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Chronic pain after surgery Bill Macrae, The Pain Service, Ninewells Hospital, Dundee, Scotland [email_address]
NORTH BRITISH PAIN ASSOCIATION SURVEY <ul><li>10 Pain Clinics in Scotland & North of England </li></ul><ul><li>5130 New pa...
BREAST SURGERY <ul><li>  3 weeks 1 year 6 years </li></ul><ul><li>Phantom breast PAIN  13.3% 12.7% 17.4% </li></ul><ul><li...
THORACOTOMY <ul><li>INCIDENCE OF CHRONIC PAIN </li></ul><ul><li>Connacher 1992 5% </li></ul><ul><li>Dajczman et al 1991 54...
CHOLECYSTECTOMY <ul><li>Bates et al 1984 </li></ul><ul><li>Prospective study 115 patients, 1 year follow up. </li></ul><ul...
HERNIA <ul><li>Cooperative hernia study, Cunningham et al 1996 </li></ul><ul><li>Prospective, 2 year follow up, 315 patien...
Hip arthroplasty <ul><li>Nikolajsen et al 2006 </li></ul><ul><li>1231 patients, 12-18m after op. </li></ul><ul><li>93.6% r...
VASECTOMY <ul><li>Second commonest operation on men </li></ul><ul><li>Performed for social not medical reasons </li></ul><...
Prevalence of phantom limb pain <ul><li>Jensen et al  1983 & 85 72% at 8 days </li></ul><ul><li>59% at 2 years </li></ul><...
Why do patients have pain after surgery?
<ul><li>Because they’ve had an operation stupid! </li></ul>Why do patients have pain after surgery?
Why do patients have surgery? <ul><li>Was the surgery necessary? </li></ul><ul><li>Was the surgery appropriate? </li></ul>...
Prevention of post amputation pain <ul><li>Avoid amputation </li></ul>
 
Why do people have a mastectomy? <ul><li>Breast cancer </li></ul><ul><li>Treatment choice </li></ul><ul><li>What about cos...
 
Preventing mastectomy <ul><li>Screening and early detection </li></ul><ul><li>Appropriate treatment </li></ul><ul><ul><li>...
What causes pain after surgery <ul><li>Peripheral tissue injury </li></ul><ul><li>Nerve damage and its consequences </li><...
What causes pain after surgery? <ul><li>Tissue injury </li></ul><ul><ul><li>Skin, subcutaneous tissues </li></ul></ul><ul>...
<ul><li>Peripheral tissue injury changes the nervous system in two ways. </li></ul><ul><li>1. Peripheral sensitisation </l...
What causes pain after surgery <ul><li>It is complex but extremely interesting </li></ul><ul><li>The pain syndromes are di...
What causes pain after surgery <ul><li>It is complex but extremely interesting </li></ul><ul><li>The pain syndromes are di...
BREAST SURGERY <ul><li>Phantom breast - painful </li></ul><ul><li>- non painful </li></ul><ul><li>Post-mastectomy pain syn...
BREAST SURGERY <ul><li>Other problems. </li></ul><ul><li>Numbness  39 - 78% </li></ul><ul><li>Tingling    19 - 35% </li></...
THORACOTOMY <ul><li>Several different types of syndrome: </li></ul><ul><li>Numbness </li></ul><ul><li>Mechanical / musculo...
What causes pain after surgery <ul><li>It is complex  </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>O...
BREAST SURGERY <ul><li>Type of surgery  ( Wallace et al 1996) </li></ul><ul><li>Breast reduction  22% </li></ul><ul><li>Ma...
What causes pain after surgery <ul><li>It is complex  </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>O...
BREAST SURGERY <ul><li>Surgery + radiotherapy + chemotherapy </li></ul><ul><li>increases the incidence of arm pain </li></...
Phantom Pain in Children <ul><li>Smith et al  1995  (75 patients) </li></ul><ul><li>12% in trauma related amputees </li></...
What causes pain after surgery <ul><li>It is complex  </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>O...
