The Role of Nerve Surgery in the Management of Post-Breast Surgery Pain Syndrome: A Systematic Review and Meta-analysis.

Abstract

Post-breast surgery pain syndrome (PBSPS) is a chronic neuropathic pain condition that affects up to 50% of patients undergoing various breast surgeries, including mastectomy, lumpectomy, reconstruction, reduction, and gender-affirming procedures. The pain is believed to result from peripheral nerve injury, neuroma formation, fibrosis, and maladaptive central nervous system changes. Despite the prevalence of PBSPS, treatment options remain limited, with most management strategies focusing on pharmacologic interventions that provide inconsistent pain relief. There is growing interest in surgical approaches targeting nerve injury to improve outcomes. This systematic review and meta-analysis evaluate the efficacy of nerve surgery in reducing pain severity in PBSPS patients. A comprehensive literature search was conducted using PubMed, Scopus, and clinicaltrials.gov to identify studies published between 2008 and 2022 that examined surgical treatments for PBSPS. Inclusion criteria required original studies that reported preoperative and postoperative pain scores using the visual analog scale (VAS). Surgical techniques analyzed included neurectomy with transposition into muscle, regenerative peripheral nerve interfaces (RPNI), targeted muscle reinnervation (TMR), and cadaveric nerve grafting. Studies that did not report numerical pain outcomes were excluded. A meta-analysis was conducted on five studies that met the statistical inclusion criteria, with a subset analysis focusing on neurectomy and muscle transposition. Our literature yielded 8 studies that met the inclusion criteria, of which 5 were included in the meta-analysis. A significant reduction in VAS scores was observed following surgical intervention (preoperative, 8.7 ± 0.84; postoperative, 1.59 ± 1.15; P < 0.001). In the subset analysis of neurectomy with transposition into muscle, pain scores also showed a statistically significant reduction (preoperative, 8.63 ± 0.95; postoperative, 1.74 ± 1.27; P < 0.001). RPNI demonstrated promising pain relief in a small cohort, with patients experiencing median pain score reductions from 9 to 1 ( P = 0.02). TMR was evaluated in a small case series and suggested potential for prophylactic neuroma prevention. Surgical management of PBSPS significantly reduces pain severity, supporting nerve surgery as a viable treatment option. Neurectomy with transposition into muscle remains the most studied and widely utilized technique, with consistently positive outcomes. Emerging strategies, including RPNI and TMR, show promise for both treatment and prevention of PBSPS but require further validation in larger studies. Although high-quality data are limited, a focus on surgical intervention is emerging. PSBPS remains a significant problem, and surgical techniques to treat it have shown promise yet require further validation.