Chronic pain after surgery

Bill Macrae,The Pain Service, Ninewells Hospital,

Dundee, Scotlandw.a.macrae@dundee.ac.uk

NORTH BRITISH PAIN ASSOCIATION SURVEY

10 Pain Clinics in Scotland & North of England5130 New patients over 3 year period

In 22.5% of patients surgery was identified as a cause of pain -

10.9% sole cause 9.2% in combination with other causes

Davies, Crombie, Macrae & Rogers (1992) Crombie, Davies & Macrae (1998)

BREAST SURGERY 3 weeks 1 year 6 years

Phantom breast PAIN 13.3% 12.7% 17.4%Scar pain 35% 22.7% 30.9%

Kroner et al. 1992

Post-mastectomy pain syndrome Incidence 20 - 50%(Neuropathic pain in arm, axilla & chest wall.)

Stevens et al 1995, Wallace et al 1996.

THORACOTOMY

INCIDENCE OF CHRONIC PAIN

Connacher 1992 5%

Dajczman et al 1991 54%

Keller et al 1994 11%

Kalso et al 1992 44%

Richardson et al 1994 22.3% 2m

CHOLECYSTECTOMY

Bates et al 1984• Prospective study 115 patients, 1 year follow up.• 43% rated their operation less than completely

successful.• 46% still complained of indigestion• 27% complained of abdominal pain, most often in

or deep to the scar.

HERNIA

Cooperative hernia study, Cunningham et al 1996Prospective, 2 year follow up, 315 patients.

1 year 62.9% had groin or inguinal pain

11.9% moderate to severe pain

2 years 53.6% had pain,

10.6% moderate to severe pain

Callesen, Bech & Kehlet 1999Prospective, 1 year follow up, 93% response, 500 consecutive hernia repairs

19% reported pain, 6% moderate or severe

Restricted daily activities in 6%

Hip arthroplastyNikolajsen et al 2006

1231 patients, 12-18m after op.

93.6% response rate

28% had chronic pain

12% limitation of daily activities

Related to early post op pain & pain in other sites

Did not relate to pre-op pain

Genetic and psychosocial factors may be important

VASECTOMY

• Second commonest operation on men• Performed for social not medical reasons• No pain before operation• Chronic testicular pain in 5 - 33%(Ahmed et al 1997, McMahon et al 1992)

Prevalence of phantom limb pain

• Jensen et al 1983 & 85 72% at 8 days59% at 2 years

• Houghton et al 1994 78%• Wartan et al 1997 55%• Smith et al 1999 63%• Lacoux et al 2002 32% (upper limb)

Why do patients have pain after surgery?

Why do patients have pain after surgery?

Because they’ve had an operation stupid!

Why do patients have surgery?

• Was the surgery necessary?

• Was the surgery appropriate?Visceral hyperalgesic syndromes– Irritable bowel syndrome– Chronic interstitial cystitis– Atypical chest pain

• Can we reduce the number of operations?

Prevention of post amputation pain

Avoid amputation

Why do people have a mastectomy?

• Breast cancer

• Treatment choice

• What about cosmetic breast surgery?

Preventing mastectomy

• Screening and early detection

• Appropriate treatment– Mastectomy rates (4700 patients with early

breast Ca)• France 28%• UK 31%• USA 56%• Poland 98%

What causes pain after surgery

• Peripheral tissue injury

• Nerve damage and its consequences

• Functional change

• Psychological damage

What causes pain after surgery?

• Tissue injury– Skin, subcutaneous tissues– Muscles– Bones and joints– Viscera– Nervous system

• What does peripheral tissue injury do to the nervous system?

Peripheral tissue injury changes the nervous system in two ways.

1. Peripheral sensitisationA reduction in the threshold of peripheral afferent

nociceptors

2. Central sensitisationIncreased excitability of spinal neuronsRewiring in the spinal cord Changes in the brain

What causes pain after surgery?

What causes pain after surgery

• It is complex but extremely interesting

• The pain syndromes are diverse

• Other factors may influence it– Type of operation – Other treatments– Genetic factors– Anaesthesia and analgesia

What causes pain after surgery

• It is complex but extremely interesting

• The pain syndromes are diverse• Other factors may influence it

– Type of operation – Other treatments– Genetic factors– Anaesthesia and analgesia

BREAST SURGERY

Phantom breast - painful

- non painful

Post-mastectomy pain syndrome

Scar pain

Numbness

Tingling

Sensitivity

BREAST SURGERY

Other problems.

