Prediction of postoperative pain using path analysis in older patients

Prevalence of preoperative depression and adverse outcomes in older patients undergoing elective surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Depression is a common cause of long-lasting disability and preoperative mental health state that has important implications for optimizing recovery in the perioperative period. In older elective surgical patients, the prevalence of preoperative depression and associated adverse pre- and postoperative outcomes are unknown. This systematic review and meta-analysis aimed to determine the prevalence of preoperative depression and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) for relevant articles from 2000 to present.

PATIENTS

Patients aged ≥65 years old undergoing non-cardiac elective surgery with preoperative depression assessed by tools validated in older adults. These validated tools include the Geriatric Depression Scale (GDS), Hospital Depression and Anxiety Scale (HADS), Beck Depression Inventory-II (BDI), Patient Health Questionnaire-9 (PHQ-9), and the Centre for Epidemiological Studies Depression Scale (CESD).

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the prevalence of preoperative depression. Additional outcomes included preoperative cognitive impairment, and postoperative outcomes such as delirium, functional decline, discharge disposition, readmission, length of stay, and postoperative complications.

MAIN RESULTS

Thirteen studies (n = 2824) were included. Preoperative depression was most assessed using the Geriatric Depression Scale-15 (GDS-15) (n = 12). The overall prevalence of preoperative depression was 23% (95% CI: 15%, 30%). Within non-cancer non-cardiac mixed surgery, the pooled prevalence was 19% (95% CI: 11%, 27%). The prevalence in orthopedic surgery was 17% (95% CI: 9%, 24%). In spine surgery, the prevalence was higher at 46% (95% CI: 28%, 64%). Meta-analysis showed that preoperative depression was associated with a two-fold increased risk of postoperative delirium than those without depression (32% vs 23%, OR: 2.25; 95% CI: 1.67, 3.03; I2: 0%; P ≤0.00001).

CONCLUSIONS

The overall prevalence of older surgical patients who suffered from depression was 23%. Preoperative depression was associated with a two-fold higher risk of postoperative delirium. Further work is needed to determine the need for depression screening and treatment preoperatively.

Predicting the Severity of Acute Pain after Cesarean Delivery: A Narrative Review

PURPOSE OF THE REVIEW

Cesarean delivery is one of the most common surgical procedures performed worldwide. Approximately 28-78% of the patients have reported experiencing severe pain after Cesarean delivery, which is associated with adverse outcomes. Current analgesic management strategies employ a one-size-fits-all approach, which may not be suitable for all post-Cesarean patients. Our ongoing research and the purpose of this review are focusing on preoperative risk assessment to identify patients at risk of severe pain or needing higher doses of opioid or other analgesics.

RECENT FINDINGS

Recent clinical investigations have found that by utilizing the demographic and psychological evaluations, screening tests, quantitative sensory testing, and assessment of response to local anesthetic infiltration, clinicians were potentially able to stratify the risks for severe post-cesarean pain. Several modalities demonstrated significant correlations with pain outcomes, although most of these correlations were weak to modest. Since consensus statement regarding predicting post-CD pain control are still lacking, these correlations can be clinically helpful. It is possible to identify patients at high risk of developing severe acute pain after cesarean section by preoperative demographic data, screening questionnaires, or other tools. Further studies are needed to identify additional variables or screening tools for more accurate prediction and investigate whether personalized analgesic regimens can lead to improved analgesic outcomes.

Influence of Anxiety and Depression on Opioid Use After Cervical Spine Fusion: An Analysis of a National Claims Database

Patients with spine pathology demonstrate an above average rate of active psychiatric disorders, which can influence their recovery. This study was designed to understand how mental health diagnoses (ie, anxiety and depression) influence a patient's postoperative need for opioids after a single level cervical spine fusion. The PearlDiver database was used to identify patients. Patients were placed into one of four groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. Chi-square tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days after their fusion. A total of 168,967 patients who underwent an elective cervical spine fusion in the United States between 2010 and 2021 were included in this study. The control group filled significantly more opioid prescriptions within the first 90 days after their cervical fusion (P<.001). There was no difference among the study groups regarding the need to fill additional opioid prescriptions. Patients with a diagnosis of depression and/or anxiety may present as complex patients; however, results suggest they do not need additional opioids for pain control after a single level cervical spine fusion. [Orthopedics. 2024;47(2):89-94.].

Influence of Anxiety and Depression on Opioid Use Following Lumbar Spine Fusion: A Large Database Study

STUDY DESIGN

Retrospective database.

OBJECTIVE

The purpose of this study was to understand how a mental health disorder, specifically anxiety and depression, influences a patient's postoperative opioid needs following single-level lumbar spine fusion.

SUMMARY OF BACKGROUND DATA

Patients with spine pathology commonly demonstrate symptoms of an active psychiatric disorder. Mental health significantly influences how a patient perceives pain and a patient's opioid pain control needs after surgery.

MATERIALS AND METHODS

The Pearldiver Patient Claims Database was used to identify patients undergoing single-level posterior spine fusion within the United States between 2010 and 2020. Patients were placed into 1 of 4 groups: those with a diagnosis of depression, those with a diagnosis of anxiety, those with a diagnosis of both anxiety and depression, and a control group. χ 2 tests were used to assess differences in the number of patients filling initial and additional opioid prescriptions for up to 90 days following their fusion.

