QUESTION: A patient who underwent a mastectomy 6 months ago complains of chest pain at the surgical site and tingling down her operative arm. Shouldn't the pain be gone by now? None of the pain medications I give her seem to help. What can I do for her?

ANSWER Your patient has two of the classic signs of a largely unrecognized condition called postmastectomy pain syndrome (PMPS): chest wall pain and tingling down her arm. An estimated 30% to 60% of women develop this chronic neuropathic pain syndrome after lumpectomy or mastectomy. Other common complaints include numbness, shooting or pricking pain, or unbearable itching.

The pain syndrome may develop as a result of surgical trauma to nerves or if acute pain isn't treated properly in the first 24 hours after surgery.

Undertreatment of acute postoperative pain places the patient at risk for developing neuropathic pain months later.

To help your patient, start with a thorough assessment.

Assessing for PMPS

Document your patients signs and symptoms. The following criteria define PMPS:

The pain is neuropathic; patients typically describe this pain as pins and needles, peculiar sensations, burning, or stabbing (see Nociceptive or Neuropathic: What's the ference?).

Patients report feeling the pain sensation in the chest wall or axilla or down the arm on the operative side.

The pain persists for more than 3 months, which qualifies it as chronic.

Treating her pain

Make effective treatment of PMPS a priority:, If your patient continues to experience pain in her arm, she may avoid using it, which may lead to significant functional impairment.

Medications commonly used to treat nociceptive pain, such as opioids, may be less effective for neuropathic pain. Neuropathic pain may respond best to a combination of treatments; for example, two drugs with differing mechanisms of action.

First-line medications for PMPS include tricyclic antidepressants such as nortriptyline (Pamelor) and amitriptyline (Elavil), which target neurotransmitter activity. Anticonvulsant medications such as gabapentin (Neurontin) may also relieve neuropathic pain. For topical application, up to three lidocaine (Lidoderm) patches a day can be placed directly over the painful area for up to 12 hours. Some patients find that applying capsaicin cream (Zostrix) or cold packs to the painful area helps.

Don't let your patient settle for continuing pain. Encourage her to give her health care providers information on her pain and support her as she finds the treatment combination that works best for her. This may take some experimenting, so reassure her that she can be helped. Advise her to keep a pain diary that includes what medications relieve her pain, the onset of pain, and the time in between doses; also encourage her to follow up with her primary health care provider regularly.

Nociceptive or neuropathic: What's the difference?

Nociceptive pain

What causes it? An injury to the pain receptors found in the skin or joints (somatic sources) from an acute mechanical, thermal (such as burn), or chemical (such as an irritant) injury

What are the symptoms? Aching or throbbing Neuropathic pain

What causes it? A change in the way pain is normally processed by the central or peripheral nervous system. The change can be caused by a medical condition such as diabetes or nerve damage from surgery or trauma such as complex regional pain syndrome. This type of pain is usually chronic.

What are the symptoms? Shooting, tingling, burning, stabbing, 'pins and needles" For more information on the different types of pain, see "Understanding Nociceptive Pain' in the Controlling Pain department in the March issue of Nursingn 2002.

Carpenter, J., et aL: "Postmastectomy/Postlumpectomy Pain in Breast Cancer Suriivors,"Journal of Clinical Epidemiology. 51(12):1285-1292, December 1998.

Galer, B., and Dworkin, R.: A Clinical Guide to Neuropathic Pain. Minneapolis, Minn., 2000. McGraw-Hill Healthcare Information.

Jemal, A. et al.: "Cancer Statistics, 2002,"CA: A Cancer Journal for Clinicians. 52(1):23-47,January-February 2002. Miaskowski, C.: "Women and Pain," Critical Care Nursing Clinics of North America. 9(4):453-458, December 1997. Smith, W., et al.: "A Retrospective Cohort Study of Post Mastectomy Pain Syndrome," Pain. 83(1):91-95, October 1999.

BY YVONNE DARCY, CRNP, CNS, MS

Yvonne D'Arcy is a nurse practitioner at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Oncology Center and an independent pain management consultant in Baltimore, Md.

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