chronic pain after surgery: does it matter and can we prevent it?
TRANSCRIPT
Colin J.L. McCartney Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of Anesthesiology and Pain Professor and Chair of Anesthesiology and Pain MedicineMedicineUniversity of OttawaUniversity of OttawaHead of Anesthesiology and Pain MedicineHead of Anesthesiology and Pain MedicineThe Ottawa HospitalThe Ottawa HospitalScientist, Ottawa Hospital Research InstituteScientist, Ottawa Hospital Research Institute
Chronic Pain after Chronic Pain after Surgery: Does it matter Surgery: Does it matter and can we prevent it? and can we prevent it?
Conflicts of InterestConflicts of Interest
Objectives (40 mins)Objectives (40 mins) Understand incidence of CPSP (5 mins)Understand incidence of CPSP (5 mins) Who are the populations at risk? (5 Who are the populations at risk? (5
mins)mins) What new approaches exist for What new approaches exist for
preventing CPSP? (10 mins)preventing CPSP? (10 mins) What does the future hold? (10 mins)What does the future hold? (10 mins)
SummarySummary CPSP common and varies by type of surgeryCPSP common and varies by type of surgery Preoperative pain and psychological factors Preoperative pain and psychological factors
major predictorsmajor predictors Prevention possible with high quality Prevention possible with high quality
perioperative pain relief including LA perioperative pain relief including LA techniques, NMDA antagonists and surgical techniques, NMDA antagonists and surgical approachapproach
Future management possibilities include Future management possibilities include novel therapeutic, psychological and novel therapeutic, psychological and pharmacogenomic approaches pharmacogenomic approaches
Incidence of Incidence of Chronic Post-Surgical PainChronic Post-Surgical Pain
Pain after surgery of primary concern to Pain after surgery of primary concern to patients (Apfelbaum et al 1999)patients (Apfelbaum et al 1999)
Acute postoperative pain remains Acute postoperative pain remains undertreated undertreated
Incidence of severe acute pain a problemIncidence of severe acute pain a problem Severe acute pain associated with CPSPSevere acute pain associated with CPSP Definition: pain >2 months after surgeryDefinition: pain >2 months after surgery
A&A 2003
300 patients300 patients 2/3 had moderate-severe pain after 2/3 had moderate-severe pain after
surgerysurgery No change from 10 years earlierNo change from 10 years earlier
Gan TJ et al CMRO 2014
Or does it?
5130 patients attending chronic pain 5130 patients attending chronic pain clinicsclinics
Surgery contributed to pain in 22.5%Surgery contributed to pain in 22.5% Research needed into: aetiology and Research needed into: aetiology and
procedures contributing to highest risk procedures contributing to highest risk of CPSP.of CPSP.
Preventive strategiesPreventive strategiesPain 1998
Prevalence of persistent postsurgical painPrevalence of persistent postsurgical pain 12982 participants/3111 undergone surgery 12982 participants/3111 undergone surgery
within 3 yearswithin 3 years Persistent pain in 40.4%. Mod-Severe 18.3%Persistent pain in 40.4%. Mod-Severe 18.3%
Poulakka PA et al EJA 2010
Differentiating CPSPDifferentiating CPSP
Systematic review. 281 studies assessed Systematic review. 281 studies assessed investigating PSPS in 11 surgical typesinvestigating PSPS in 11 surgical types
Prevalence of NeuP determined using NeuP Prevalence of NeuP determined using NeuP grading systemgrading system
Prevalence of NeuP high after thoracic and Prevalence of NeuP high after thoracic and breast surgery (66/68%). 31% after groin breast surgery (66/68%). 31% after groin hernia repair and 6% after THA and TKAhernia repair and 6% after THA and TKA
Prevalence of PneuP varies by type of surgery Prevalence of PneuP varies by type of surgery and probability of nerve injuryand probability of nerve injury
>200 patients with MSK trauma>200 patients with MSK trauma Testing at baseline and 4 months Testing at baseline and 4 months
after injuryafter injury Injury severity, pain, anxiety, Injury severity, pain, anxiety,
depression and PTSDdepression and PTSD 21% moderate to severe pain at 21% moderate to severe pain at
baseline and 11% at 4 monthsbaseline and 11% at 4 months High prevalence of neuropathic painHigh prevalence of neuropathic pain Neuropathic pain poorly managed in-Neuropathic pain poorly managed in-
hospitalhospital
Risk Factors for CPSP?Risk Factors for CPSP? Preoperative: Pain, Repeat surgery, Preoperative: Pain, Repeat surgery,
Psychological factors, Female gender Psychological factors, Female gender and younger age, Genetic and younger age, Genetic predispositionpredisposition
Intraoperative: Surgical approach and Intraoperative: Surgical approach and risks of nerve injuryrisks of nerve injury
Postoperative: Acute Pain, Radiation Postoperative: Acute Pain, Radiation Rx, Neurotoxic chemotherapy, Anxiety Rx, Neurotoxic chemotherapy, Anxiety and Depression, Neuroticismand Depression, Neuroticism
McIntyre et al 2010
What can we do about the What can we do about the problem?problem?
