Risk factors for acute and chronic postoperative pain in patients with benign and malignant renal disease after nephrectomy

Aims: This longitudinal study was performed in order to analyze the incidence of and perioperative risk factors for the development of chronic postsurgical pain (CPSP) in patients after nephrectomy. Methods: For baseline data acquisition, valid instruments were used for scoring sociodemographic, psychological, psychosocial, pain, pain treatment, and comorbidity factors: the Mainz Pain Staging System (MPSS) for pain chronicity, the Chronic Pain Grading Questionnaire (CPGQ), the Neuropathic Pain Scale (NPS), the Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF‐12) for health‐related quality of life, the Habitual Well‐Being Questionnaire (HWBQ), the Symptom Check List (SCL‐8) for detecting psychosomatic dysfunction, and the Weighted Illness Check List (WICL) for evaluation of comorbidities and their impact on activities of daily living. Pain intensities were recorded over the first 6 postoperative days after nephrectomy. A sample of 35 patients was followed up for 3 and 6 months. Results: Patients with more intense postoperative pain during the first 6 days had significantly higher preoperative anxiety scores. The incidence of CPSP 3 and 6 months after nephrectomy was 28.6% and 8.6%, respectively. Preoperatively increased anxiety scores, reduced physical health‐related quality of life (SF‐12), multiple comorbid conditions, and increased comorbidity‐related disability were significantly associated with the occurrence of CPSP after 3 months. These patients also reported more severe pain during the first week after surgery. Preoperative “current pain intensity” was significantly increased in CPSP patients. Conclusions: Our results demonstrate a multifactorial development of CPSP. This process may contribute not only to the occurrence of chronic postsurgical pain but also to the biopsychosocial impairment in these patients as often seen in other chronic pain populations.     

High incidence of chronic pain following surgery for pelvic fracture

OBJECTIVES: To determine the incidence of chronic pain after surgery for pelvic fracture using a strict definition and measures of intensity and health-related quality of life. METHODS: In April 2004, a questionnaire was sent to 221 patients who underwent surgery for pelvic fracture in the period 1996 to 2000. Chronic pain was defined as pain at present that related back to the pelvic fracture and was not a consequence of other disease. Health-related quality of life was measured using the 15D questionnaire. RESULTS: The response rate was 72.9% after a median follow-up of 5.6 years. Chronic pain was seen in 48.4% (95% confidence interval, 40.7%-56.2%). These patients had a combination of somatic nociceptive, visceral nociceptive, and neuropathic pain and had significantly lower health-related quality of life. Also, the use of opioids (14.1% vs. 4.8%) and nonsteroidal anti-inflammatories/paracetamol (57.7% vs. 21.7%), the request for financial compensation (75.6% vs. 45.8%), and complications related to leg function (62.8% vs. 20.5%) were significantly higher in the group with chronic pain than in the group without chronic pain. CONCLUSIONS: Chronic pain after pelvic fracture is a major problem that affects a patient's quality of life. The use of analgesics was higher in these patients, and they had more complications. Chronic pain after surgery for pelvic fracture deserves more attention.     

Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post‐thoracotomy pain control

Epidural analgesia is regarded as the gold method for controlling post‐thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post‐thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid‐related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia‐like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1–72.1%), and no significance between the groups. The incidence of allodynia‐like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post‐thoracotomy acute pain. The incidence of post‐thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain.     

Cognitive and behavioral interventions for the management of chronic neuropathic pain in adults – A systematic review

