Elsevier

Acute Pain

Volume 8, Issue 2, June 2006, Pages 73-81
Acute Pain

Review
Chronic post-surgical pain: Epidemiology and clinical implications for acute pain management

https://doi.org/10.1016/j.acpain.2006.05.002Get rights and content

Summary

Chronic post-surgical pain (CPSP) is an under-recognised and prevalent healthcare problem associated with significant morbidity and potential economic costs. Risk factors include the type of surgery, pre-existing pain, re-operation, nerve damage, moderate-to-severe acute post-operative pain, neurotoxic radio or chemotherapy and psycho-social factors.

CPSP has a multifactorial aetiology, principally nerve injury and wound inflammatory response, leading to peripheral and central sensitisation. The extent of wound hyperalgesia following abdominal surgery correlates with the incidence of CPSP but not with acute pain outcomes, reflecting the relative importance of central sensitisation in the development of CPSP. The contributions of genetics, gender, age, opioid-induced hyperalgesia, pre-existing pain disorders and psycho-social factors to the pathogenesis of CPSP have yet to be clarified.

The prevention of CPSP includes limiting nerve and tissue injury at the time of surgery and in some cases using preventive analgesia techniques such as regional neural blockade or low-dose ketamine infusion. Other strategies such as education, patient surveillance, management of psycho-social factors and functional rehabilitation may also be beneficial, although there are no data to support this. Further research is required to develop ‘predictive tools’ and to examine the effects of multimodal “protective” analgesia and multidisciplinary approaches in the prevention and treatment of CPSP.

Introduction

Chronic or ‘persistent’ post-surgical pain (CPSP) is defined as pain of at least 2 months duration which has developed after a surgical procedure, where other causes such as disease recurrence or a pre-existing pain syndrome have been excluded [1].

CPSP is an under-recognised and prevalent healthcare problem. Surgery contributed to the development of chronic pain in approximately 20% of patients attending pain management clinics in Northern Britain [2]. The incidence of chronic neuropathic pain 1 year after surgery is between 0.5% and 1.5% [3]. In Canada, there are an estimated 72 000 new cases of CPSP each year [4] and in the United States of America, the incidence of complex regional pain syndrome (CRPS) following orthopaedic surgery is estimated at between 74 000 and 191 000 new cases per year [5]. Given these staggering figures and the fact that chronic pain is associated with significant disability and health care utilisation [6], CPSP should be considered a “silent epidemic” that deserves further attention by health care professionals and patients alike.

Section snippets

Epidemiology and ‘risk factors’ for CPSP

Most studies examining CPSP report on incidence rather than other pain-related factors such as intensity or qualitative features. However, Bruce et al. noted that most patients, across a wide variety of CPSP disorders, used ‘sensory-discriminative’ features of the McGill Pain Questionnaire to describe their pain. The most frequent descriptive words were aching, annoying, numb, sharp, stabbing and tiring. Chronic post-mastectomy pain patients reported higher pain rating intensity scores and used

Wound hyperalgesia and CPSP

The area of punctate mechanical hyperalgesia or allodynia around a surgical wound on quantitative sensory testing (QST) (with Von Frey hairs) up to 72 h post-abdominal surgery, correlated with the incidence of CPSP at 6 months (R = 0.81; p < 0.001) but not with acute post-surgical pain, in randomised controlled trials (RCTs) using peri-operative intravenous ketamine or epidural analgesia [30], [31], [32].

In contrast, there was no correlation between the area of stump allodynia, acute pain outcomes

Aetiology of CPSP

CPSP has a multifactorial aetiology and pathology, principally nerve injury and wound inflammatory response, leading to peripheral and central sensitisation and the development of ‘pathological pain’ (severe acute or persistent pain), hyperalgesia or allodynia in the region of the surgical incision.

Central sensitisation may be defined as a state of central nervous system (dorsal horn, thalamus and cortex) ‘hyperactivity’ (including pain ‘amplification’ and ‘memorisation’), due to intensive or

Prevention of CPSP

Although CPSP is a complex bio-psycho-social phenomenon, the utility of a multi-dimensional approach, using a combination of preventive analgesia, modified surgical techniques, psychotherapy, physical rehabilitation, public health, educational and occupational approaches has not yet been validated.

The role of an acute pain service

Severe acute post-surgical pain is common [71] and is a potential risk factor for CPSP [8]. Acute pain services (APS) reduce acute post-operative pain [72] and may therefore reduce CPSP, although this ‘link’ has not been studied directly. An APS may facilitate identification and surveillance of ‘at risk’ patients and optimise the use of preventive analgesia techniques such as epidurals or intravenous ketamine infusions. Ideally, a ‘multidisciplinary APS’ should provide patient education,

Conclusion

Chronic post-surgical pain (CPSP) is an under-recognised and prevalent healthcare problem associated with significant morbidity and potential economic costs. Risk factors include the type of surgery, particularly where there is likelihood of significant nerve or tissue damage, pre-operative pain, moderate-to-severe acute post-operative pain, neurotoxic radio or chemotherapy and psycho-social factors.

CPSP has a multifactorial aetiology including nerve injury and wound inflammatory response,

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