.citation: Reg Anesth Pain Med. 2000 Jul-Aug;25(4):350-5
references.pmid: 10925929
references.citation: Acta Anaesthesiol Scand. 2008 Sep;52(8):1038-45
references.pmid: 18840101
references.citation: N Engl J Med. 2003 Nov 13;349(20):1943-53
references.pmid: 14614170
references.citation: Pain. 2005 Mar;114(1-2):29-36
references.pmid: 15733628
references.citation: Anesth Analg. 2008 Nov;107(5):1720-5
references.pmid: 18931238
references.citation: Pain. 2011 Jun;152(6):1279-1288
references.pmid: 21398038
references.citation: Anesthesiology. 2002 Sep;97(3):560-4
references.pmid: 12218520
references.citation: J Korean Med Sci. 2004 Feb;19(1):74-8
references.pmid: 14966345
references.citation: Ann Thorac Surg. 2003 Oct;76(4):1055-8
references.pmid: 14529984
references.citation: Pain. 1987 Aug;30(2):191-197
references.pmid: 3670870
references.citation: Anesth Analg. 2002 Oct;95(4):985-91, table of contents
references.pmid: 12351281
references.citation: Ann Thorac Surg. 2011 Mar;91(3):869-73
references.pmid: 21353017
references.citation: BMC Anesthesiol. 2011 Nov 24;11:23
references.pmid: 22114900
references.citation: Pain. 2008 Mar;135(1-2):108-18
references.pmid: 17583431
references.citation: Anesth Analg. 2006 Sep;103(3):703-8
references.pmid: 16931684
references.citation: Eur J Cardiothorac Surg. 2013 Mar;43(3):e64-70
references.pmid: 23248207
references.citation: Br J Anaesth. 2008 Jul;101(1):77-86
references.pmid: 18434337
references.citation: Scand J Gastroenterol. 2005 Nov;40(11):1358-64
references.pmid: 16334446
references.citation: Anaesthesia. 2004 Nov;59(11):1073-7
references.pmid: 15479314
references.citation: Anesth Analg. 2010 Jan 1;110(1):199-207
references.pmid: 19910619
references.citation: Nat Neurosci. 2007 Nov;10(11):1361-8
references.pmid: 17965656
references.citation: Acta Anaesthesiol Scand. 2011 Mar;55(3):290-6
references.pmid: 21288209
references.citation: Interact Cardiovasc Thorac Surg. 2013 Jun;16(6):814-8
references.pmid: 23424242
references.citation: J Pain. 2007 Feb;8(2):102-9
references.pmid: 16949876
references.citation: Rev Esp Anestesiol Reanim. 2011 May;58(5):290-4
references.pmid: 21692253
references.citation: Pain. 2001 May;92(1-2):147-57
references.pmid: 11323136
references.citation: Curr Opin Anaesthesiol. 2008 Oct;21(5):590-5
references.pmid: 18784484
references.citation: Eur J Cardiothorac Surg. 2012 Oct;42(4):e58-65
references.pmid: 22790008
references.citation: Eur J Pain. 2008 Apr;12(3):378-84
references.pmid: 17870625
references.citation: Anesthesiology. 2010 Mar;112(3):514-5
references.pmid: 20124977
references.citation: Anesthesiology. 2006 Nov;105(5):1008-15
references.pmid: 17065896