Persistent post surgical pain Jim Olson Waitemata DHB Auckland
Declaration Within the last five years I have accepted hospitality from the pharmaceutical industry, received honoraria from Mundipharma NZ and attended meetings sponsored by Eisai Europe Ltd.
Persistent post surgical pain Jim Olson Waitemata DHB Auckland
Definition - CPSP Pain developed after a surgical procedure; Pain is of at least two months duration; Other causes have been excluded (for example continuing malignancy or chronic infection); and The possibility of continuing pain from a preexisting problem must be explored and exclusion attempted.
Incidence Schug SA, Pogatzki-Zahn EM. IASP Pain Clinical Update Vol. XIX, Issue 1 January 2011 Niraj G, Rowbotham D.J. Persistent postoperative pain: where are we now? BJA 2011;107(1):25-29
Breivik H, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006; 10( 4): 287-333 Direct Burden Indirect burden Indirect costs Direct costs Pain Disability Lost productivity Individual/society
What causes pain after surgery? Cut nerves & tissues Induced injury response Altered peripheral & central nervous system pain processing Aasvang EK, et al. Neurophysiological characterization of postherniorrhaphy pain. Pain 2008; 137:173 81 Gärtner R, et al. Prevalence and factors associated with persistent pain following breast cancer surgery. JAMA 2009;302:1985 92.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618 25.
Predictors Who gets CPSP?
Predictors
Preoperative risk factors Preoperative pain Genetic susceptibility Psychosocial factors Niraj G, Rowbotham D.J. Persistent postoperative pain: where are we now? BJA 2011;107(1):25-29
Psychological Factors Depression, psychological vulnerability (definition varies between studies), and stress were predictors. Hinrichs-Rocker A, et al. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) a systematic review. Eur J Pain 2009;13:719 30. Preoperative pain related to impairment of activities predicted Preoperative anxiety and depression per se were not independent predictors (n=464) Aasvang EK, et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology 2010; 112: 957 69 Pre-operative pain expectations, pain catastrophizing and surgical fear were predictors (n=648) Gramke HF, et al. Predictive factors of postoperative pain after day-case surgery. Clin J Pain. 2009 Jul-Aug;25(6):455-60. Pre-surgical pain severity and pain catastrophizing were predictors Sullivan M. et al. Psychological determinants of problematic outcomes following Total Knee Arthroplasty Pain. Volume 143, Issues 1-2, May 2009, Pages 123-129 Low pre-operative optimism and low perceived control over pain at 1week after surgery predicted higher pain intensity at 4 months. No emotional variables were independently predictive of CPSP. Powell R, et al. Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: A prospective cohort study Eur J Pain 2011 Sept in press
Testing with experimental pain DNIC or CPM Reported heat pain intensity was shown to have a positive correlation with postoperative pain. Abrishami A, et al. Preoperative pain sensitivity and its correlation with postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2011 Feb;114(2):445-57. Low CPM efficiency was predictive of chronic post surgical pain Yarnitsky D et al. Prediction of chronic post-operative pain: pre-operative DNIC testing identifies patients at risk. Pain. 2008 Aug 15;138(1):22-8. Yarnitsky D. Conditioned pain modulation (the diffuse noxious inhibitory control-like effect): its relevance for acute and chronic pain states. Curr Opin Anaesthesiol. 2010 Oct;23(5):611-5.
Kalkman pain prediction
Intraoperative Factors Surgical Invasiveness Nerve injury Long duration of surgery Redo interventions Surgery in a previously injured area Damaging surgical techniques such as crushing / retraction Aasvang EK, et al. Pre-operative pain and sensory function in groin hernia. Eur J Pain. 2009 Nov;13(10):1018-22
Postoperative Factors Post op Pain severity and duration Radiation therapy to area Neurotoxic chemotherapy Psychological factors as pre-op Genetics Schug SA, Pogatzki-Zahn EM. IASP Pain Clinical Update Vol. XIX, Issue 1 January 2011
Psychology interventions Explanation of pain and pain relief improved post op pain scores in children Lin L., Wang R. Abdominal surgery, pain and anxiety: preoperative nursing intervention. Journal of Advanced Nursing 2005; 51(3), 252 60 Self hypnosis improved pain scores in children Restif AS. Self-hypnosis, a resource for children undergoing painful treatment. Soins Pediatr Pueric 2010;254:37 9. Instruction in coping skills led to less postoperative anxiety and pain for adolescents ages 13 and younger LaMontagne LL, et al. Cognitive-behavioral intervention effects on adolescents' anxiety and pain following spinal fusion surgery. Nurs Res. 2003; 52(3): 183-90. psychologist-directed pain coping skills training intervention improved pain scores at 2 months. Riddle DR et al. Pain Coping Skills Training for Patients With Elevated Pain Catastrophizing Who Are Scheduled for Knee Arthroplasty: A Quasi-Experimental Study. Arch of Phys Med and Rehab 2011, 92 (6), 859-65
Surgical Interventions Techniques preserving nerves or materials inducing reduced inflammatory reaction decreased CPSP Reinpold WMJ, et al. Nerve Management and Chronic Pain After Open Inguinal Hernia Repair. A Prospective Two Phase Study. Annals of Surgery. 2011;254(1):163-8 Chronic groin pain was significantly more common after open repair than after laparoscopic repair (38.3 versus 22.5 per cent; P < 0.01, n= 454). Kumar S, et al. Chronic pain after laparoscopic and open mesh repair of groin hernia. Br J Surg. 2002 Nov;89(11):1476-9.
