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Predictors of Post-operative Pain One Week After Breast Reconstruction
Anita R. Kulkarni, MD1, Andrea L. Pusic, MD, MHS1, Randy S. Roth, PhD2, Jenni B. Hamill, MPH3, Hyungjin M. Kim, ScD3, David Childers, MA3, Edwin G. Wilkins, MD, MS3.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2University of Michigan Health Systems, Ann Arbor, MI, USA, 3University of Michigan, Ann Arbor, MI, USA.
Previous research has shown that patient characteristics such as age, anxiety, and depression may be associated with increased postoperative pain. Furthermore, poor control of postoperative pain may put patients at increased risk for developing chronic post-surgical pain. Breast reconstruction patients have not traditionally been included in these analyses; therefore, we sought to prospectively evaluate patients undergoing breast reconstruction to identify patient factors that are associated with more severe early postoperative pain.
As part of the Mastectomy Reconstruction Outcomes Consortium (MROC) study, patients undergoing breast reconstruction at 11 centers in the United States and Canada were prospectively evaluated for mood disturbance (anxiety and depression) and sociodemographic characteristics. Pain assessments were made preoperatively and at 1-week postoperatively using the McGill Pain Questionnaire (MPQ) Short Form (2 subscales - Sensory and Affective pain) and the Numerical Pain Rating Scale (NPRS). Regression model was used to assess the relationships between patient factors (independent variables) and 1-week post-op pain (dependent variable). Patient factors considered to be potential predictors of pain included age, preoperative depression as measured by the Patient Health Questionnaire (PHQ-9), preoperative anxiety as measured by the General Anxiety Scale (GAD), preoperative pain scores, and various procedural factors including type of reconstruction, timing of reconstruction (immediate vs. delayed) and laterality (unilateral vs. bilateral surgery). Robust estimation of variance was used to adjust for within-center correlation.
A total of 468 patients completed questionnaires before and after surgery. In all three regression models for MPQ-Sensory, MPQ- Affective, and NPRS (see figures), high preoperative baseline pain and receipt of bilateral reconstruction were significantly associated with more severe early postoperative pain. For the MPQ-Affective pain, greater preoperative depression level was significantly associated with increased postoperative pain. For both the MPQ-Sensory pain and NPRS, older age and receipt of DIEP flap reconstruction were associated with less postoperative pain. In the NPRS model, receipt of a unilateral free TRAM was associated with increased pain. Preoperative anxiety was not associated with increased postoperative pain.
This study identified patient characteristics that may correlate with more severe early postoperative pain after breast reconstruction. High preoperative baseline pain, depression, younger patient age, receipt of bilateral reconstruction, and unilateral free TRAM flap were all significantly associated with more severe early postoperative pain. Identifying patients who may have increased postoperative pain will allow clinicians to counsel patients and make appropriate referrals to pain management in advance of surgery. The goal of these interventions is to improve patient comfort and ultimately improve patient satisfaction with the breast reconstruction experience.
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