Background: Chronic neuropathic pain is often associated with conditions such as depression and anxiety and strongly affects daily functioning and overall quality of life. It is argued, therefore, that psychosocial interventions should be added to traditional biomedical interventions. This systematic review evaluates the effectiveness of cognitive and behavioral interventions for the management of chronic neuropathic pain. Methods: Electronic databases were searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was assessed with the Health Technology Assessment‐Disease Management instrument. Furthermore, an explorative meta‐analysis of four selected studies was performed. Results: Fourteen studies were assessed: three randomized controlled trials, three controlled before–after studies, seven uncontrolled before–after studies and one time series analysis. The findings of the meta‐analysis were not consistent with a significant effect on pain intensity. Only one study had good methodological quality; it showed some significant effects of the interventions, but only in female participants. Other studies of limited methodological quality did report positive effects on pain and quality of life. Conclusions: This is the first systematic review that has evaluated the effectiveness of cognitive and behavioral techniques for the management of chronic neuropathic pain. Given the limited methodological quality, no informative conclusions can be drawn with respect to the study objective. However, this review does provide insight into the difficulties of this specific area, the need for a clear and widely accepted definition of neuropathic pain and the need for standardized multidimensional measurement instruments.     

Are oral cannabinoids safe and effective in refractory neuropathic pain?

Although cannabinoids have anti-hyperalgesic effects in animal models of nerve injury, there are currently very few prospective trials of the efficacy of cannabinoids in neuropathic pain in humans. This open label prospective study investigated the safety, tolerability and analgesic benefit of oral Delta-9-tetrahydrocannabinol (THC) titrated to a maximal dosage of 25 mg/day in 8 consecutive patients with chronic refractory neuropathic pain. Spontaneous ongoing and paroxysmal pain, allodynia and paresthesias were assessed. The sensory and affective components of pain using the McGill pain questionnaire, quality of life, mood, anxiety and functionality were also evaluated. Seven patients suffered from side effects necessitating premature arrest of the drug in 5 of them. THC (mean dosage: 16.6+/-6.5 mg/day) did not induce any significant effects on ongoing and paroxysmal pain, allodynia, quality of life, anxiety/depression scores and functional impact of pain. These results do not support an overall benefit of THC in pain and quality of life in patients with refractory neuropathic pain.     

The specific disease burden of neuropathic pain: results of a French nationwide survey

We report the first nationwide survey of the impact of neuropathic pain, as opposed to nonneuropathic pain, on quality of life and health care utilization in the French general population. A postal questionnaire was sent to a representative sample of 4554 respondents from an initial nationwide survey of 30,155 subjects with or without chronic pain. It included pain characteristics (Neuropathic Pain Symptom Inventory, DN4), quality of life (Medical Outcomes Short Form 12, SF-12), sleep, anxiety/depressive symptoms (Hospital Anxiety and Depression Scale) and health care utilization. In total, 3899 (85.6%) questionnaires were returned, 3816 (97.9%) could be assessed and 3165 subjects (82.9%) confirmed their pain status. Subjects reporting pain and neuropathic characteristics based on the DN4 displayed a higher degree of impairment of all dimensions relating to quality of life and sleep and had higher anxiety/depression scores than those reporting pain without neuropathic characteristics and those without pain (P < .01). They also made greater use of health care facilities, particularly as concerned neurological treatments and visits to neurologists (21% vs 9%; P < .01). Multivariate analyses showed that the neuropathic characteristics of pain made an independent contribution to quality-of-life impairment (P < .0001 and P = .0005 for the physical and mental scores of the SF-12 respectively). Our study indicates that the disease burden of chronic pain depends on the nature of the pain, independently of its intensity and duration.     

Demographic Characteristics of Patients with Severe Neuropathic Pain Secondary to Failed Back Surgery Syndrome