Genetic factors <ul><li>There is inter-individual variation in </li></ul><ul><ul><li>Pain sensitivity </li></ul></ul><ul><...
Genetic factors <ul><li>1990 - Mice can be bred for susceptibility to autotomy (Devor & Raber) </li></ul><ul><li>2001- one...
 
Genetic factors <ul><li>“… it seems to me that given the wide range of variability in pain sensitivity among humans, and s...
What causes pain after surgery <ul><li>It is complex  </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>O...
BREAST SURGERY <ul><li>Remembered intensity of postoperative pain correlated with chronic pain </li></ul><ul><li>Tasmuth e...
THORACOTOMY <ul><li>Katz et al 1996. </li></ul><ul><li>Prospective study, 30 patients. </li></ul><ul><li>All given PCA mor...
Thoracotomy <ul><li>Tiippana, Nilsson & Kalso, 2003,  </li></ul><ul><li>(Acta Scand 47:433-8) </li></ul><ul><li>Thoracic e...
Thoracotomy <ul><li>Senturk et al 2002  (Anesth Analg 94:11-15) </li></ul><ul><li>RCT of 69 patients – 3 groups  </li></ul...
Thoracotomy <ul><li>Senturk et al 2002  (Anesth Analg 94:11-15) </li></ul><ul><li>Post-op: </li></ul><ul><li>Group 1 had l...
HERNIA <ul><li>Tverskoy et al 1990 </li></ul><ul><li>RCT, 36 Inguinal hernia patients  </li></ul><ul><li>G.A.  </li></ul><...
Tonsillectomy & adenoidectomy <ul><li>Jebeles J.A. et al, 1993  </li></ul><ul><li>22 children having Ts & As under GA </li...
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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Chronic pain after surgery. More than just a nuisance?

Chronic pain can complicate a third of even relatively minor surgical procedures with far-reaching consequences for patient and family. Why does it happen? What can be done to mitigate the problem?

A seminar in three movements held jointly with the Glasgow Southern Medical Society:
'Magnitude' Dr William Macrae, Dundee
'Molecules' Dr Mick Serpell, Glasgow
'Meaning' Dr David Craig, Glasgow

In this lecture, Dr Bill Macrae discusses the magnitude of the problem.

Published in: Health & Medicine, Business
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  • Transcript of "Chronic Pain After Surgery Magnitude"

    1. 1. Chronic pain after surgery Bill Macrae, The Pain Service, Ninewells Hospital, Dundee, Scotland [email_address]
    2. 2. NORTH BRITISH PAIN ASSOCIATION SURVEY <ul><li>10 Pain Clinics in Scotland & North of England </li></ul><ul><li>5130 New patients over 3 year period </li></ul><ul><li>In 22.5% of patients surgery was identified as a cause of pain - </li></ul><ul><li>10.9% sole cause </li></ul><ul><li>9.2% in combination with other causes </li></ul><ul><li>Davies, Crombie, Macrae & Rogers (1992) </li></ul><ul><li>Crombie, Davies & Macrae (1998) </li></ul>
    3. 3. BREAST SURGERY <ul><li> 3 weeks 1 year 6 years </li></ul><ul><li>Phantom breast PAIN 13.3% 12.7% 17.4% </li></ul><ul><li>Scar pain 35% 22.7% 30.9% </li></ul><ul><li>Kroner et al. 1992 </li></ul><ul><li>Post-mastectomy pain syndrome Incidence 20 - 50% </li></ul><ul><li>(Neuropathic pain in arm, axilla & chest wall.) </li></ul><ul><li>Stevens et al 1995, Wallace et al 1996. </li></ul>
    4. 4. THORACOTOMY <ul><li>INCIDENCE OF CHRONIC PAIN </li></ul><ul><li>Connacher 1992 5% </li></ul><ul><li>Dajczman et al 1991 54% </li></ul><ul><li>Keller et al 1994 11% </li></ul><ul><li>Kalso et al 1992 44% </li></ul><ul><li>Richardson et al 1994 22.3% 2m </li></ul>
