The Korean Journal of Pain

Chronic postsurgical pain: current evidence for prevention and management

Additional article information

Abstract

Chronic postsurgical pain (CPSP) is an unwanted adverse event in any operation. It leads to functional limitations and psychological trauma for patients, and leaves the operative team with feelings of failure and humiliation. Therefore, it is crucial that preventive strategies for CPSP are considered in high-risk operations. Various techniques have been implemented to reduce the risk with variable success. Identifying the risk factors for each patient and applying a timely preventive strategy may help patients avoid the distress of chronic pain. The preventive strategies include modification of the surgical technique, good pain control throughout the perioperative period, and preoperative psychological intervention focusing on the psychosocial and cognitive risk factors. Appropriate management of CPSP patients is also necessary to reduce their suffering. CPSP usually has a neuropathic pain component; therefore, the current recommendations are based on data on chronic neuropathic pain. Hence, voltage-dependent calcium channel antagonists, antidepressants, topical lidocaine and topical capsaicin are the main pharmacological treatments. Paracetamol, NSAIDs and weak opioids can be used according to symptom severity, but strong opioids should be used with great caution and are not recommended. Other drugs that may be helpful are ketamine, clonidine, and intravenous lidocaine infusion. For patients with failed pharmacological treatment, consideration should be given to pain interventions; examples include transcutaneous electrical nerve stimulation, botulinum toxin injections, pulsed radiofrequency, nerve blocks, nerve ablation, neuromodulation and surgical management. Physical therapy, cognitive behavioral therapy and lifestyle modifications are also useful for relieving the pain and distress experienced by CPSP patients.

Keywords: Chronic pain, Drug therapy, Incidence, Intractable pain, Neuropathic pain, Operative surgical procedure, Pain management, Physical therapy modalities, Postoperative pain, Prevention, Therapeutic methods

INTRODUCTION

Pain lasting longer than the normal healing process after surgery is an unwanted adverse event in any operation. Chronic postsurgical pain (CPSP) was first defined in 1999 by Macrae and Davies [1], and later expanded by Macrae [2] in 2001, as “pain that develops after surgical intervention and lasts at least 2 months; other causes of pain have to be excluded, in particular, pain from a condition preceding the surgery”. An updated definition of CPSP, or persistent postsurgical pain (PPSP), was later proposed by Werner and Kongsgaard in 2014 [3]. The proposed definition was “pain persisting at least three months after surgery, that was not present before surgery, or that had different characteristics or increased intensity from preoperative pain, localized to the surgical site or a referred area, and other possible causes of the pain were excluded (e.g., cancer recurrence, infection)”. CPSP can represent a severe nuisance to patients, leading to functional limitation and psychological trauma, as well as a problem for the operative team in the form of feelings of frustration and disappointment.

We sought to explore the acute to chronic pain transition in postsurgical patients. To identify the incidence, risk factors, preventive and treatment strategies for CPSP, we searched the Ovid MEDLINE, EMBASE, and Cochrane databases between 1990 and 2017. The search utilized combinations of the following keywords: chronic postsurgical pain, persistent postsurgical pain, pain after surgery, chronic postoperative pain, incidence, risk factors, prevention, phantom limb pain, failed back surgery, post-laminectomy pain, post-thoracotomy pain and post-mastectomy pain. We limited our search to humans and English. Relevant articles were identified by the authors from the abstracts and the bibliographies.

MAIN BODY

1. Incidence

A study by Fletcher et al. of surgical patients in Europe demonstrated that 11.8% of patients have moderate to severe pain, while 2.2% have severe pain (NRS ≥ 6), at 12 months after surgery [4]. Persistent pain can occur following various operations, ranging from simple and common ones (to illustrate, herniorrhaphy, caesarean section or dental extraction) to complicated surgeries (such as thoracotomy, radical mastectomy or hysterectomy).

The reported incidence of CPSP varies for different surgical procedures and in different studies, ranging from a low of 5% to a high of 85%. For example, studies have reported incidences ranging from 50%–85% following limb amputation, 11%–57% following mastectomy, 30%–55% after cardiac surgery, 5%–65% after thoracotomy, and 5%–63% following hernia repair [5]. One reason for this variability is the difference in the time reference considered by each researcher for labeling pain as CPSP (varying from 2 months to 1 year postoperatively).

Also, the amount of injury to the tissues or nerves and the degree of inflammation differ by operation type and procedure for the same surgery. For instance, according to the study by Fletcher, there is a reduced incidence of moderate to severe CPSP with laparoscopic cholecystectomy (8.8%) than with open cholecystectomy (28%). Fletcher's study also found that orthopedic surgery is associated with an almost three-fold increased risk of moderate to severe CPSP, compared with all other procedures, at 12 months [4]. The sensitivity of patients to pain is also variable.