Background: Neuropathic pain commonly affects the back and legs and is associated with severe disability and psychological illness. It is unclear how patients with predominantly neuropathic pain due to failed back surgery syndrome (FBSS) compare with patients with other chronic pain conditions. Aims: To present data on characteristics associated with FBSS patients compared with those with complex regional pain syndrome, rheumatoid and osteoarthritis, and fibromyalgia. Methods: The PROCESS (Prospective Randomized Controlled Multicenter Trial of the Effectiveness of Spinal Cord Stimulation, ISRCTN 77527324) trial randomized 100 patients to spinal cord stimulation (n = 52) plus conventional medical management (CMM) or CMM alone (n = 48). Baseline patient parameters included age, sex, time since last surgery, employment status, pain location and severity (visual analogue scale), health‐related quality of life (HRQoL), level of disability, medication, and nondrug therapies. Reference population data was drawn from the literature. Results: At baseline, patients in the PROCESS study had a similar age and gender profile compared with other conditions. PROCESS patients suffered from greater leg pain and had lower HRQoL. PROCESS patients treatment cost was higher and they commonly took opioids, while antidepressants and nonsteroidal anti‐inflammatory drugs were more often used for other conditions. Prior to baseline, 87% of patients had tried at least 4 different treatment modalities. Conclusions: Patients suffering from chronic pain of neuropathic origin following FBSS often fail to obtain adequate relief with conventional therapies (eg, medication, nondrug therapies) and suffer greater pain and lower HRQoL compared with patients with other chronic pain conditions. Neuropathic FBSS patients may require alternative and possibly more (cost‐) effective treatments, which should be considered earlier in their therapeutic management.     

全臂丛根性损伤患者疼痛控制状况及其生活质量的研究

目的 了解全臂丛根性损伤患者的疼痛控制状况及其生活质量状况,探讨全臂丛根性损伤患者疼痛与生活质量的关系。方法 采用一般情况调查表、数字评定表(Number Rating Scale,NRS)、世界卫生组织生存质量测定量表(WHOQOL-BEFF)对111例全臂丛根性损伤患者进行调查并做相关分析。结果 111例全臂丛根性损伤患者中,疼痛发生率为91.00%,平均得分为2.23±1.65分。生活质量总平均得分为48.99±7.58分;各维度平均得分均显著低于正常国人得分(P＜0.001)。不同程度的疼痛患者生活质量总评分有差异(P＜0.05);疼痛NRS评分及严重程度与生活质量总评分、生理领域得分、心理领域得分之间有显著的相关性(P＜0.001,P＜0.001,P＜0.05)。结论 全臂丛根性损伤患者疼痛控制不佳、生活质量水平低,疼痛影响生活质量,临床医务人员应重视疼痛的治疗与管理以提高全臂丛根性损伤患者的生活质量。     

Acute neuropathic pain after surgery: Are we treating them early/late?

Acute neuropathic pain (ANP) is now recognised as a cause of post surgical pain. We describe an 80 year old female who presented with sciatic nerve injury following a total hip replacement surgery. Clinical presentation included acute neuropathic pain, numbness, paraesthesia and foot drop. Symptoms and signs of nerve injury and pain were confirmed by neurophysiological studies to be due to a proximal sciatic nerve lesion. Its aetiology, pathogenesis, diagnosis and pharmacotherapy is discussed.In conclusion, we had a patient who demonstrated acute post operative neuropathic pain in combination with post surgical nociceptive pain after hip surgery. ANP responded well to Amitriptyline and Gabapentin. Early diagnosis and treatment with antineuralgics is recommended to prevent progression to chronic post operative neuropathic pain.However, clinical trials are required to confirm efficacy of these treatments in acute neuropathic pain.     

Cryoneurolysis of alveolar nerves for chronic dental pain: A new technique and a case series

Background

Chronic neuropathic dental pain has a poor prognosis with a low chance of significant spontaneous improvement. Local or oral therapies may be efficient, however short in terms of duration with potential side effects. Cryoneurolysis has been described to prevent acute postoperative pain or to treat some chronic pain conditions; however, application to dental orofacial pain has not been reported so far.

Case Series

Following a positive diagnostic block on the corresponding alveolar nerve, neuroablation was performed using a cryoprobe on three patients suffering from persistent pain after a dental extraction and 1 after multiple tooth surgeries. The effect of treatment was assessed using a Pain Numeric Rating Scale (NRS) and determined by changes in medication dosage and quality of life at day 7 and 3 months. Two patients experienced more than 50% of pain relief at 3 months, 2 by 50%. One patient was able to wean off pregabalin medication, one decreased amitriptyline by 50%, and one decreased tapentadol by 50%. No direct complications were reported. All of them mentioned improvement in sleep and quality of life.

Conclusion

Cryoneurolysis on alveolar nerves is a safe and easy-to-use technique allowing prolonged neuropathic pain relief after dental surgery.     