Acute Pain Management Good postoperative analgesia in THR or TKR decreased moderate and severe ambulatory pain at all follow ups to 6 months (15% versus 4%, n=249) Morrison RS, et al. A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery. J Am Geriatr Soc 2009;57:1 10. But. 41% of patients experience moderate to severe pain after surgery (n=20,000) Dolin SJ, et al. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002;89:409 23. 31% of patients had severe or extreme pain and another 47% had moderate pain after surgery (n=250) Apfelbaum JL, et al. Postoperative pain experience from a national survey suggests postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534 40. 26.9% report severe pain during movement in first 24hrs (n=1900) Fletcher D et al. A patient-based national survey on postoperative pain management in France reveals significant achievements and persistent challenges. Pain. 2008 Jul 15;137(2):441-51.
Surgery specific guidelines Prospect U.S. Veteran s Health Administration & University of Iowa http://www.healthquality.va.gov/
Breast Surgery Paravertebral Block improved at 1yr Venlafaxine decreased movement pain 6/12 Gabapentin decreased burning pain at 3/12 Gabapentin, EMLA and ropivacaine decreased pain at 3 months Kairaluoma PM, et al. Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesth Analg 2006; 103: 703 8 Amr YM, et al. Evaluation of efficacy of the perioperative administration of Venlafaxine or gabapentin on acute and chronic postmastectomy pain. Clin J Pain 2010; 26: 381 5 Fassoulaki A, et al. Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer. Anesth Analg 2005; 101: 1427 32 Fassoulaki A, et al. The analgesic effect of gabapentin and mexiletine after breast surgery for cancer. Anesth Analg 2002; 95: 985 91
Thoracotomy Perioperative Ketamine did not reduce pain at 4 months (n=86) Duale C et al. Perioperative ketamine does not prevent chronic pain after thoracotomy. Eur J Pain 2009; 13: 497 505 No change with epidurals (6 study Meta analysis, n=458) Bong CL et al. Effects of preemptive epidural analgesia on post-thoracotomy pain. J Cardiothorac Vasc Anesth 2005;19:786 93. No reliable benefit of any analgesic intervention Wildgaard K et al. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg 2009; 36: 170 80
Lower limb amputation Prevention techniques were not convincing. 11 studies. One showed benefit but small numbers. Ypsilantis E et al. Pre-emptive analgesia for chronic limb pain after amputation for peripheral vascular disease: a systematic review. Ann Vasc Surg 2010; 24: 1139 46 Good pain control before amputation may minimize the risk of persistent pain after amputation. (n=65) Karanikolas M et al. Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: A prospective, randomized, clinical trial. ANESTHESIOLOGY 2011; 114:1144 54
Joint replacement 15% severe pain post TKR, 6% severe pain post THR at 3 yrs Wylde V. et al. Persistent pain after joint replacement: Prevalence, sensory qualities and post-operative determinants. Pain 2011;152:566 72. Ketamine had no significant effect on CPSP following total knee replacement Adam et al. Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty. Anaesth Anal 2005 Feb;100(2):475-80. Pregabalin reduced neuropathic pain at 3 and 6 months (0% vs 8.7% and 5.2%) Buvanendran A et al. Perioperative Oral Pregabalin Reduces Chronic Pain After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Anaesth Anal 2010; 110 (1): 199-207.
Future Developments Predictive scoring systems Bedside testing Genetic testing New Drugs Targeted therapies
Conclusions Persistent postoperative pain is affecting thousands of patients in NZ and worldwide. Significant cost and burden Should be considered preoperatively Evidence for interventions is not consistent yet Minimally invasive surgery and good post op pain relief are best bet.
The aim of the wise is not to secure pleasure, but to avoid pain. Aristotle 384-322 BC