Chronic Pain After Surgery Magnitude

Chronic pain after surgery Bill Macrae, The Pain Service, Ninewells Hospital, Dundee, Scotland [email_address]

NORTH BRITISH PAIN ASSOCIATION SURVEY
10 Pain Clinics in Scotland & North of England
5130 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 1996
Prospective, 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 1999
Prospective, 1 year follow up, 93% response, 500 consecutive hernia repairs
19% reported pain, 6% moderate or severe
Restricted daily activities in 6%

Hip arthroplasty
Nikolajsen 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 days
59% 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?

Because they’ve had an operation stupid!
Why do patients have pain after surgery?

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 sensitisation
A reduction in the threshold of peripheral afferent nociceptors
2. Central sensitisation
Increased excitability of spinal neurons
Rewiring in the spinal cord
Changes in the brain
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

It is complex
Type of operation
Other treatments
Genetic factors

BREAST SURGERY
Type 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%

It is complex
Type of operation
Other treatments
Genetic factors

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 amputees
48 % in cancer patients
12% if no chemotherapy
44% with chemotherapy after amputation
74% with chemotherapy before or at the time of amputation

It is complex
Type of operation
Other treatments
Genetic factors

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

It is complex
Type of operation
Other treatments
Genetic factors

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
Epidural T7-8. Pre-op bupiv/morphine + infusion
Post-op PCEA
Epidural T7-8. Post-op PCEA
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 1990
RCT, 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 al Int. 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

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Chronic Pain After Surgery Magnitude

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