Chronic blockade of interleukin‐1 (IL‐1) prevents and attenuates neuropathic pain behavior and spontaneous ectopic neuronal activity following nerve injury

Neuropathic pain is a chronic pain state resulting from peripheral nerve injury, characterized by hyperalgesia and allodynia. We have reported that mice with genetic impairment of IL‐1 signaling display attenuated neuropathic pain behavior and ectopic neuronal activity. In order to substantiate the role of IL‐1 in neuropathic pain, WT mice were implanted subcutaneously with osmotic micropumps containing either IL‐1ra or vehicle. Two days following the implantation, two models of neuropathic pain were used; partial nerve injury (spinal nerve transection, SNT), or complete nerve cut (spinal neuroma model). Mechanosensitivity was assessed seven consecutive days following SNT, and on day 7 recordings of spontaneous ectopic activity were performed. In the spinal nerve neuroma model, autotomy scores were recorded up to 35 days. Vehicle‐treated mice developed significant allodynia and autotomy, and clear ectopic activity (4.1±1.1% of the axons); whereas IL‐1ra‐treated mice did not display allodynic response, displayed delayed onset of autotomy and markedly reduced severity of autotomy scores, and displayed reduced spontaneous activity (0.8±0.4% of the axons). To test whether IL‐1 is involved in maintenance of mechanical allodynia, a separate group of WT mice was treated with a single injection of either saline or IL‐1ra four days following SNT, after the allodynic response was already manifested. Whereas saline‐treated mice displayed robust allodynia, acute IL‐1ra treatment induced long‐lasting attenuation of the allodynic response. The results support our hypothesis that IL‐1 signaling plays an important role in neuropathic pain and in the ectopic neuronal activity that underling its development.     

Management of chronic neuropathic pain with methadone: a review of 13 cases

The synthetic opioid methadone has generated much interest in recent years among clinicians involved in the management of intractable chronic cancer pain. Its use as an analgesic is starting to extend to the treatment of noncancer pain, particularly neuropathic pain. Unfortunately, the evidence for its use in the management of neuropathic pain is limited to a few case studies. We examined retrospectively during a 12-month study period the clinical response of all 13 patients at our pain clinic who were prescribed methadone in an attempt to control neuropathic pain resistant to conventional analgesics. A questionnaire was also administered to the 9 patients who continued to take methadone at 12 months posttreatment. A total of 4 patients (31%) discontinued it by the end of the 12-month study period. Patients discontinued methadone due to the absence of pain relief and due to various intractable, undesirable side effects. Somnolence was the most common adverse effect reported, followed by nausea, constipation, and vomiting. All patients took coanalgesics (eg, amitriptyline, gabapentin) or other analgesics (eg, morphine, nonsteroidal anti-inflammatory drugs) during methadone treatment to control pain. The 9 patients who continued to take methadone at 12 months reported experiencing on average 43% pain relief (range 0-80%), 47% improvement in quality of life (range 0-100%), and 30% improvement in quality of sleep (range 0-60%). Methadone was effective at relieving pain and ameliorating quality of life and sleep in 62% of patients. These findings suggest that methadone can offer an acceptable success rate for the treatment of neuropathic pain. Prospective randomized, placebo-controlled studies are now needed to examine more rigorously the benefits of methadone for this type of pain.     

Epidemiology of Refractory Neuropathic Pain

Abstract:   Although neuropathic pain can be acute in nature, in most patients the pain is persistent (or "refractory"). Patients with chronic neuropathic pain are seen most often in clinical practice. It consists of a number of different disease-specific indications, each of which can have differing diagnostic definitions and cutoffs. Consequently, it is difficult to estimate precisely the prevalence and incidence of neuropathic pain. The limited currently available epidemiological literature is reviewed in this article. The burden of neuropathic pain on patients and healthcare systems appears to be potentially large, with an estimated prevalence of 1.5%. Patients with neuropathic pain experience a poor health-related quality of life and consume a high level of healthcare resources, and costs. The future prioritization by healthcare policy makers for neuropathic pain treatment funding requires further data to clarify its epidemiology, the burden on the health of patients, and the demand on healthcare budgets.     

