chronic pain after surgery” (chronic post surgical pain=cpsp)how to prevent it? - prof. a. husni...

CURRICULUM VITAE

Name : Prof. dr. A. Husni Tanra, Sp.An-KICPlace, Date of Birth : Sengkang, January 29, 1943Address : Hertasning Street E7/ 15 Makassar, 90222

South Sulawesi, IndonesiaEmail : [email protected] : MD : 1975 in Hasanuddin University, Faculty of Medicine, Makassar, South

Sulawesi, Indonesia. Ph.D : 1981 in University of Hiroshima, School of Medicine, Hiroshima City, Japan. Visiting scholar : 1987 – 1988 in Multidiciplinary Pain Center in Departement of

Anesthesiology, School of Medicine, University of Washington, Seattle USA. Lemhanas KSA VIII : in 2000Organization :

Member of the Indonesian Doctors Association Member of Indonesian Society of Anesthesiologist and Reanimation Member of The Asian and Oceanic Society of Regional Anesthesia (AOSRA) Member of The World Association for Study of Pain (IASP) Past President of Indonesian Pain Society (IASP chapter Indonesia)

“Chronic Pain After Surgery” (Chronic Post Surgical Pain=CPSP)

How to prevent it?

Andi Husni TanraChairman of ISAPM

(Indonesia Society of Anesthesiology for Pain Management)

1 st National meeting “Indonesian Society of Anesthesiology for Pain management” (ISAPM)

INTRODUCTION *Good Pain, is an alarm symptom, tell us

that something wrong in our body Acute Pain or Inflammation pain. Pain with nociception

*Bad pain, is a disease entity is a disease of nervous system Chronic Pain. Pain without nociception

Chronic pain is a pain that persists beyond normal tissue healing time, which is assumed to be three – six months.

What is Chronic Pain After Surgery?1) Chronic Pain After Surgery or Chronic

Post Surgical Pain is a new emerging disease “a disease of nervous system” Intractable pain after surgery Persistent pain after surgery

2) Is a common disease after surgery but under recognized ( about 1% of total surgery)

3) Affects million patients world wide a “silent epidemic” disease. (in us 40 million surgical cases/year) incidence in US = 400.000 pts

Pain Clinics in UK, See a Lot of Chronic Pain After Surgery and Trauma!

5130 chronic pain patients in 10 pain clinics in the UK post surgery: 22.5% post trauma: 18.7%

So, about 2000 chronic pain patients, due to surgery and trauma, in UK.

(Crombie et al. Pain Clin 1992; 5: 436-7)

Definition for CPSP (Chronic Post-Surgical Pain).Based on four criteria, namely:

1. Pain developed after surgical procedure.2. It was at least 2 months duration.3. Other causes for the pain had been

excluded.(e.g. continuing malignancy, infection, etc )

4. An attemp had been made to explore and exclude the possibility that the pain was cotinuing from a pre-existing problem.

(Macrae and Davies 1999)

Predisposing factors to develope CPSP.

1. The type of surgery.2. Postoperative pain

intesity. (under-treatment of postoperative pain).

3. Psychological factor.4. Genetic factors.

1. The Type of Surgery, Common surgeries which may develope to CPSP are:

1.Limb amputation2.Thoracic surgery3.Breast surgery4.Herniorrhapy5.Cholicystectomy

1. CPSP; After limb amputationTwo type of pain syndrome

Stump pain Phantom pain

The incidence of phantom pain varies from 50% - 85%

About 40% of amputees having severe phantom pain

Prevalence of phantom pain After trauma was 12% Due to cancer was 48%

Phantom Limb Pain is a ‘Pain Memory’!

In 57% of subjects with phantom pain, this resembled preamputation pain. “… somatosensory inputs of sufficient intensity and duration can produce long-lasting changes in central neural structures”

Katz&Melzack, Pain 1990;43:319

2. CPSP; After thoracic surgery Pain after thoracotomy is fairly common. Incidence up to 50% Damage to intercostal nerve has been

assumed to be the main cause of chronic pain.

Sternotomy also showed almost similar results, the incidence was 28 %.

This suggest a more comlicated aethiology of chronic pain after post thoracotomy.

Even endoscopic surgery may not able to prevent CPSP.

3. CPSP; After breast surgery Several type of pain syndrome; Phantom pain (13-24%

Pain in the scar ( 11-57%) Pain in the arm (12- 51%)

Incidence of pain at one or

more these sites is 50 % Damage to intercostobrachial

nerve is considered the main cause.

Carpenter ‘s found only a lumpectomy developed chronic pain.

