Postoperative pain--an update.

Adequate treatment of pain after surgery is central to the care of postoperative patients. Preventing pain or reducing its impact makes subsequent pain management easier. The establishment of 'acute pain relief services' will improve relief offered. Recent pharmacological, psychological and technical advances in this field are briefly discussed.     

Symptom relief in terminal illness

It is the goal of palliative care to provide as large a relief of the disease symptoms as possible for patients, who are incurably sick, in order to improve the quality of the remaining life. Some of the symptoms can hardly be treated; others like pain, dyspnea, gastrointestinal complaints or sweating can usually be well alleviated. The condition for this is a careful evaluation of the clinical status before the treatment, in order to reach symptom relief by purposeful actions without new side effects.     

The surgical management of pancreatic neuroendocrine tumors.

NETs of pancreas are rare and may or may not be associated with symptoms of hormone overproduction. Treatment is required for control of tumor growth and for relief of symptoms associated with excess hormone. With advances in the nonsurgical management of many hormone-related symptoms (e.g., proton pump inhibitors or somatostatin analogues), care for many of these patients has shifted toward the control of tumor progression. Complete surgical resection is the only curative treatment for these tumors. With improvements in the preoperative imaging and intraoperative localization techniques, it is hoped that these tumors will be identified and resected for cure with increased frequency. For patients with hepatic metastasis, initial expectant observation and medical management of symptoms is appropriate in view of the long and indolent course of the disease. Hepatic arterial embolization is the preferred mode of palliation for pain and hormonal symptoms. A curative hepatic resection may be possible in selected patients.     

How to implement an acute pain service

To implement a successful acute pain service the following factors are the most important for success: anaesthesiologist-supervised pain nurses and an ongoing educational programme for patients and all health personnel involved in the care of surgical patients. The benefits in increased patient satisfaction and improved outcome after surgery will far outweigh the costs of running an acute pain service that raises standards of pain management throughout the hospital.Optimal use of basic pharmacological analgesia will improve relief of post-operative pain for most surgical patients. More advanced approaches, such as well-tailored epidural analgesia, are needed to relieve severe dynamic pain (e.g. when coughing). This may reduce markedly risks of complications in patients at high risk of developing post-operative respiratory infections and cardiac ischaemic events.More aggressive methods for post-operative pain management need robust routines that will discover the early symptoms and signs of potentially serious complications. High preparedness must be present for swift and correct handling of the rare but potentially catastrophic complications of bleeding and infection in the spinal canal.Chronic pain is common after surgery. Better acute pain relief may reduce this distressing long-term complication of surgery. Research into the long-term effects of optimal neuraxial analgesia and drugs that dampen glutamatergic hyperphenomena (hyperalgesia/allodynia) are urgently needed to verify whether these approaches can reduce the problem of intractable chronic post-operative pain.     

Postoperative intravenous morphine titration

Relief of acute pain during the immediate postoperative period is an important task for anaesthetists. Morphine is widely used to control moderate-to-severe postoperative pain and the use of small i.v. boluses of morphine in the post-anaesthesia care unit allows a rapid titration of the dose needed for adequate pain relief. The essential principle of a titration regimen must be to adapt the morphine dose to the pain level. Although morphine would not appear to be the most appropriate choice for achieving rapid pain relief, this is the sole opioid assessed in many studies of immediate postoperative pain management using titration. More than 90% of the patients have pain relief using a protocol of morphine titration and the mean dose required to obtain pain relief is 12 (7) mg, after a median of four boluses. Sedation is frequent during i.v. morphine titration and should be considered as a morphine-related adverse event and not evidence of pain relief. The incidence of ventilatory depression is very low when the criteria to limit the dose of i.v. morphine are enforced. Morphine titration can be used with caution in elderly patients, in children, or in obese patients. In practice, i.v. morphine titration allows the physician to meet the needs of individual patients rapidly and limits the risk of overdose making this method the first step in postoperative pain management.     

Pediatric disk herniation

Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty-eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short-term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long-term data suggest that 20% to 30% of patients will require additional surgery later in life.     

Lumbar spinal stenosis: postoperative results in terms of preoperative posture-related pain

Thirty-three consecutive patients with lumbar spinal stenosis were treated with decompressive surgery aimed at relieving pain. The selection criteria for surgery included marked symptoms and lumbar spinal stenosis demonstrated by myelography. Preoperatively, only 15 patients had claudication; however, 23 experienced relief or exacerbation of symptoms related to changes in posture. A good postoperative result was obtained in 82% of the entire series, but in only 50% of patients whose symptoms were not affected by posture. Of those whose symptoms did have a postural component, a good result was obtained in 96%. The relief of back pain by decompressive surgery was significantly less successful than the relief of leg pain. It is therefore suggested that surgery be restricted to as few levels as possible.     

Acute pain control and accelerated postoperative surgical recovery.