Prevalence,severity, and chronicity of pain and general health‐related quality of life in patients with localized prostate cancer

Aims: To analyze the prevalence and the severity spectrum of pain and its relationships to health‐related quality of life and the bio‐psycho‐social consequences of pain among patients scheduled for radical prostatectomy. Methods: Urological inpatients completed an epidemiological pain questionnaire extensively exploring pre‐operative acute and chronic pains in 21 body regions. The severity of pain was determined using von Korff's Pain Grading (CPGQ). Pain chronicity was estimated employing the Mainz Pain Staging System (MPSS). Anxiety and depressive symptoms were identified with the HADS and the Habitual Well‐Being Questionnaire (FW‐7). Health‐related quality of life was measured using the SF‐12. Comorbidities and comorbidity‐related interferences with daily activities were ascertained with the Weighted Illness Checklist (WICL). Results: Eighty of 115 patients (69.6%) reported about pain during the last 3 months pre‐operatively. 28.7% of the pain patients had pain related to urological disease. Severe dysfunctional pain was identified by pain Grades 3 and 4 of the CPGQ in 20% and 13.8%, respectively. Advanced pain chronicity characterized by pain Stages II and III of the MPSS was present in 38.8% and 11.3%. Patients with localized prostate cancer without pain complaints had significantly better health‐related quality of life and habitual well‐being and lower anxiety and depression scores and fewer comorbidities. Patients with cancer‐related and non‐cancer pain did not differ in pain chronicity, pain severity, pain intensities, anxiety, comorbidities and physical health (SF12‐PCS). Conclusions: The high prevalence of severe and chronic pain in cancer patients before scheduled radical prostatectomy – combined with considerable disability effects and markedly reduced quality of life necessitate a short routine screening‐analysis of the severity spectrum of pain and psychopathology. Patient self‐rated pain chronicity staging and psychological distress analysis will allow a disorder severity‐guided treatment and the prevention of suffering and additional new chronic post‐surgical pain.     

Perioperative ketamine does not prevent chronic pain after thoracotomy

Thoracotomy is often responsible for chronic pain, possibly of neuropathic origin. To confirm preclinical studies, the preventive effects of perioperative ketamine were tested in a randomized, double‐blind, placebo‐controlled clinical trial on persistent neuropathic pain after thoracotomy. Eighty‐six patients scheduled for thoracotomy under standardised general anaesthesia were randomised to receive either ketamine (1mgkg⁻¹ at the induction, 1mgkg⁻¹h⁻¹ during surgery, then 1mgkg⁻¹ during 24h; n=42) or normal saline (n=44). Postoperative analgesia included a single dose of intrapleural ropivacaine, intravenous paracetamol and nefopam, and patient‐controlled intravenous morphine. Vital parameters and analgesia were recorded during the 48 first postoperative hours. Seventy‐three patients were followed up. The patient's chest was examined 1–2 weeks, 6 weeks and 4 months after surgery. At the last two observations, spontaneous pain score over a one‐week period (visual analogue scale), neuropathic pain score (NPSI), and intake of analgesics, were assessed. No drug affecting neuropathic pain (except opiates) was given during the follow‐up. Two patients in each group were lost to follow‐up after the 6 week visit. Ketamine improved immediate postoperative pain, but the groups were similar in terms of neuropathic pain and intake of analgesics, 6 weeks (NPSI score: ketamine: 1.25 [0–4.125]; placebo: 1 [0–4]) and 4 months after surgery. Thus, ketamine given in 24‐h infusion failed to prevent chronic neuropathic pain after thoracotomy. Other perioperative preventive long‐lasting treatments or techniques could be tested in this context.     