2. Risk factors

Besides the type and approach of surgery, various other risk factors have been attributed to CPSP. Some of them are patient factors (including female gender, being a young adult, genetic predisposition, and psychosocial factors), preexisting patient conditions (for example, pain present preoperatively, and any preexisting painful conditions in other parts of the body), and perioperative factors (for instance, duration and type of surgery, extent of nerve damage intraoperatively, and severity and duration of acute postoperative pain).

A recent study has also demonstrated that the severity of pain in CPSP is correlated with the mRNA expression of the signal transduction genes, representing the genetic influence on CPSP [6]. The most consistent feature associated with the occurrence of CPSP is the duration of the severe acute postoperative pain. Acute pain can lead to central sensitization, which reduces the mechanical threshold and exaggerates the response to noxious stimuli. The patient can thus present with both hyperalgesia and allodynia [78].

3. Prevention

Currently, there is no definitive way to prevent the occurrence of CPSP. Various techniques have been tried, by anesthesiologists and surgeons alike, to reduce the risks, but with variable success. Identifying the risk factors in each patient and applying a timely preventive strategy may help patients to avoid the distress of chronic pain.

1) Modification of surgical technique

Minimally invasive surgery is also recommended for orthopedic surgery to limit tissue damage and nerve injury [16]. Unfortunately, arthroscopic surgeries can also lead to CPSP due to injury to the nerves (to illustrate, branches of the saphenous nerve during a knee arthroscopy) as this cannot always be avoided due to the proximity of the nerves to the bones.

(2) Less extensive surgery

Despite there being insufficient evidence to recommend a definite surgical technique to eliminate the possibility of CPSP, surgeons can minimize the risk of CPSP by choosing a minimally invasive surgical technique, employing careful dissection to avoid injury to nerves, avoiding extensive surgery whenever possible, and/or minimizing the duration of surgery if possible.

2) Treatment of preoperative pain

The presence of pain before surgery and the severity and duration of acute postoperative pain are predictors of CPSP. Neuroplasticity (spinal sensitization) following trauma may transform an acute pain to chronic pain if not treated in a timely manner. This can be prevented by aggressive treatment of acute pain [18]. Therefore, good perioperative pain management is thought to prevent the occurrence of CPSP. In a study by Karanikolas et al. of 65 patients who underwent lower limb amputation, the incidence of phantom limb pain after 6 months decreased significantly more following the use of an optimized perioperative epidural analgesia, or if an intravenous patient-controlled analgesia was started 48 hours preoperatively and continued for 48 hours postoperatively, compared with patients who received conventional analgesia and genral anesthesia [22].

3) Modification of anesthetic technique

Perioperative management, especially the analgesic technique adopted, has a significant effect on the prevention of CPSP. Randomized controlled trials have demonstrated a positive effect of regional anesthesia on the prevention of CPSP following laparotomy, caesarean section, cardiac surgery, breast surgery, etc. Regional analgesia techniques, for instance, epidural anesthesia, wound infiltration and intercostal nerve blocks, have been studied [23]. Unfortunately, the results are not as consistent for the prevention of chronic pain as they are for the prevention of acute pain [24].

A Cochrane review has found epidural anesthesia and paravertebral blocks significantly decrease the incidence of CPSP at 6 months following thoracotomy and breast surgery, respectively. The review, however, did not comment on the benefits for other surgeries because of the lack of studies and the small sample size [25]. Another non-randomized study by Borghi et al. examined the preoperative percutaneous insertion of a peripheral nerve catheter for the postoperative infusion of local anesthetics following limb amputation. The infusion was continued for a median of 30 days. They found that the incidence of phantom limb pain at 12 months was 16%, much less than the background incidence quoted in other studies [2627]. Intraarticular injections of local anesthetics during arthroplasty and other joint surgeries can be effective in achieving better postoperative pain control. Wound infiltration with local anesthetics following removal of an iliac crest bone graft led to lowered iliac bone chronic pain over 4 years of follow-up [18]. Still, the result with wound infiltration is not consistent with the prevention of CPSP [28].

