Surgical Sadness

The invitation

I was kindly invited to the recent Royal Australian and New Zealand College of Surgeons meeting last week in Auckland to speak about pain related to surgery. My session was concurrent and the other talks in my session included a superb one on central sensitisation by a rheumatologist and one by a psychologist on anxiety and wound healing.

About 1200 surgeons were in attendance and it was an honour to be invited especially as I am not “in the trade”. I was quite chuffed and I was enjoying the preparation of the talk…

The excitement builds…

I was aware of recent papers on the problem of post-surgical pain. Just out was Johansen A et al 2012 reporting that of 2043 surgical patients in the last 3-36 months in northern Norway, around 40% still had symptoms in the area of surgery, around 20% above 3 on a Visual Analogue Scale. Similar results have been reported in the literature for 12 years. In the Norwegian study, there were strong links between hypoesthesia (possibly suggesting nerve cutting) and hyperesthesia (suggesting peripheral and central sensitisation). Some surgeries, such as thoracotomies, sternotomies, breast surgery, spinal surgery and amputation were more likely to lead to lingering pain.

But what was really exciting were recent papers taking serious looks at both peripheral and central  mechanisms of post incisional allodynia (e.g. Granat, I et al. 2012) and even one on mechanisms and systems approaches to post-surgical pain ( Deumans R et al 2013). I was thinking “wow – an awareness of the problem and of central sensitisation must be happening”. In a recent commentary in the journal Pain, calls have been made for better pre-emptive therapies, for putting the likelihood of chronic pain on the informed consent form (Schug SA 2012) and I would also add – why not seek ways of treating it.

I thought – surgeons must be ready to take it on!

The talk…

Only 11 turned up – 3 of those were other speakers, two were friends and another 2 were only interested in medicolegal issues and pain.  I guess the surgical world, for many reasons, are not ready or do not want to confront the problem. Or perhaps it was just me?

– David Butler
www.noigroup.com

What are your experiences with post-surgical pain?

References:

Johansen, A. et al 2012 Pain:153:1390

Granat, I. et al. 2012 Eur J Pain:257:255

Deumans, R. et al 2013 Prog Neurobiol:104: 1

Schug, SA. 2012 Pain:153:1344

14 Responses to “Surgical Sadness”

  1. davenolan22

    How depressing.

    Surgeons must be fed up with reviewing their patients and a significant number still struggling. But I suspect a tough nut to crack.

    Reply
  2. Leonie

    I suspect you might have had a larger audience at a conference of anaesthesiologists. A few years ago, I (physio) was observing some knee surgery, and the anaesthetist encouraged the surgeon to infiltrate the incision site with local anaesthetic before he made the incision. He then commented on the known issues with post surgical pain, and we had a bit of a chat about scar issues and pain post surgery.

    It’s a dilemma, I think. When I’m working with my chronic pain patients, there are quite a number looking for “the surgical fix” – sometimes for a different injury to the one that has wound them up – and as we work through the concepts of central sensitisation, they struggle with the idea of an already sensitised nervous system having an effect on the surgical outcomes of an unrelated injury. And that’s even if they’ve seemed to understand the concept in relation to their current issues.

    Reply
  3. nccspine

    G’day David,
    Take heart as I am sure it wasn’t just you.
    A number of years ago Prof Karel Lewitt from the Prague School Of Rehabilitation prepared a paper on ‘The Clinical Importance of Active Scars: Abnormal Scars as a Cause of Myofascial Pain’.
    According to Prof Lewitt his paper was rejected for publication in the surgical journals because the topic was of ‘no interest’ or ‘not relevant’ to surgeons.
    It eventually appeared in JMPT (Volume 27, Issue 6, July–August 2004, Pages 399–402).
    Wouldn’t life be simpler if you just knew that your care couldn’t possibly cause some unexpected consequences apart from the rare catastrophes.
    Keep up the great work!
    Bruce Scott

    Reply
  4. John Barbis

    The day when general surgeons see post surgical pain( except for that acute pain that may delay discharge from hospital or affect pulmonary/bowel function) as important will only be the period after they have had a surgery. Even that may not be sufficient. I think that day has about as much chance of happening as the day our Republican Congress thinks Obama is one of our best presidents. It ain’t goin to happen. My experience has been once surgeons zip the patient back up and the patient is sufficiently stable to be discharged, their work is done. The patient is now someone else’s problem and the better for that. They see their roles as strictly “one night stands”. Whether that is good or bad is for others, most importantly their patients to decide. I think that the sooner the patient gets out of the general surgeon’s hands, the better.

    Reply
  5. chisholmalex

    I am a physio. The thoracic surgeons I work with all warn patients of chronic pain pre-op, but the wording they use almost insures pain. (It will be the most painful operation you have ever had) However, our patients now get routine epidurals post-op, which has made a trememdous difference in pain control, and reducing pain related complications. The thoracic surgeons are considering allowing me to make some self-hypnosis/mental preparation cd’s for patients for pre-and post-op use. Change is glacially slow, but I think it is slowly coming. But it is my experience that Thoracic surgeons are much more holistic than other surgeons, in our facility.
    I would love to learn more about the anxiety and wound healing topic.

    Reply
  6. painphysio

    Reblogged this on CRPS UK and commented:
    Indeed sad. Two thoughts:
    1. The well known phenomena that change is threatening, avoid, avoid, avoid.
    2. Each person will have their priority and work out the ‘line-up’ that they will follow at a conference, much like a music festival. It may not come on to the radar of importance, or perhaps they feel that this is someone else’s role in the team to deal with pain.

    I once gave a lecture to a group of mixed doctors and physiotherapists about pain. One piece of feedback always stuck in my head: ‘why did we have to have a lecture on pain?’. Not only sad, but very worrying.

    We will persevere!

    Reply
  7. Jorge Ribas

    They did not know they would lose, they would not be faced with new scientific knowledge and how this should be implemented in surgical and clinic practice.
    You always did revolutions, but some took longer…

    Reply
  8. Sue Croft Physiotherapist

    Sounds like a Continence audience during Continence Awareness Week 5 years ago- going to it might mean admitting you have a problem. I find that any residual pelvic pain post surgery is viewed as a ‘patient’ specific problem- although the mesh (catastrophe) litigation has been sobering for gynae surgeons.

    Reply
  9. Mary Byrne Eigel

    Mine was not just physical, it was emotionally feeling that pain still existed. To have the overnight removal of decades of pain was disarming. It has led me to understand that any physical problem has also existed on an emotional and spiritual level. I have had to work to reintegrate all these things to remove the “debris” left from my pain experience.

    Reply
  10. unravel2013

    Surgeons are so caught up on technique, they have no interest in the aftermath. As a victim of surgery, that has resulted in central sensitisation, I was told “you shouldn’t be in pain – go way and live a happy life”. Six years later, my sexuality and quality of life is still impacted by pain, but lots of mindfulness meditation, the explain pain book and a great gynae physio have helped me to hover above the daily pain.

    Reply
  11. davidboltononoi

    In the words of David Frost “Go forth and multiply” is the only other comment I could find
    David

    Reply

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