Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update

ABSTRACT

Introduction

Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids.

Areas covered

This is a narrative review of the literature.

Expert opinion

Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.

Plain Language Summary

The majority of surgery patients experience pain right after surgery that diminishes day by day as the tissue heals. Surgeons can usually advise patients how long their postsurgical pain will last, but in some cases, pain persists much longer and can even become chronic. Chronic postsurgical pain or CPSP is a condition that occurs most often in people who have open-chest surgery, breast surgery, or have a lower limb amputated. However, CPSP can occur after any type of surgery, even minimally invasive procedures with no complications.

CPSP is a form of chronic pain and can be treated as chronic pain. CPSP can be mild or severe. In some patients, CPSP can include a form of numbness or ‘pins and needles’ around the affected area.

There are certain things that can increase a person’s risk for developing CPSP. Some of these things cannot be changed, like the higher risk for females, younger people, and for certain types of surgery. Pre-existing pain before surgery can increase the risk of CPSP and so can having a very negative attitude called ‘catastrophizing.’ People who ‘catastrophize’ tend to focus and think constantly about worst-case scenarios. Genetics may also play a role in CPSP, but less is known about what genes are involved and how to reduce the risk.

Some CPSP is unavoidable, such as a surgery that might cut or compress a nerve. In other cases, the inflammation following surgery can set the stage for CPSP.

The best strategy to prevent or minimize CPSP is for the clinical team to effectively treat the acute postsurgical pain.] The recommended approach is to use a multimodal pain therapy which is based on two or more agents and may also combine nonpharmacologic approaches as well. Multimodal pain care solves two pain problems. First, CPSP tends to be different types of pain that occur together in something called a ‘mixed pain syndrome.’ Multimodal pain treatment uses more than one agent with different mechanisms of action. Second, multimodal pain regimens reduce or may even eliminate the use of opioid pain relievers. By using the lowest effective amount of opioids, patients are spared opioid-associated side effects and fewer opioids are used. Opioids are associated with opioid use disorder and new policies about good opioid stewardship urge hospitals and prescribers to use opioids only to the extent appropriate.

KEYWORDS:

• Chronic postsurgical pain
• chronic pain
• chronic postoperative pain
• neuropathic pain
• postsurgical pain management
• multimodal pain therapy

Article highlights

• Chronic postsurgical pain (CPSP) is prevalent, challenging to treat, and may complicate recovery.

• CPSP is defined as pain that persists and/or occurs two or more months after surgery when other causes can be ruled out.

• Rates of CPSP vary by type of surgery (thoracic and breast surgery and amputation have high rates) and with risk factors.

• Risk factors include long duration of surgery, type of surgery and technique, younger age, cancer, obesity, pre-existing pain syndromes, and certain psychosocial factors.

• CPSP often involves multiple pain mechanisms necessitating multimodal therapy; there is often a neuropathic and an inflammatory component.

• Effective multimodal analgesia in the acute postoperative period and prompt pain control may help prevent or mitigate CPSP. However, the lowest effective doses of opioids for the shortest effective period of time is recommended, if opioids are to be used at all.

Declaration of interest

JV Pergolizzi, Jr and JA LeQuang are both employees of NEMA Research. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.