The adoption of preventive analgesia (providing analgesia throughout the perioperative period, thereby blocking the noxious stimulus during this painful period) rather than preemptive analgesia (providing analgesia to block the noxious preoperative stimulus) has also shown benefit in preventing CPSP [2129]. One study compared three analgesic techniques: thoracic epidural analgesia initiated preoperatively and intraoperatively (with patient-controlled epidural analgesia provided postoperatively in both instances); and intravenous patient-controlled analgesia with morphine, started postoperatively. It was found that CPSP was significantly reduced 6 months postoperatively by using the thoracic epidural analgesia initiated preoperatively [30]. In contrast, another study did not find a difference in the incidence of chronic phantom pain with an epidural analgesia throughout the perioperative period, compared with the use of a patient-controlled opioid analgesia throughout the perioperative period [27]. Consequently, good pain control throughout the perioperative period seems more important than the technique used to achieve the pain control.

Evidence shows that the duration of acute pain influences the development of CPSP. A one-year follow-up study showed that the sum of the postoperative visual analog scores (VAS) during the first week after a laparoscopic cholecystectomy was a better predictor of the development of CPSP than the maximum reported VAS [31]. Hence, aggressive postoperative pain management might reduce the chance of developing CPSP.

The use of multimodal analgesia during the perioperative period has been proven to be better for acute postoperative pain management. Drugs acting by various mechanisms can more effectively manage pain by modulating pain signals at various points of the pain pathway than by using a single drug.

Multimodal pain regimens might include combinations of gabapentin, NSAIDs, acetaminophen, and regional anesthesia with the conventional analgesia technique [32]. Very few studies have been done to evaluate the effects of multimodal analgesia on CPSP. Fassoulaki et al. randomized 50 patients undergoing breast cancer surgery to receive gabapentin, a eutectic mixture of local anesthetic cream and ropivacaine wound infiltration, or three placebos. They found that pain and analgesic consumption was significantly less 3 months after the surgery in the multimodal analgesia group than the control [33].

4) Pharmacological treatment

Various pharmacologic agents have been tried to prevent CPSP, with some agents showing promising results. Some of the reference studies are listed in Table 1.

(1) Gabapentin and pregabalin
Table 1

This promising result with gabapentin and pregabalin is now considered to be due to the preventive analgesic effect provided by gabapentinoids [35]. Despite that, a recent review of 18 randomized controlled trials (RCTs) with published and unpublished studies demonstrated that pregabalin could not reduce the incidence of CPSP at 3 months with a moderate quality of evidence [36].

(2) Antidepressants

Overall, the limited data on the use of antidepressants presently precludes their use for the prevention of CPSP.

(3) NMDA antagonists

The use of other NMDA antagonists, one example being memantine, has not yet been established, but the pain relief does not seem to persist for long enough to prevent CPSP [2139].

(4) Clonidine

Even though there are currently few studies on the use of these agents in preventing CPSP, it has been suggested that their anti-inflammatory and anti-sensitizing effects warrants the further investigation of these drugs for the prevention of chronic pain [27].

(5) Lidocaine

However, a Cochrane review did not find many studies to further analyze the effects of lidocaine. Consequently, more research is required before its use in the prevention of CPSP can be recommended [42].

(6) NSAIDs and acetaminophen

A study by Reuben et al. of 200 patients undergoing anterior cruciate ligament surgery who received acetaminophen (1 gram) and either celecoxib or a placebo for 1–2 hours preoperatively, along with intraarticular analgesics, found that more patients in the control group developed patellofemoral complications, which included anterior knee pain and complex regional pain syndrome, among others, 6 months after the surgery [44].

(7) Steroids

Thus, the use of steroids for the prevention of CPSP cannot be recommended with the data currently available.

(8) Opioids

Thus, good pain control with opioids is important for CPSP prevention, despite their known hyperalgesia risk.

(9) Other pharmacological agents

Limited studies are available for other drugs, including memantine, dextromethorphan, mexiletine, and nitrous oxide, with variable effects shown on CPSP [42]. Based on the available data, the use of these drugs for the prevention of CPSP cannot be recommended.

5) Psychological intervention

The association of psychological factors with chronic pain has been well documented. Hinrichs-Rocker did a systematic review on the psychological predictors and correlates for CPSP, and found that depression, psychological vulnerability, stress and late return to work showed a probable correlation with CPSP [47]. Pain catastrophizing is sometimes found to be related to decreased CPSP, which can be due to early medical help being sought [48]. Patients having negative beliefs about opioids have a higher CPSP risk [32].

Adequate preoperative counselling regarding the surgery and expected outcomes can alleviate stress and help prevent CPSP. Identifying psychologically vulnerable patients and early intervention pre- as well as post-operatively may help prevent the development of chronic pain in these patients [32].

4. Management of CPSP

1) Pharmacotherapy

RCTs of drugs for the management of CPSP are limited, and most of the recommendations have been extrapolated from data for other types of chronic pain, especially neuropathic pain. Similar to other neuropathic pain conditions, anticonvulsants (gabapentin and pregabalin), tricyclic antidepressants (amitriptyline and nortriptyline), serotonin-norepinephrine reuptake inhibitors (duloxetine and venlafaxine), topical lidocaine or topical capsaicin form the first line of treatment for most patients (Table 2).