Numbness 39 - 78%Tingling 19 - 35%Sensitivity 23 - 32%

Variation because of different types of surgery

Polinsky 1994

THORACOTOMY

Several different types of syndrome:

• Numbness

• Mechanical / musculoskeletal pain

• Neuropathic pain

• Tumour recurrence

What causes pain after surgery

• It is complex

• The pain syndromes are diverse

• Other factors may influence it– Type of operation– Other treatments – Genetic factors– Anaesthesia and analgesia

BREAST SURGERYType of surgery (Wallace et al 1996)

• Breast reduction 22%• Mastectomy 31%• Breast augmentation - silicone 22%

- saline 33%- submuscular 50%- subglandular 21%

• Mastectomy & recon. - no implant 30%- implants 53%

What causes pain after surgery

• It is complex

• The pain syndromes are diverse

• Other factors may influence it– Type of operation– Other treatments– Genetic factors– Anaesthesia and analgesia

BREAST SURGERY

Surgery + radiotherapy + chemotherapy

increases the incidence of arm pain

Tasmuth et al 1995

Phantom Pain in Children

• Smith et al 1995 (75 patients)12% in trauma related amputees48 % in cancer patients

12% if no chemotherapy 44% with chemotherapy after

amputation74% with chemotherapy before or

at the time of amputation

What causes pain after surgery

• It is complex

• The pain syndromes are diverse

• Other factors may influence it– Type of operation– Other treatments – Genetic factors– Anaesthesia and analgesia

Genetic factors

• There is inter-individual variation in– Pain sensitivity– Analgesic response– Susceptibility to painful pathology

Genetic factors• 1990 - Mice can be bred for susceptibility to

autotomy (Devor & Raber)• 2001- one of the genes was mapped (Seltzer et al)

Genetic factors

“…it seems to me that given the wide range of variability in pain sensitivity among humans, and since at least some of this variability is inherited, clinicians and others should destigmatize pain-sensitive individuals. Such patients may indeed be feeling more pain than others do, even with the same ‘objective’ stimulus.”

Jeffrey S. Mogil

What causes pain after surgery

• It is complex

• The pain syndromes are diverse

• Other factors may influence it– Type of operation– Other treatments – Genetic factors– Anaesthesia and analgesia

BREAST SURGERY

Remembered intensity of postoperative pain correlated with chronic pain

Tasmuth et al 1996

THORACOTOMY

Katz et al 1996.

Prospective study, 30 patients.All given PCA morphine, pain assessed.Follow up at 18 months.

Intensity of post-op pain predicted long term post-thoracotomy pain.

Thoracotomy

Tiippana, Nilsson & Kalso, 2003,

(Acta Scand 47:433-8)

Thoracic epidural analgesia produced lower incidence of chronic post thoracotomy pain than previous studies.

Not an RCT.

Thoracotomy

Senturk et al 2002 (Anesth Analg 94:11-15)

RCT of 69 patients – 3 groups

All had isoflurane/fentanyl GA

1. Epidural T7-8. Pre-op bupiv/morphine + infusion

Post-op PCEA

2. Epidural T7-8. Post-op PCEA

3. IV PCA morphine post-op

Thoracotomy

Senturk et al 2002 (Anesth Analg 94:11-15)

Post-op:

Group 1 had less pain at rest & on coughing / moving

Chronic pain at 2m 1. 50% 6m. 1. 45%

2. 67% 2. 63%

3. 87% 3. 78%

HERNIA

Tverskoy et al 1990RCT, 36 Inguinal hernia patients

• G.A. • G.A. + L.A. • Spinal anaesthesia.

Postop pain significantly decreased in LA & spinal groups even at 10 days

Tonsillectomy & adenoidectomy

Jebeles J.A. et al, 1993

• 22 children having Ts & As under GA

• Prospective double blind RCT

• Peritonsillar infiltration with saline or bupivacaine + adrenaline pre-op

• Less pain in LA group up to 10 days

Jebeles J.A. et alInt. J. Pediatric

Otorhinolaryngology

1993. 25, 149-54

Jebeles J.A. et al,Int. J. Pediatric Otorhinolaryngology,1993. 25, 149-54

Between the painful part and the patient’s experience of pain lies the nervous system