Postoperative pain relief continues to demand our awareness, and surgeons should be fully aware of the potential physiologic benefits of effective dynamic pain relief regimens and the great potential to improve postoperative outcome if such analgesia is used for rehabilitation. To achieve advantageous effects, accelerated multimodal postoperative recovery programs should be developed as a multidisciplinary effort, with integration of postoperative pain management into a postoperative rehabilitation program. This requires revision of traditional care programs, which should be adjusted according to recent knowledge within surgical pathophysiology. Such efforts must be expected to lead to improved quality of care for patients, with less pain and reduced morbidity leading to cost efficiency.     

The COVID-19 pandemic and its consequences for chronic pain: a narrative review

The COVID-19 pandemic transformed everyday life, but the implications were most impactful for vulnerable populations, including patients with chronic pain. Moreover, persistent pain is increasingly recognised as a key manifestation of long COVID. This narrative review explores the consequences of the COVID-19 pandemic for chronic pain. Publications were identified related to the COVID-19 pandemic influence on the burden of chronic pain, development of new-onset pain because of long COVID with proposed mechanisms and COVID-19 vaccines and pain interventions. Broadly, mechanisms underlying pain due to SARS-CoV-2 infection could be caused by ‘systemic inflammatory-immune mechanisms’, ‘direct neuropathic mechanisms’ or ‘secondary mechanisms due to the viral infection or treatment’. Existing chronic pain populations were variably impacted and social determinants of health appeared to influence the degree of effect. SARS-CoV-2 infection increased the absolute numbers of patients with pain and headache. In the acute phase, headache as a presenting symptom predicted a milder course. New-onset chronic pain was reportedly common and likely involves multiple mechanisms; however, its prevalence decreases over time and symptoms appear to fluctuate. Patients requiring intensive support were particularly susceptible to long COVID symptoms. Some evidence suggests steroid exposure (often used for pain interventions) may affect vaccine efficacy, but there is no evidence of clinical repercussions to date. Although existing chronic pain management could help with symptomatic relief, there is a need to advance research focusing on mechanism-based treatments within the domain of multidisciplinary care.     

Nonoperative treatment of adult acquired flat foot with the Arizona brace

Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities. At this time, the Arizona AFO brace can be a useful weapon in the orthopedist's armamentarium for treating acquired flat foot deformity.     

Treatment of lumbosacral radicular pain with epidural steroid injections

Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis.     

Attitudes of patients, housestaff, and nurses toward postoperative analgesic care

A survey was carried out among housestaff and nurses involved with postoperative patient care to assess their knowledge of analgesics and their attitudes toward postoperative analgesic care. Only one-fifth of the respondents prescribed for complete pain relief. There were some misconceptions about adding other drugs to narcotic analgesics as well as fear of the addictive properties of these narcotics. The respondents lacked confidence about their knowledge of narcotic analgesics. Fear of respiratory depression was less prominent. Nine percent of the physicians and 31% of the nurses believed that response to a placebo indicates factitious pain. Fifty-four percent of the physicians and 74% of the nurses believed that patients receive adequate pain relief. Eighty-one patients were questioned on their beliefs about pain and its relief. Sixty-six of these were monitored postoperatively to assess the effectiveness of pain relief, which was judged by the authors to be ineffective (i.e., moderate to severe pain at the peak of analgesia) in 41%. Seventy-five percent of the patients reported that their overall postoperative pain relief had been adequate. There was no correlation between the amount of analgesic required postoperatively and either the degree to which patients believed pain builds character or the degree to which they rated themselves sensitive to pain. This study emphasizes the need for better and more comprehensive training of housestaff and nurses in analgesic care.     

Repeat radiosurgery for refractory trigeminal neuralgia

OBJECTIVE: Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. METHODS: Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. RESULTS: After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. CONCLUSION: Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.     

Intravenous regional anesthesia with clonidine in the management of complex regional pain syndrome of the knee

STUDY OBJECTIVE: To evaluate the safety and efficacy of administering intravenous regional anesthesia (IVRA) with clonidine in the management of complex regional pain syndrome (CRPS) of the knee. DESIGN: Prospective, non-blinded study. SETTING: University-affiliated pain management center. PATIENTS: 7 patients with the diagnosis of CRPS of the knee. The diagnosis of CRPS was made if a) patients had at least four of these symptoms: allodynia, hyperesthesia, edema, vasomotor changes, pain with a burning quality, sudomotor changes, joint stiffness, or temperature differences between extremities; b) patients had significant pain relief (>75%) after a lumbar sympathetic block. INTERVENTIONS: Each patient received IVRA with a solution containing clonidine 1 microg/kg in a total volume of 50 mL 0.5% lidocaine. IVRA clonidine (IVRA-C) was performed on each patient up to six times (maximum of once a week for six weeks). MEASUREMETNS: Pain was assessed using a verbal pain scale (VPS) between 0 and 10 before each IVRA-C treatment. Duration of pain relief was defined as the time during which the patients experienced no pain (VPS = 0). Continuous electrocardiogram (ECG) and pulse oximetry (SpO2) were monitored and blood pressure was recorded every 5 minutes for the first 60 minutes after tourniquet deflation. MAIN RESULTS: Five patients received complete pain relief with 4 to 6 IVRA-C blocks. The two remaining patients reached a therapeutic plateau from IVRA-C, but had persistent anatomic lesions contributing to the recurrence of their CRPS. No patient experienced hypotension (mean arterial pressure < or = 20% baseline), hypoxemia (SpO2 < or = 90%), bradycardia (heart rate < or =H 60 beats/min), or excessive sedation. CONCLUSIONS: IVRA-C is a useful treatment modality in the management of CRPS of the knee. Clonidine doses of 1 microg/kg appear to be well tolerated without significant side effects.     