Table 2

Paracetamol, NSAIDs, and weak opioids (tramadol and codeine) can be used according to symptom severity, but strong opioids should be used with great caution, weighing the risks and benefits. Other drugs that may be helpful are ketamine, muscle relaxants, clonidine and intravenous lidocaine infusion.

Some studies have found low-concentration capsaicin to be useful for post-mastectomy pain [49]. In contrast, a recent Cochrane review of low concentration (< 1%) capsaicin cream was not found useful for neuropathic pain [50]; a high concentration was also not useful for persistent pain following inguinal herniorrhaphy, though it was useful for postherpetic neuralgia, painful diabetic neuropathy and HIV neuropathy [51]. The number of studies was too limited to form any recommendations.

A 5% lidocaine patch was found effective for neuropathic pain associated with allodynia following cancer surgery [52]. A conclusion from a meeting of 44 pain specialists from 17 countries, and based on a retrospective analysis of case reports, concluded that CPSP associated with localized, superficial pain and allodynia showed a positive response to 5% lidocaine plaster [53]. An observational study of patients with posttraumatic and postsurgical localized neuropathic pain also showed a significant reduction in pain and a decrease in painful areas following treatment with lidocaine-medicated plaster [5455]. A randomized, double-blind, placebo-controlled, cross-over trial among 21 male patient having unilateral severe persistent inguinal pain following herniorrhaphy, showed no significant improvement with a 14-day application of a 5% lidocaine patch [56].

A nitroglycerine transdermal patch has been found useful for chronic post-thoracotomy pain [57]. A topical 5% amitriptyline cream has also been tried, but it was not found to be effective compared with 5% lidocaine cream or a placebo [58]. A pilot study of topical 1% amitriptyline, 0.5% ketamine or their combination for the treatment of neuropathic pain, including CPSP, found the combination cream to be effective after 7 days' application, whereas they were ineffective when applied individually [59]. The subsequent open-label, prospective study with a 2% amitriptyline/1% ketamine combination cream applied for 6–12 months showed significant pain relief, with long-term patient satisfaction and minimal side effects [60].

2) Pain interventions

For patients who do not improve with pharmacotherapy, various interventions have been tried, ranging from nerve blocks to nerve ablation and neuromodulation (Table 2).

Nerve blocks, neuraxial blocks and sympathectomies have been tried. Successful treatment of sternotomy-induced neuralgia has been reported, using repeated bupivacaine blocks, phenol blocks or alcohol blocks [49]. Pain relief was seen with epidural injections for lumbar or cervical post-surgery syndrome [61], but no significant difference was seen when caudal or cervical epidural local anesthetic injections alone were used, compared with combined epidural steroid and local anesthetic injections [6263].

Entrapment of the superficial nerves of the abdominal wall, or trauma to nerves during surgery, can be a source of chronic abdominal wall pain following any abdominal surgery. The injection of local anesthetic agents, with or without steroids, in the transverse abdominis plane, rectus sheath or tender point can produce pain relief in such patients [646566]. An axillary brachial plexus block with patient-controlled analgesia was found to be useful for the treatment of complex regional pain syndrome I, developed after surgical release in case of carpel tunnel syndrome [67].

Botulinum toxin injections in the painful areas of chronic post-thoracotomy pain have been reported to provide significant pain relief for patients unresponsive to oral therapy [68]. Positive results have also been seen with botox injections in the area of abdominal wall pain following ventral hernia repair, and for trigeminal neuropathic pain following dental implants [6970].

Phenol injections or radiofrequency ablation of stump neuroma and dorsal root ganglia have been found useful for stump and phantom pain [7172]. If other options fail, lesioning the dorsal root entry zone (DREZ) and motor cord stimulation have been found useful [73]. Radiofrequency percutaneous partial rhizotomy has been found to be useful in the management of chronic thoracic segmental pain, including post-thoracotomy and post-mastectomy pain [74]. A retrospective study comparing the effects of pulsed radiofrequency (PRF) of the dorsal root ganglia (DRG) with that of the intercostal nerve (ICN) or medical management found the PRF of DRG to be superior to PRF of the ICN or medical management, in terms of success in pain relief and the duration of pain relief [75]. Radiofrequency ablation of the DRG or the DREZ has been used to successfully treat chronic ilioinguinal pain following inguinal hernia repair, and chronic post-thoracotomy pain [76]. Pulsed radiofrequency treatments to the ilioinguinal and genitofemoral nerves and nerve roots have resulted in complete relief lasting up to 6 months [77] longer than steroid injections [78]. Transcutaneous electrical nerve stimulation and mirror therapy can provide benefits in patients with phantom limb syndrome [79].

