Assiut University - Acute and Chronic Pain Following Modified Radical Mastectomy


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Acute and Chronic Pain Following Modified Radical Mastectomy


Assiut University

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Breast cancer is the most frequent neoplastic tumor in women, and surgical treatment is indicated in most patients. Complications related to this treatment, such as post-mastectomy pain syndrome (PMPS), a persistent pain that develops after surgery, have been reported. Although the genesis of the pain is multifactorial, sectioning of the intercostobrachial nerve is the nerve lesion diagnosed more often (1) . It is reported that post-mastectomy pain syndrome (PMPS) is a common problem, ranging from 25% to 60%. The pain is localized in the axilla, medial upper arm, breast, and/or chest wall and lasting beyond three months after surgery when all other causes of pain such as infection have been eliminated. This pain seriously affects the patient's mood, everyday activities, and social functions and causes heavy economic burden for the healthcare system. Several risk factors for the development of persistent postsurgical pain have been proposed, including adjuvant therapy, age, psychosocial status, preoperative breast pain, type of surgery, type of analgesia, and genetics (2). The pathogenic mechanisms of PMPS are multifactorial including tissue injury, nerve damage related to surgical procedures, and neuroma pain. Different types of sensory disturbances (e.g., numb, electric shock, distending, itchy, burning, or loss of sensation) are sequel to surgery and may be an important part of the pain characteristics (2). The concept of preemptive analgesia has gained popularity and previous studies have demonstrated the value of preemptive effect of some drugs such as opioid, local anesthetics, and nonsteroidal anti-inflammatory drugs (3). Pain relief using drugs with high efficacy provides significant improvement in the patients' lives. Drugs like lamotrigine (LTG) and gabapentin (GBP) have the ability to overcome the symptoms of neuropathic pain (4). Both LTG and PGB have been extensively reviewed in the past for management of painful neuropathic conditions (5). Lamotrigine inhibits the voltage-gated sodium and calcium channels. Inhibition of the voltage-gated sodium channel stabilizes the presynaptic neuronal membrane, thus preventing the release of excitatory neurotransmitters such as glutamate and inhibiting sustained repetitive neuronal firing. These merits of lamotrigine are suggestive of its antinociceptive properties (6). Lamotrigine has weak 5-hydroxytryptamine-3 (5-HT3) receptor inhibitory action as well (7). Lamotrigine-mediated blockade of supraspinal 5-HT3 receptors in the spinal descending pronociceptive pathway may also have contributed to its antinociceptive potentials (8). The clinical finding of superior preemptive analgesic efficacy of lamotrigine compared to diclofenac can be explained on the basis of these multimodal actions (5). Pregabalin is a structural analogue of the inhibitory neurotransmitter gama-aminobutyric acid (GABA), with anticonvulsant, antihyperalgesic, and anxiolytic properties such as gabapentin, but with a more favorable pharmacokinetic profile (9, 10). There are several reports for the use of pregabalin in the management of postoperative pain with a positive result in a variety of surgical models (11-13). In addition, both drugs have minimal effects on hematological and biochemical indices, are not associated with hepatic enzyme induction, have minimal drug interactions and protein binding which makes them suitable for use (10). Also, in comparison to other drugs, both require only twice daily administration, increasing the patient's compliance substantially. The adverse-effect profiles of both the drugs have also been found to be acceptable (14). The aim of our study is to compare analgesic effect of pre-emptive oral lamotrigine 100 mg versus pregabalin 150mg on acute postoperative and chronic post-mastectomy pain following modified radical mastectomy


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