Pain-free hospital audit: a pre-post assessment

OBJECTIVE: To evaluate improvement after implementation of care through a nurse-managed acute pain unit in a district hospital, using statistical process control (SPC) methods. MATERIAL AND METHODS: Each month we measured 3 acute pain unit quality indicators: pain prevalence, pain relief, and satisfaction with pain management. The indicators were monitored on P-charts according to SPC procedures that determine their distribution within control limits and track variability. RESULTS: The hospital prevalence of acute pain stabilized at 30% after a year. Eight-five percent of patients achieved adequate pain relief and 90% were satisfied with pain management. CONCLUSIONS: A nurse-managed acute pain unit designed and managed with tools for monitoring quality assurance produces significant absolute and relative improvements in the prevalence of pain, pain relief, and patient satisfaction (P < .001), leading to a savings of 15 000 days of unnecessary suffering per year.     

Surgical management of groin pain of neural origin

BACKGROUND: An approach to surgical management of the patient with groin pain is described based on our experience with 54 patients, six of whom had bilateral symptoms. History and physical examination are sufficient to relate the pain to one or more of the lateral femoral cutaneous (LFC), ilioinguinal (II), iliohypogastric (IH), or genitofemoral (GF) nerves. STUDY DESIGN: Retrospective analysis of patients with groin pain is reported, with emphasis on cause, involved nerves, and outcomes of operative management. The LFC was decompressed. The II, IH, and GF nerves were resected. Outcomes were graded as excellent, good, and poor in terms of pain relief and functional restoration. RESULTS: For the entire series of patients with painful groins, excellent relief of pain was achieved in 68% and restoration of function achieved in 72%. Ten percent had a poor result. The best results were for II and IH, which were 78% and 83% excellent for both pain relief and restoration of function, with 11% and 17% having a poor result, respectively. The worst results were for the small group of patients with a GF problem, 50% of whom had an excellent and 25% a poor result. Patients who were likely to get an LFC entrapment were those with a nerve located above or within the inguinal ligament. Complications included bruising and cautery injury to the LFC. CONCLUSIONS: Groin pain of neural origin can be relieved with a high degree of patient satisfaction by considering whether one or more of four different nerves are the source of that pain, by realizing that symptoms can be referred to regions other than the groin, such as the pelvic viscera (IH), the knee (LFC), and the testicle (GF), and by treating the appropriate nerve(s) by either neurolysis (LFC) or resection.     

A retrospective analysis of the efficacy of epidural steroid injections

Forty patients were studied retrospectively to evaluate the effect of epidural steroid injections on low back pain and sciatica characteristic of spinal stenosis or a herniated lumbar disc. All but one of these patients had radicular symptoms. The average age was 55 years, and the average follow-up time was eight months. All patients were injected by the same anesthesiologist with 2 cc of Depomedrol-40. Thirty-six patients received either one, two, or three injections. Four patients received either four or five injections. The overall results were poor, with about 60% of patients reporting varying degrees of relief from leg and back pain immediately after injection. However, at follow-up examination, only 24% were asymptomatic; 40% reported no change in preinjection numbness, weakness, or pain; and approximately 35% had varying degrees of relief with no consistent pattern. Of those who had complete relief, there was no correlation between relief of pain, age, or number of injections. From this study, it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.     

Analysis and management of chronic testicular pain

A total of 45 patients was seen in consultation between May 1980 and April 1989 for chronic unilateral or bilateral orchialgia, defined as intermittent or constant testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient so as to prompt him to seek medical attention. We analyzed 34 patients available for followup in terms of socioeconomic parameters, etiology and duration of pain, associated urological symptomatology, specific treatment and results of therapy. Of the patients 31 underwent surgical treatment after failing medical management (24 orchiectomies, 10 epididymectomies, 5 orchiopexies and 1 hydrocelectomy). Of 10 patients who underwent epididymectomy 9 underwent subsequent orchiectomy as definitive treatment. Of 15 patients who underwent inguinal orchiectomy 11 (73%) reported complete relief of pain, while 4 had partial relief. Of the 9 patients who underwent scrotal orchiectomy 5 (55%) reported complete relief of pain, 3 had partial relief and 1 denied improvement. On the basis of these results we recommend inguinal orchiectomy as the procedure of choice for the management of chronic testicular pain when conservative measures are unsuccessful.