    5. 5. CHOLECYSTECTOMY <ul><li>Bates et al 1984 </li></ul><ul><li>Prospective study 115 patients, 1 year follow up. </li></ul><ul><li>43% rated their operation less than completely successful. </li></ul><ul><li>46% still complained of indigestion </li></ul><ul><li>27% complained of abdominal pain, most often in or deep to the scar. </li></ul>
    6. 6. HERNIA <ul><li>Cooperative hernia study, Cunningham et al 1996 </li></ul><ul><li>Prospective, 2 year follow up, 315 patients. </li></ul><ul><li>1 year 62.9% had groin or inguinal pain </li></ul><ul><li>11.9% moderate to severe pain </li></ul><ul><li>2 years 53.6% had pain, </li></ul><ul><li> 10.6% moderate to severe pain </li></ul><ul><li>Callesen, Bech & Kehlet 1999 </li></ul><ul><li>Prospective, 1 year follow up, 93% response, 500 consecutive hernia repairs </li></ul><ul><ul><li>19% reported pain, 6% moderate or severe </li></ul></ul><ul><ul><li>Restricted daily activities in 6% </li></ul></ul>
    7. 7. Hip arthroplasty <ul><li>Nikolajsen et al 2006 </li></ul><ul><li>1231 patients, 12-18m after op. </li></ul><ul><li>93.6% response rate </li></ul><ul><li>28% had chronic pain </li></ul><ul><li>12% limitation of daily activities </li></ul><ul><li>Related to early post op pain & pain in other sites </li></ul><ul><li>Did not relate to pre-op pain </li></ul><ul><li>Genetic and psychosocial factors may be important </li></ul>
    8. 8. VASECTOMY <ul><li>Second commonest operation on men </li></ul><ul><li>Performed for social not medical reasons </li></ul><ul><li>No pain before operation </li></ul><ul><li>Chronic testicular pain in 5 - 33% </li></ul><ul><li>(Ahmed et al 1997, McMahon et al 1992) </li></ul>
    9. 9. Prevalence of phantom limb pain <ul><li>Jensen et al 1983 & 85 72% at 8 days </li></ul><ul><li>59% at 2 years </li></ul><ul><li>Houghton et al 1994 78% </li></ul><ul><li>Wartan et al 1997 55% </li></ul><ul><li>Smith et al 1999 63% </li></ul><ul><li>Lacoux et al 2002 32% (upper limb) </li></ul>
    10. 10. Why do patients have pain after surgery?
    11. 11. <ul><li>Because they’ve had an operation stupid! </li></ul>Why do patients have pain after surgery?
    12. 12. Why do patients have surgery? <ul><li>Was the surgery necessary? </li></ul><ul><li>Was the surgery appropriate? </li></ul><ul><li>Visceral hyperalgesic syndromes </li></ul><ul><ul><li>Irritable bowel syndrome </li></ul></ul><ul><ul><li>Chronic interstitial cystitis </li></ul></ul><ul><ul><li>Atypical chest pain </li></ul></ul><ul><li>Can we reduce the number of operations? </li></ul>
    13. 13. Prevention of post amputation pain <ul><li>Avoid amputation </li></ul>
    14. 15. Why do people have a mastectomy? <ul><li>Breast cancer </li></ul><ul><li>Treatment choice </li></ul><ul><li>What about cosmetic breast surgery? </li></ul>
    15. 17. Preventing mastectomy <ul><li>Screening and early detection </li></ul><ul><li>Appropriate treatment </li></ul><ul><ul><li>Mastectomy rates (4700 patients with early breast Ca) </li></ul></ul><ul><ul><ul><li>France 28% </li></ul></ul></ul><ul><ul><ul><li>UK 31% </li></ul></ul></ul><ul><ul><ul><li>USA 56% </li></ul></ul></ul><ul><ul><ul><li>Poland 98% </li></ul></ul></ul>
