Post-operative chronic pain – Surgical Sadness or hope?

From a recent article in the Herald Sun

Tests to identify future sufferers of chronic pain after operations

“Speaking at the Australian and New Zealand College of Anaesthetists annual scientific meeting Prof Audun Stubhaug, from the Oslo University Hospital, said new research had shown genes were responsible for about half the increased risk of suffering chronic pain.

He said lifestyle and environment factors also decided whether a person would feel ongoing pain, and specialists needed to better screen patients, particularly those undergoing operations on their abdomen, breast surgery and amputations.

After a Finish study was able to identify four out of five breast cancer patients to suffer chronic pain by their backgrounds, Prof Stubhaug said advanced genetic screening and pain tests could be used further pinpoint those at risk.”

Professor Stubhaug has been involved in The Tromsø Study (some pretty impressive numbers – 40,051 different participants in the study since 1974) and has written a number of papers relating to pain based on the data collected including this one – “We conclude that most cases of persistent post-surgical pain are coexistent with other chronic pain, and that, in an unselected post-surgical population, persistent post-surgical pain is not significantly associated with pain sensitivity when controlling for comorbid pain from other causes” and this one – “Findings suggest that changes in cardiovascular stress responsiveness associated with chronic pain are of limited clinical significance and unlikely to contribute to increased cardiovascular risk in the chronic pain population.”

An abstract of Professor Stubhaug’s presentation at the ANZCA meeting, titled “Chronic pain after surgery: epidemiology and risk factors” is available online. On the risk factors for postoperative chronic pain:

Several risk factors for persistent postoperative pain have been identified and can logically be divided into preoperative, intraoperative and postoperative risk factors (1,3). Better knowledge of risk factors may allow preventive strategies. The preoperative risk factors include psychosocial factors,genetic factors and preoperative pain – both pain in the area of surgery and other preoperative pain syndromes. A recent systematic review found evidence that preoperative anxiety and catastrophizing play a role in the development of CPSP (4). Knowing the bidirectional nature of relationship between pain and mood disorders, it is quite obvious that data collection must start before surgery and that the interaction with preoperative pain should be elucidated. Standardized instruments should be used as suggested in a recent review (5). 

The presence of other pain syndromes before surgery seems to be a very important risk factor (6,7) In addition, many patients have inappropriate operations due to a pain syndromes like irritable bowel syndrome or back pain. Many of these patients continue to have the same pain after the operation, and in many cases their pain will be more severe

Those patients who have severe pain and abnormal sensory changes four to six weeks after surgery are risk patients for persistent pain (8). Thus, it may be an interesting approach to treat more aggressively patients with severe acute postoperative pain and signs of neuropathic components 1-3 weeks after surgery, at a time when pain subsides in most patients.” (Bold emphasis added)

On what might be done to reduce the risk of chronic pain:

“For most of the risk factors mentioned above remains to confirm whether the relationship with persistent postoperative pain is causal. Furthermore, no preventive strategy is yet fully documented, but several interventions are promising. The idea of preventive analgesia has evolved from preemptive analgesia by shifting the focus from timing of treatment to aiming at blocking noxious stimuli across the entire perioperative period. Since most interventions have potential side-effects it would be advantageous to reserve the most intense treatments to those at greatest risk only. Preoperative assessment as detailed above including tests of nociceptive function may help identify a high risk group suited for intervention.” (Bold emphasis added)

 

I’d humbly suggest that some pre- and post- operative neuroimmune pain science education might have a role while having no side effects, being cheap to administer and available to all.

It’s great to see the topic of post-operative chronic pain being discussed at a large gathering of anaesthetists, however a lot of what is being said makes David Butler’s Surgical Sadness that much more poignant.

 

-Tim Cocks

www.noigroup.com

 

 

Explain Pain 2nd Ed, the Graded Motor Imagery Handbook and all noigroup courses are all bursting at the seams with the latest and greatest neuroimmune pain science, neuroscience nuggets and pain education tips; click on the links to get your hands on a copy or to find a course near you.

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