Recently, spinal cord stimulation has provided promising results and is commonly used for phantom pain [73]. It has been used for the management of chronic post-thoracotomy pain, but the evidence is presently limited to case studies [80]. Its use has also been found effective for the management of neuropathic arm or leg pain following cervical or spinal surgeries, and in complex regional pain syndrome type 1 [81].

3) Surgical management

For patients with post-mastectomy pain syndrome, surgical resection of the neuroma and allowing the cut-ending of the nerve to retract deep into the intercostal muscles has been found to be helpful [82]. Since a neuroma can reform, relocation of the nerve to a protected site and helping regrowth via a nerve graft can be a better option [19]. Excision of a painful intercostal neuroma and implantation of the proximal end of the nerve into the latissimus dorsi muscle has been found to be effective for neuromas developed following thoracic and upper abdominal surgeries [83].

An autologous fat graft to the dermo-hypodermal junction at the painful scar area has been shown to be effective [84]. A scar excision can also help relieve pain following surgery. In the case of patients with chronic neuropathic pain following an inguinal herniorrhaphy who are not relieved by conservative measures, some pain relief can be provided by revision surgery; a triple neurectomy of the ilioinguinal nerve, iliohypogastric nerve and genitofemoral nerve; or removal of the fixation material and the mesh [85].

Though surgery is an option for pain management in CPSP when other options have failed, we must consider the possibility of the recurrence of CPSP following surgery. Preventive measures, including effective perioperative pain management and counselling, should be instituted on time.

4) Lifestyle modification

Physical therapies, including massage, physiotherapy and acupuncture, have been tried in the management of CPSP. These modalities can reduce pain, but only temporarily. Lifestyle modifications in the form of rest and activity limitation are not advised as these can lead to further complications, especially poor functional outcomes.

5) Psychological interventions

Operant conditioning and cognitive behavioral therapy (CBT) have been found to be useful for the management of chronic pain. In operant conditioning, the clinician emphasizes the modification of responses to maladaptive behaviors, and the modification of behaviors that consist of overt expressions of pain, distress and suffering in response to chronic pain. By comparison, CBT focuses on improving physical and emotional functioning despite the pain, rather than attempting to eliminate the pain. It provides positive reinforcement to wellness behavior, physical fitness and cognitive reframing so that the patients can become desensitized to the persistent pain and can function better. It usually combines stress management, problem solving, goal setting, relaxation, and the pacing of activities [8687].

In a randomized study comparing the effectiveness of lumbar fusion with posterior transpedicular screw fixation, and cognitive intervention and exercises among patients with CPSP after previous surgery for disc herniation, the surgery and the combination of cognitive intervention and exercise showed similar levels of effectiveness in managing the pain [88]. Aggressive exercise with CBT has been found to be useful for various back pain conditions, including those following surgery [89].

CONCLUSIONS

CPSP is a common but overlooked complication of surgery which can cause functional limitation and psychological distress to patients. Though we are still unable to completely prevent this problem, with a proper knowledge of the condition, we can easily identify the risk factors in a patient undergoing surgery and institute appropriate preventive measures.

These range from modification of the surgical, anesthetic and analgesic techniques to psychological counselling. Any event of CPSP should be identified in a timely manner, and proper management–consisting of pharmacotherapy, appropriate pain interventions, surgery and/or psychological managements by a multidisciplinary team–can improve the pain as well as the physical and social functionality of the patient (Fig. 1).

Figure F1
Step-by-step approach to the prevention of chronic postsurgical pain.

Article information

The Korean Journal of Pain.Jul 31, 2018; 31(3): 155-173.
Published online 2018-07-02. doi:  10.3344/kjp.2018.31.3.155
1Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Nepal.
2Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Correspondence to: Pramote Euasobhon. Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. Tel: +66-2-419-7842, Fax: +66-2-411-3713, pramoteo@hotmail.com
Received: January 17, 2018.
Accepted: March 15, 2018.
Articles from The Korean Journal of Pain are provided here courtesy of The Korean Journal of Pain

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Figure 1

Step-by-step approach to the prevention of chronic postsurgical pain.

Table 1

Summary of the Randomized Controlled Studies on Prevention of Chronic Postsurgical Pain

Table 2

Summary Table of Studies on Topical Agents and Pain Interventions for Chronic Postsurgical Pain

RCT: Randomized controlled trial.