    16. 18. What causes pain after surgery <ul><li>Peripheral tissue injury </li></ul><ul><li>Nerve damage and its consequences </li></ul><ul><li>Functional change </li></ul><ul><li>Psychological damage </li></ul>
    17. 19. What causes pain after surgery? <ul><li>Tissue injury </li></ul><ul><ul><li>Skin, subcutaneous tissues </li></ul></ul><ul><ul><li>Muscles </li></ul></ul><ul><ul><li>Bones and joints </li></ul></ul><ul><ul><li>Viscera </li></ul></ul><ul><ul><li>Nervous system </li></ul></ul><ul><li>What does peripheral tissue injury do to the nervous system? </li></ul>
    18. 20. <ul><li>Peripheral tissue injury changes the nervous system in two ways. </li></ul><ul><li>1. Peripheral sensitisation </li></ul><ul><ul><li>A reduction in the threshold of peripheral afferent nociceptors </li></ul></ul><ul><li>2. Central sensitisation </li></ul><ul><ul><li>Increased excitability of spinal neurons </li></ul></ul><ul><ul><li>Rewiring in the spinal cord </li></ul></ul><ul><ul><li>Changes in the brain </li></ul></ul>What causes pain after surgery?
    19. 21. What causes pain after surgery <ul><li>It is complex but extremely interesting </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    20. 22. What causes pain after surgery <ul><li>It is complex but extremely interesting </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    21. 23. BREAST SURGERY <ul><li>Phantom breast - painful </li></ul><ul><li>- non painful </li></ul><ul><li>Post-mastectomy pain syndrome </li></ul><ul><li>Scar pain </li></ul><ul><li>Numbness </li></ul><ul><li>Tingling </li></ul><ul><li>Sensitivity </li></ul>
    22. 24. BREAST SURGERY <ul><li>Other problems. </li></ul><ul><li>Numbness 39 - 78% </li></ul><ul><li>Tingling 19 - 35% </li></ul><ul><li>Sensitivity 23 - 32% </li></ul><ul><li>Variation because of different types of surgery </li></ul><ul><li>Polinsky 1994 </li></ul>
    23. 25. THORACOTOMY <ul><li>Several different types of syndrome: </li></ul><ul><li>Numbness </li></ul><ul><li>Mechanical / musculoskeletal pain </li></ul><ul><li>Neuropathic pain </li></ul><ul><li>Tumour recurrence </li></ul>
    24. 26. What causes pain after surgery <ul><li>It is complex </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    25. 27. BREAST SURGERY <ul><li>Type of surgery ( Wallace et al 1996) </li></ul><ul><li>Breast reduction 22% </li></ul><ul><li>Mastectomy 31% </li></ul><ul><li>Breast augmentation - silicone 22% </li></ul><ul><li> - saline 33% </li></ul><ul><li>- submuscular 50% </li></ul><ul><li>- subglandular 21% </li></ul><ul><li>Mastectomy & recon. - no implant 30% </li></ul><ul><li>- implants 53% </li></ul>
    26. 28. What causes pain after surgery <ul><li>It is complex </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    27. 29. BREAST SURGERY <ul><li>Surgery + radiotherapy + chemotherapy </li></ul><ul><li>increases the incidence of arm pain </li></ul><ul><li>Tasmuth et al 1995 </li></ul>
    28. 30. Phantom Pain in Children <ul><li>Smith et al 1995 (75 patients) </li></ul><ul><li>12% in trauma related amputees </li></ul><ul><li>48 % in cancer patients </li></ul><ul><ul><li>12% if no chemotherapy </li></ul></ul><ul><ul><li>44% with chemotherapy after amputation </li></ul></ul><ul><ul><li>74% with chemotherapy before or at the time of amputation </li></ul></ul>