4. CPSP; After herniorrhapy Incidence of chronic pain after hernia

repair was 0- 37%. Cunningham* et al found that

Pain at 12 months was 65% 12% moderate to severe pain

Pain at 2 years was 54% 11% moderate to severe pain

Incidence of chronic pain after transperitoneal laparascopic hermorrhapy 15% at 9 m follow-up

* Cunningham et al. Pain in the post-repair patient. Ann Surg 1999;224:598-602

5. CPSP After Cholecystectomy Difficult to investigate because most

patient have pain before surgery and persist after cholecystectomy.

Arround 40% of patients complain pain -related after cholecystectomy.

Incidence of chronic pain varying from 3% =20%

Laparascopic cholecystectomy. Incidence of chronic pain is lower than open

cholecystectomy.

The incidence of CPSP varies with the surgical procedures.

Limb amputation 0 – 81 % Thoracotomy 0 – 50 % Mastectomy 13 –

24 % Herniorrhaphy 0 – 37 % Cholecystectomy 3 – 56

% H. Kehlet world congress on pain 2005

CPSP; After other surgeries Symphatectomy Total hip replacement 28%

(Nikolajsen) Cardiac surgery Rectal amputation Vasectomy Dental extraction Histerectomy 14 % (Brandsborg) Cesarian Section 12% (Nikolajsen) Etc.

Postoperative pain intensityClinical studies have demonstrated that

the development of chronic pain postoperatively is associated with the intensity of acute pain experienced.

Laboratory research showed that neuropathic pain may appear within hours of nerve injury and persist for weeks to months thereafter.

• Kalso E, et al Pain after thoracic surgery . Acta Anesthesiolo Scand 1992; 36: 96-100.

• Peter , et al Somatic and psychosocial predicts long term outcome after surgical inetrvetion. Ann Surg 2007; 245: 487- 94.

2. Postoerative pain intensity

After surgery some changes in the NS may occur:

1. Peripheral sensitization2. Constant bombardment of the

CNS with noxious input.3. Central Sensitization, what we

called “wind-up” “Recruitment”

ASIC/BNC

1.Peripheral sensitization

2. Constant Bombardment of the CNS

TO BRAIN

Dorsal HornPain Neuron + +

+

C

IN

A-delta

+Mediated in part by NMDA receptor on the dorsal horn pain neuron

A-beta

_ _

0

IN

IN = interneuron; NMDA = N-methyl-D-aspartate.Woolf CJ, et al. Science. 2000;288:1765-1769.

3. Central Sensitization Central sensitization refers to enhanced

excitability of dorsal horn neurons and is characterized by:

1. increased spontaneous activity2. An increase in responses evoked by C fibers3. Enlarged receptive field area

Windup is progressive increase in the magnitude of C-fiber evoked responses of dorsal horn neurons produced by repetitive activation of C-fibers.

Recruitment During ongoing activation after

injury, the receptive fields of these neurons

expand, leading to spread of pain.

progressive increase in response of second order neurons to repetitive C-fiber input

4. “Wind-Up”

Mendel and Wall, 1965

Now is appreciated that “wind-up” is a crucial factor for chronic pain after surgery

wind-up

NMDA unblockedNMDA blocked (AP5)

Stimulus frequency applied toC-fiber nerve endings

Act

ion

pote

ntia

l dis

char

ge in

Seco

nd o

rder

spi

nal n

euro

ns 60

50

40

30

20

10

02 4 6 8 1

012

14

Ongoing activation after injury, the receptive fields of these neurons expand, leading to spread of pain.

Recruitment

Even Peripheral Changes of CRPS are Result of Central Sensitization!

So, the main cause neuro-plasticity after surgery or trauma are

Tissue damage Nerve damage

PERIPHERAL ACTIVITY

CENTRAL SENSITIZATION

Decreased threshold to peripheral

stimuli

Increased spontaneous

activityExpansion ofreceptive

field

Hyperalgesia AllodyniaTissue damagePrimary Hyperalgesia

Nerve damage

Spontaneous pain

Secondary Hyperalgesia

Consequences of Unrelieved of Postoperative Pain

Myocardialischaemia

Increasedsympathetic

activity

MyocardialO2

consumption

GI effectsShallow

breathingIncreasedcatabolicdemands

Anxietyand fear

Peripheral/central

sensitisation

GI motilityAtelectasishypoxaemiahypercarbia

Poor woundhealing/muscle

breakdown

Sleeplessness,

helplessness

Neuro-plasticity

Delayed recovery Pneumonia

Weaknessand impaired

rehab.

Psycho-logicaldistress

Chronic

pain

Under treatment of Postoperative pain

GI = gastrointestinal

3.Psychological factors There are consistent relationship between

preoperative anxiety and acute postoperative pain.

Psycholocical factors include: anxiety extroversion depression educational level attitudes to medication, ect.

Postoperative pain is influenced by exaggerated negative beliefs and responses.

Postoperative pain is consistenly found to be the risk factor for CPSP across many study.

Patient educationInformation influences the pain experience

after surgery. In one study, that good preoperative

information resulted in; post-operative pain declining rapidly lower pre-operative anxiety and more satisfaction with post-operative

pain management.

