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)

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.

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

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.

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%

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

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)

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)

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?

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?

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

Avoid amputation

Why do people have a mastectomy? Breast cancer Treatment choice What about cosmetic breast surgery?

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%

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

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?

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?

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

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

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

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

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

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

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 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%

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%

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

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

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

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

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

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

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)

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 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

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

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.

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.

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

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%

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

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, 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