    29. 31. What causes pain after surgery <ul><li>It is complex </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    30. 32. Genetic factors <ul><li>There is inter-individual variation in </li></ul><ul><ul><li>Pain sensitivity </li></ul></ul><ul><ul><li>Analgesic response </li></ul></ul><ul><ul><li>Susceptibility to painful pathology </li></ul></ul>
    31. 33. Genetic factors <ul><li>1990 - Mice can be bred for susceptibility to autotomy (Devor & Raber) </li></ul><ul><li>2001- one of the genes was mapped (Seltzer et al) </li></ul>
    32. 35. Genetic factors <ul><li>“… 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.” </li></ul><ul><li>Jeffrey S. Mogil </li></ul>
    33. 36. What causes pain after surgery <ul><li>It is complex </li></ul><ul><li>The pain syndromes are diverse </li></ul><ul><li>Other factors may influence it </li></ul><ul><ul><li>Type of operation </li></ul></ul><ul><ul><li>Other treatments </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><ul><li>Anaesthesia and analgesia </li></ul></ul>
    34. 37. BREAST SURGERY <ul><li>Remembered intensity of postoperative pain correlated with chronic pain </li></ul><ul><li>Tasmuth et al 1996 </li></ul>
    35. 38. THORACOTOMY <ul><li>Katz et al 1996. </li></ul><ul><li>Prospective study, 30 patients. </li></ul><ul><li>All given PCA morphine, pain assessed. </li></ul><ul><li>Follow up at 18 months. </li></ul><ul><li>Intensity of post-op pain predicted long term post-thoracotomy pain. </li></ul>
    36. 39. Thoracotomy <ul><li>Tiippana, Nilsson & Kalso, 2003, </li></ul><ul><li>(Acta Scand 47:433-8) </li></ul><ul><li>Thoracic epidural analgesia produced lower incidence of chronic post thoracotomy pain than previous studies. </li></ul><ul><li>Not an RCT. </li></ul>
    37. 40. Thoracotomy <ul><li>Senturk et al 2002 (Anesth Analg 94:11-15) </li></ul><ul><li>RCT of 69 patients – 3 groups </li></ul><ul><li>All had isoflurane/fentanyl GA </li></ul><ul><li>Epidural T7-8. Pre-op bupiv/morphine + infusion </li></ul><ul><ul><ul><li> Post-op PCEA </li></ul></ul></ul><ul><li>Epidural T7-8. Post-op PCEA </li></ul><ul><li>IV PCA morphine post-op </li></ul>
    38. 41. Thoracotomy <ul><li>Senturk et al 2002 (Anesth Analg 94:11-15) </li></ul><ul><li>Post-op: </li></ul><ul><li>Group 1 had less pain at rest & on coughing / moving </li></ul><ul><li>Chronic pain at 2m 1. 50% 6m. 1. 45% </li></ul><ul><li>2. 67% 2. 63% </li></ul><ul><li>3. 87% 3. 78% </li></ul>
    39. 42. HERNIA <ul><li>Tverskoy et al 1990 </li></ul><ul><li>RCT, 36 Inguinal hernia patients </li></ul><ul><li>G.A. </li></ul><ul><li>G.A. + L.A. </li></ul><ul><li>Spinal anaesthesia. </li></ul><ul><li>Postop pain significantly decreased in LA & spinal groups even at 10 days </li></ul>
    40. 43. Tonsillectomy & adenoidectomy <ul><li>Jebeles J.A. et al, 1993 </li></ul><ul><li>22 children having Ts & As under GA </li></ul><ul><li>Prospective double blind RCT </li></ul><ul><li>Peritonsillar infiltration with saline or bupivacaine + adrenaline pre-op </li></ul><ul><li>Less pain in LA group up to 10 days </li></ul>
    41. 44. Jebeles J.A. et al Int. J. Pediatric Otorhinolaryngology 1993. 25, 149-54
    42. 45. Jebeles J.A. et al,Int. J. Pediatric Otorhinolaryngology , 1993. 25, 149-54
    43. 46. Between the painful part and the patient’s experience of pain lies the nervous system
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