* (Burke, S and Shorten, G.D. when pain after surgery doesn’t go away. Biochemical Society transactions 2009. vol 37, part 1 )

4. Genetic factorsSome diseases may be markers for

developing CPSP, include ; 1. Fibromyalgia Syndrome2. Migraine/headache3. Irritable Bowel Syndrome4. Irritable Bladder Syndrome5. Raynaud’s Syndrome

We must be warning the possibility for developing CSPS in these patients.

2 Studies on CPSP found many patients with a history of IBS, backpain or headache.

How to prevent CPSP ?Since Chronic Post Surgical Pain;

is common cause suffering reduced Quality of Life difficult to treat

Prevention is very important

Preventing chronic pain after surgeryPossible strategies for

1. Avoid unnecessary surgery, Avoid to wish to have surgery for reasons other than

ilness or disability ( cosmetic surgery, sterilization).

2. Modify surgical technique Minimal invasive technique, laparascopic or endoscopic surgery or nerve sparing.

3. Aggressive multimodal analgesia or Aggressive treatment of early inflammatory pain.

If surgery can not be avoided2 things can be done for preventing

Using minimal invasive surgical techniques . (the role of surgeon)

Agressive Perioperative multimodal Analgesia ( the role of anesthesiologist)

Agressive Multimodal Analgesias

Jin et al. J Clin Anesth;13:524, 2001 Kehlet et al. Anesth Analg;77:1048. 1998Woolf CJ, Science, 288:1765-1768, 2000

Optimal effect can be achieved when combined with LA - Epidural

- Nerve block- Infiltration

Cox-2 agents

Opioids

Multimodal

NSAIDs

Gabapentinoid

NorAdr & 5HT antagonists

NMDA antagonists

Parecoxib

IbuprofenKetamine

Tramadol

Pain free andStress free

iv

iv

iviv

iv

iv

Clinical evidenceMultimodal analgesia using a continuous

paravertebral block + acetaminophen and parecoxib has less pain during the first 96 h post-operatively, and had a lesser incidence of CPSP 10 weeks after breast surgery.(Iohom, G., Abdallah, H,. Et al. (2006) Anesth. Analg. 103, 995-1000)

The peri-operative use of anti-neuropathic agents, such as gabapentin and prgabaalin, has also been associated with improved long-term outcomes following mastectomy.

Fassoulaki A, et al. – Anesth Analg 2002;95(4):985-91. Reuben SS, et al. J Pain Symptom Manage 2004;27(2):133-9.

Clinical evidence* A Single dose of gabapentin administered

to patients before mastectomy decreases post-operative morphine consumption and pain during movement.

* Gabapentin, as part of a multimodal analgesic regimen, decreased the incident of CPSP at 10 weeks after breast surgery.

* (Burke, S and Shorten, G.D. when pain after surgery doesn’t go away. Biochemical Society transactions 2009. vol 37, part 1 )

Clinical evidence Studies have shown that effective peri-operative

analgesia using epidural analgesia reduces acute and chronic pain in thoracotomy and major abdominal surgery.

Obata H, et al. –Can J. Anaesth 1999;46(12):1127-32 Senturk M, et al. – Anesth Analg 2002;94(1):11-5 Lavand’homme P, et al. – Anesthesiology 2005;103(4):813-20

For thoracic insertion at Th 4-5-6

For upper abdominal at Th 8-9-10 For lower abdominal at Th 11-12-L1

1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.

+Local Anesthetic- Epidural- Nerve Block- Infiltration

Opioids

Paracetamol, NSAID, COXIB, Gabapentinoid,

2 agonist

Agressive Multimodal Analgesia

Lower Dose Reduced Side Effects

Optimal Analgesia

May Prevent CPSP

Treatment of CPSP depend on the symptoms Neurophatic pain

Tricyclic anti depressantsAnti-epileptic drugs;

Gabapentin and pregabalin are efficacious in the treatment of PHN and DPN but also may play a big role the treatment CPSP, particularly after mastectomy.

Nociceptive pain Paracetamol NSAIDs Opioid if necessary

conclusionCPSP is a new emerging disease but can

be a silent epidemic.Optimal perioperative management may

reduce the incidence of CPSP. Minimal invasive surgical

techniques Agressive perioperative multimodal

analgesia, inluding epidural or nerve blocks.

Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!

This Concept is Not NewGW Crile proposed in 1913,that pain can cause ‘scars’ in the central nervous system, if the noxious stimuli of surgery have unsuppressed access to this system.

Crile, Lancet 1913;185:7

Some chronic pain patients after surgery and trauma.

in Pain clinic at Hiroshima University Hospital, Japan

Thank youvery much

chronic pain after surgery” (chronic post surgical pain=cpsp)how to prevent it? - prof. a. husni...

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