Elsevier

The Lancet

Volume 367, Issue 9522, 13–19 May 2006, Pages 1618-1625
The Lancet

Review
Persistent postsurgical pain: risk factors and prevention

https://doi.org/10.1016/S0140-6736(06)68700-XGet rights and content

Summary

Acute postoperative pain is followed by persistent pain in 10–50% of individuals after common operations, such as groin hernia repair, breast and thoracic surgery, leg amputation, and coronary artery bypass surgery. Since chronic pain can be severe in about 2–10% of these patients, persistent postsurgical pain represents a major, largely unrecognised clinical problem. Iatrogenic neuropathic pain is probably the most important cause of long-term postsurgical pain. Consequently, surgical techniques that avoid nerve damage should be applied whenever possible. Also, the effect of aggressive, early therapy for postoperative pain should be investigated, since the intensity of acute postoperative pain correlates with the risk of developing a persistent pain state. Finally, the role of genetic factors should be studied, since only a proportion of patients with intraoperative nerve damage develop chronic pain. Based on information about the molecular mechanisms that affect changes to the peripheral and central nervous system in neuropathic pain, several opportunities exist for multimodal pharmacological intervention. Here, we outline strategies for identification of patients at risk and for prevention and possible treatment of this important entity of chronic pain.

Section snippets

Clinical presentation (table 2)

Although pain is a psychological sensory experience, it is caused by various factors—eg, nociceptive, inflammatory, and neuropathic pain.

Nociceptive pain is the pain that results from activation of high threshold peripheral sensory (nociceptor) neurons by intense mechanical, chemical, or thermal noxious stimuli. This pain is the pain that results, for example, from a scalpel blade cutting through skin. It signals the presence, location, intensity, and duration of a noxious stimulus and fades

Surgical nerve injury

In most affected patients, postsurgical chronic pain closely resembles neuropathic pain.3, 18 Major nerves trespass the surgical field of most of the surgical procedures associated with chronic pain, and damage to these nerves is probably a prerequisite for the development of postsurgical chronic pain. In a subset of patients, a continuous inflammatory response, such as after inguinal mesh hernia repair, can contribute to a maintained inflammatory pain.8 Differentiation of neuropathic from

Neuronal plasticity and pain (figure)

There are then two kinds of plasticity. One is associated with essentially reversible changes in the software of the system and operates during inflammatory pain; in the other, after nerve injury, the hardware itself is altered. There is consequently no simple continuum from acute to chronic pain that correlates with the duration or intensity of peripheral injury.

Risk factors

An ideal model for studying the development of chronic pain in surgical patients, and establishing predictive factors for the condition, would include preoperative and postoperative assessment of psychological and neurophysiological factors, detailed intraoperative data on handling of tissue and nerves, and detailed early and late postoperative pain data, as well as a thorough clinical investigation to exclude other causes of the chronic pain state. No such study has been reported. However,

Predicting postsurgical chronic pain

A combined scoring system based on age, sex, type of surgery, extent of preoperative pain, and level of anxiety has been developed in an attempt to predict the severity of early postoperative pain.69 Large cohort studies are needed to validate the approach in individual procedures.

In studies in which a preoperative nociceptive stimulation test was undertaken, either with a heat stimulus before knee surgery or caesarean section70, 71 or an ice water test in patients undergoing laparoscopic

Surgical technique

Since many of the operations that produce persistent pain are associated with risk of damage to major nerves, techniques to avoid such damage merit investigation. Such techniques include, for example, laparoscopic herniorrhaphy, which can decrease the risk of nerve damage and pain compared with open surgery.8, 74 The value of a more precise dissection of the inguinal area to avoid nerve damage during open surgery has never been assessed, but elective division of the ilioinguinal nerve does not

New targets for prevention and treatment

The primary focus for prevention needs to be an increased awareness among surgeons of ways to avoid intraoperative nerve injury—eg, by careful dissection, reduction of inflammatory responses, and use of minimally invasive surgical techniques.

There are two potential approaches for the management of neuropathic pain: symptom control and disease modification. Only symptom control is possible at the moment—that is, treatment that reduces pain while the medication is administered. By identifying the

Conclusions

Postsurgical persistent pain is a major, largely unrecognised clinical problem, which is distressing and reduces the quality of life of patients. Iatrogenic neuropathic pain is probably the most common type of postsurgical persistent pain and, as such, surgical techniques that avoid nerve damage should be used wherever possible. Despite advances in the understanding of the processes that lead to persistent pain and the increasing ease of identification of patients at risk of developing such

Search strategy and selection criteria

Because of the many features of basic pain physiology and acute and chronic pain covered in the Review, we did not do a formal literature search. We based the Review on work published mostly within the past 5 years from the major anaesthesiology, surgical, pain, and neurophysiology journals and systematic reviews where appropriate. Recent articles that provided comprehensive overviews are included where appropriate instead of multiple references of original work.

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