Transition from acute to chronic postsurgical pain: risk factors and protective factors

Figures & data

Figure 1. Causal (top) and associative (bottom) hypotheses predicting the prevention and nonprevention of chronic postsurgical pain by pharmacologic blockade at various times throughout the perioperative period.

Top: transition to chronicity (A,B) may be prevented by pharmacological blockade of preoperative pain (C) and/or acute postoperative pain (D) assuming preoperative or acute postoperative pain are the causes of chronic postsurgcial pain. Bottom: transition to chronicity will not be prevented if pains are merely associated and caused by one or more inter-related factors. post-op: Postoperation.

Figure 2. Illustration of the study by Fassoulaki et al.[181] examining the preventive effect of gabapentin (a Ca_vα₂-δ ligand) in women undergoing breast cancer surgery.

EMLA: Eutectic mixture of local anesthetics; G: Group; PACU: Post-anesthetic care unit; PO: per os; post-op: Postoperation.

Figure 3. Schematic illustration of the processes involved in the development of chronic postsurgical pain and pain disability showing relationships (arrows) among preoperative, intraoperative and postoperative factors.

Lines with double arrows between variables show associative relationships reported in the literature. Lines with a single arrowhead show causal relationships based on randomized controlled trials of preventive analgesia.

Table 1. Incidence of chronic postsurgical pain following various surgical procedures.

Study	Surgical procedure	Patients with data in study (n)	Follow-up time (postoperation)	Incidence of chronic postsurgical pain (%)	Ref.
Tasmuth et al. (1997)	MRM or BCT with axillary clearance	93 MRM = 53 BCT = 40	1 year	Breast region: MRM = 17 BCT = 33 Ipsilateral arm: MRM = 13 BCT = 23	[96]
Aasvang et al. (2006)	Hernia repair	694	1 year	Inguinal pain = 56.6 Ejaculation pain = 18.3 Pain in: Testes = 39.7 Shaft = 5.4 Glans = 4.5 Thigh = 11.6	[202]
Grant et al. (2004)	Hernia repair		5 years	Groin pain = 19 Severe or very severe groin pain = 1.8 Testicular pain = 16.1	[21]
Bay-Nielsen et al. (2001) Aasvang et al. (2006)	Hernia repair	1166	1 year 6.5 years	Pain in groin area = 28.7 Pain interfering with work or leisure = 11 Chronic inguinal pain = 8.1	[20] [203]
Katz et al. (1996)	Thoracotomy	23	1.5 years	Dull, aching or burning pain on a daily to weekly basis = 52 Mean pain intensity: 3.3/10	[94]
Pertunnen et al. (1999)	Thoracotomy	67	1 year	Posthoracotomy pain = 61 Severe pain = 3–5	[14]
Gotoda et al. (2001)	Thoracotomy	91	1 year	Post-thoracotomy pain: Pain free = 59 Slight pain = 39 Moderate pain = 2 Severe pain = 0	[19]
Nikolajsen et al. (2004)	Caesarean section	220	∼1 year	Abdominal scar pain = 12.3	[204]
Nikolajsen et al. (1997)	Amputation	60	1 year	Phantom limb pain = ∼70	[15]
Richardson et al. (2006)	Amputation	52	6 months	Phantom limb pain = 78.8 Stump pain = 51.2	[205]
Jensen et al. (1985)	Amputation	58	2 years	Phantom limb pain = 59 Stump pain = 21	[17]
Hanley et al. (2007)	Amputation	57	2 years	Phantom limb pain intensity > 0/10 = 62 Phantom limb pain intensity > 3/10 = 30 Stump pain intensity > 0/10 = 57 Stump pain intensity > 3/10 = 27	[89]
Borly et al. (1999)	Open cholecystectomy	80	1 year	Pain = 26	[53]
Meyerson et al. (2001)	Sternotomy for cardiac surgery	318	1 year	Post-sternotomy pain = 28 With pain intensity ≥ 30/100 = 13	[18]
Nikolajsen et al. (2006)	Hip replacement	1048	12–18-month prevalence	Chronic hip pain = 28.1 Pain limited activities to a moderate, severe or very severe degree = 12.1	[166]

BCT: Breast-conserving surgery; MRM: Modified radical mastectomy.

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