Regional anaesthesia techniquesRegional anaesthesia techniques Systemic drug interventionsSystemic drug interventions Modified surgical techniquesModified surgical techniques Focus on postoperative pain controlFocus on postoperative pain control
Regional anesthesia Regional anesthesia techniquestechniques
23 RCTs in total23 RCTs in total Pooled 3 studies for epidural after Pooled 3 studies for epidural after
thoracotomy and 2 for PVB after thoracotomy and 2 for PVB after breast surgerybreast surgery
Unable to pool data from other Unable to pool data from other studies due to marked heterogeneitystudies due to marked heterogeneity
Andreae MH et al BJA 2013
Perioperative Perioperative pharmacotherapypharmacotherapy
KetamineKetamine LidocaineLidocaine GabapentinoidsGabapentinoids NSAIDSNSAIDS
KetamineKetamine
2013 Cochrane Collaboration
No long term benefit for:No long term benefit for:– GabapentinGabapentin– PregabalinPregabalin– NSAIDSNSAIDS– CorticosteroidsCorticosteroids– MexilitineMexilitine
2013 Cochrane Collaboration
Other techniquesOther techniques
IV LidocaineIV Lidocaine DexmedetomidineDexmedetomidine
Modified Surgical Modified Surgical TechniquesTechniques
Future PossibilitiesFuture Possibilities
Impact of psychological factorsImpact of psychological factors Pharmacogenomics and personalized Pharmacogenomics and personalized
medicinemedicine Novel ‘analgesic’ agentsNovel ‘analgesic’ agents
Psychological FactorsPsychological Factors
Preoperative painPreoperative pain Pain catastrophizingPain catastrophizing Mental healthMental health Pain at other sitesPain at other sites
Pain 2013
Predictive Factors Post-Predictive Factors Post-MastectomyMastectomy
Schreiber et al Pain 2013
Pain GeneticsPain Genetics
PharmacogenomicsPharmacogenomics
Genetics of PainGenetics of Pain 3 variants (haplotypes) of gene 3 variants (haplotypes) of gene
encoding COMT predicting low, encoding COMT predicting low, moderate and high sensitivity to painmoderate and high sensitivity to pain
Encompass 96% of humansEncompass 96% of humans Low COMT levels predict high pain Low COMT levels predict high pain
sensitivity and risk of developing TMDsensitivity and risk of developing TMD Inhibition of COMT in rat model Inhibition of COMT in rat model
increases pain sensitivityincreases pain sensitivity
Diatchenko L et al 2005
CPSP is likely 50% influenced by CPSP is likely 50% influenced by genetic determinantsgenetic determinants
Identifying genetic basis of CPSP could Identifying genetic basis of CPSP could lead to significant improvement in lead to significant improvement in treatmenttreatment
Prediction of CPSP, PharmacogenomicsPrediction of CPSP, Pharmacogenomics Improved treatmentsImproved treatments
CJA 2015
Novel neuroactive agentsNovel neuroactive agents
Not analgesic per seNot analgesic per se Prevent mechanism of transition to Prevent mechanism of transition to
chronic painchronic pain rhBDNF, neuroprotective agents (e.g. rhBDNF, neuroprotective agents (e.g.
acetyl l-carnitine) and anti-oxidantsacetyl l-carnitine) and anti-oxidants Early promising resultsEarly promising results
Bordet T et al Neurotherapeutics 2009
SummarySummary CPSP common and varies by type of surgeryCPSP common and varies by type of surgery Preoperative pain and psychological factors Preoperative pain and psychological factors
major predictorsmajor predictors Prevention possible with high quality Prevention possible with high quality
perioperative pain relief including LA perioperative pain relief including LA techniques and NMDA antagonists and techniques and NMDA antagonists and surgical approachsurgical approach
Future management possibilities include Future management possibilities include novel therapeutic, psychological and novel therapeutic, psychological and pharmacogenomic approaches pharmacogenomic approaches
Good Acute Pain Control Good Acute Pain Control Major Concern for PatientsMajor Concern for Patients
Apfelbaum et al A&A 2003
Acute pain controlAcute pain control Use regional anaesthesia where possibleUse regional anaesthesia where possible Use NSAIDS, paracetamol in multimodal Use NSAIDS, paracetamol in multimodal
regimenregimen For higher risk cases use ketamine For higher risk cases use ketamine
and/or lidocaine infusion during surgeryand/or lidocaine infusion during surgery Gabapentin/Pregabalin useful for acute Gabapentin/Pregabalin useful for acute
pain control and reduction of opioid pain control and reduction of opioid consumptionconsumption
Pain Management 2016
Transitional Pain ServiceTransitional Pain Service Pre-operative review, acute Pre-operative review, acute
postoperative and long-term follow up postoperative and long-term follow up Patients identified early and referredPatients identified early and referred Co-ordinated care by pain physicians, Co-ordinated care by pain physicians,
psychologists, physiotherapists and psychologists, physiotherapists and advanced practice nursesadvanced practice nurses
Bypasses long wait times for chronic Bypasses long wait times for chronic pain clinicpain clinic
Risk of Developing Risk of Developing Persistent Opioid Use after Persistent Opioid Use after
Major SurgeryMajor Surgery
Soneji N et al JAMA Surg 2016
Epidemiology better understoodEpidemiology better understood Literature still hampered by varying Literature still hampered by varying
definitions and types of paindefinitions and types of pain Shift in attitude occurring: transitional Shift in attitude occurring: transitional
pain programpain program Better research developing from Better research developing from
centres of excellencecentres of excellence