Chronic pain among community-dwelling elderly: a population-based clinical study

Objective: To present the occurrence, characteristics, etiology, interference, and medication of chronic pain among the elderly living independently at home. Design/setting: A total of 460 subjects in three cohorts aged 75, 80 and 85 years respectively received visits by communal home-care department nurses for a cross-sectional survey. Of them, 175 had chronic (duration ≥ 3 months) pain with an average intensity of ≥ 4/10 and/or ≥ moderate interference in daily life. Main outcome measures: Clinical assessment was performed for consenting subjects to define the location, intensity, etiology, type, interference and medications of chronic pain. Results: According to home visits, elderly people with chronic pain rated their health and mobility worse and felt sadder, lonelier and more tired than those without chronic pain. A geriatrician made clinical assessments for 106 patients with chronic pain in 2009–2013. Of them, 66 had three, 35 had two and 5 had one pain condition. The worst pain was musculoskeletal in 88 (83%) of patients. Pain was pure nociceptive in 61 (58%), pure neuropathic in 9 (8%), combined nociceptive and neuropathic pain in 34 (32%), and idiopathic in 2 (2%) patients. On a numerical rating scale from 0 to 10, the mean and maximal intensity of the worst pain was 5.7 and 7.7, respectively, while the mean pain interference was 5.9. Mean pain intensity and maximal pain intensity decreased by age. Duration of pain was longer than 5 years in 51 (48%) patients. Regular pain medication was used by 82 (77%) patients, most commonly paracetamol or NSAIDs. Although pain limited the lives of the elderly with chronic pain, they were as satisfied with their lives as those without chronic pain. Conclusions: Elderly people in our study often suffered from chronic pain, mostly musculoskeletal pain, and the origin of pain was neuropathic in up to 40% of these cases. However, elderly people with chronic pain rarely used the medications specifically for neuropathic pain. Based on increased loneliness, sadness and tiredness, as well as decreased subjective health and mobility, the quality of life was decreased among those with chronic pain compared with those without pain.

• Key Points

• It is known that chronic pain is one of the most common reasons for general practice consultations and is more common in women than men.

• In our study using detailed clinical examinations, up to 40% of patients with chronic pain in cohorts aged 75, 80 and 85 years suffered from neuropathic pain.

• However, only a few elderly people with chronic pain used medications specifically for chronic pain, which may be due to side effects or non-willingness to experiment with these drugs.

• Elderly people with chronic pain rated their health and mobility to be worse and felt sadder, lonelier and more tired but were not less satisfied with their lives than those without chronic pain.

     

Burden of Neuropathic Pain in Indian Patients Attending Urban,Specialty Clinics: Results from a Cross Sectional Study

Background and Objective: Recent studies in Western populations have reported high patient burden of neuropathic pain. No data are currently available on the burden of neuropathic pain in Indian patients. Our study evaluated the burden of neuropathic pain in patients attending urban, private‐sector, specialty clinics. Methods: This cross‐sectional, observational study surveyed 467 patients with neuropathic pain to assess the burden of pain (pain severity, patient‐reported treatment effectiveness, impact of hypothetical pain relief on overall health rating), burden because of quality of life impairment (EuroQoL health state, pain interference with daily living, sleep and mood disturbances, medication‐related adverse events), and economic burden (treatment cost, impact on employment and productivity). Physicians filled out a clinical case report form to provide information on patient's neuropathic pain disorder and treatment provided. The data were analyzed to assess the overall burden of neuropathic pain. Results: Painful diabetic neuropathy was the most common cause of neuropathic pain (72%). Majority (64%) of patients reported moderate to severe pain, and about 50% reported moderate to severe pain‐related interference in activities of daily living. Substantial sleep impairment was reported as compared with general population. About 50% of patients reported co‐morbid mood disorders, while 67% reported medication‐related adverse event in the preceding week. Fifty‐seven per cent of patients reported an adverse impact on their employment status, including 13% who retired early or were unemployed. Among those currently working, 72% reported reduced productivity, including 22% who reported reduced productivity “most” or “all” of the time. Conclusions: In Indian patients with access to urban, private‐sector, specialty clinics neuropathic pain (particularly painful diabetic neuropathy) remains a significant medical condition with substantial negative impact on their quality of life. ?