RESULTS

The control group filled significantly more initial opioid prescriptions within the first 90 days following their spine fusion ( P <0.001). However, there was no difference among the study groups in regard to the additional need for prescriptions.

CONCLUSION

Patients with mental health diagnoses may present as complex patients to spine surgeons; however, this study suggests they do not require additional opioid pain control following a single-level lumbar fusion.

Development and prospective validation of postoperative pain prediction from preoperative EHR data using attention-based set embeddings

Preoperative knowledge of expected postoperative pain can help guide perioperative pain management and focus interventions on patients with the greatest risk of acute pain. However, current methods for predicting postoperative pain require patient and clinician input or laborious manual chart review and often do not achieve sufficient performance. We use routinely collected electronic health record data from a multicenter dataset of 234,274 adult non-cardiac surgical patients to develop a machine learning method which predicts maximum pain scores on the day of surgery and four subsequent days and validate this method in a prospective cohort. Our method, POPS, is fully automated and relies only on data available prior to surgery, allowing application in all patients scheduled for or considering surgery. Here we report that POPS achieves state-of-the-art performance and outperforms clinician predictions on all postoperative days when predicting maximum pain on the 0-10 NRS in prospective validation, though with degraded calibration. POPS is interpretable, identifying comorbidities that significantly contribute to postoperative pain based on patient-specific context, which can assist clinicians in mitigating cases of acute pain.

High grade femoral stem subsidence in uncemented hip hemiarthroplasty - A radiographic analysis and an early prediction while treating femoral neck fractures

PURPOSE

Femoral component subsidence is a known risk factor affecting almost all hip replacements using a collarless, cement-less stems. High grade subsidence >5mm is functionally limiting to the patient. Early analysis and prediction of this complication on the immediate post-operative radiographs will help surgeons to opt for alternative solutions to mitigate this complication.

METHODS

A retrospective study including 116 patients, who underwent cement-less bipolar hemi-arthroplasties treated from 2020-2022 were included in the study. Body Mass Index (BMI) and pre-operative American Society Anesthesiologist (ASA) score was retrieved from the medical records. Post operative radiographs on postoperative day two, at four weeks and at eight weeks were evaluated. Dorr's score, initial subsidence ratio (ISR) , stem angulation, proximal stem-canal fit (PSCF) ratio, distal stem-canal fit (DSCF) ratio, medial flare modifier (MFM) were recorded.

RESULTS

A total of 18 patients showed subsidence over 5mm on radiographs evaluated at four weeks. The mean high-grade stem subsidence was 13.5mm +/- 2.67. Evaluating their respective postoperative day two radiographs- ISR was >1 in 16 out of 18 patients (89%), PSCF ratio <0.75 in 83% and DSCF ratio <0.5 in 78% patients. All these patients had a neutral/negative MFM. BMI >25 (p<0.05) and ASA >3 (p<0.001) correlated with a higher degree of stem subsidence.

CONCLUSION

A lower BMI and ASA score accompanied by a positive MFM were protective factors against femoral stem subsidence. A higher ISR along with a PSCF ratio <0.75 and DSCF ratio <0.5, were highly predictive of stem subsidence over 5 mm.

Opioid Dose, Pain, and Recovery following Abdominal Surgery: A Retrospective Cohort Study

Background: The optimal dosage for opioids given to patients after surgery for pain management remains controversial. We examined the association of higher post-surgical opioid use with pain relief and recovery. Methods: We retrospectively enrolled adult patients who underwent elective abdominal surgery at our hospital between August 2021 and April 2022. Patients were divided into the “high-intensity” or “low-intensity” groups based on their post-surgical opioid use. Generalized estimating equation models were used to assess the associations between pain scores at rest and during movement on days 1, 2, 3, and 5 after surgery as primary outcomes. The self-reported recovery and incidence of adverse events were analyzed as secondary outcomes. Results: Among the 1170 patients in the final analysis, 293 were in the high-intensity group. Patients in the high-intensity group received nearly double the amount of oral morphine equivalents per day compared to those in the low-intensity group (84.52 vs. 43.80), with a mean difference of 40.72 (95% confidence interval (CI0 38.96−42.48, p < 0.001) oral morphine equivalents per day. At all timepoints, the high-intensity group reported significantly higher pain scores at rest (difference in means 0.45; 95% CI, 0.32 to 0.58; p < 0.001) and during movement (difference in means 0.56; 95% CI, 0.41 to 0.71; p < 0.001) as well as significantly lower recovery scores (mean difference (MD) −8.65; 95% CI, −10.55 to −6.67; p < 0.001). A post hoc analysis found that patients with moderate to severe pain during movement were more likely to receive postoperative high-intensity opioid use. Furthermore, patients in the non-high-intensity group got out of bed sooner (MD 4.31 h; p = 0.001), required urine catheters for shorter periods of time (MD 12.26 h; p < 0.001), and were hospitalized for shorter periods (MD 1.17 days; p < 0.001). The high-intensity group was at a higher risk of chronic postsurgical pain (odds ratio 1.54; 95% CI, 1.14 to 2.08, p = 0.005). Conclusions: High-intensity opioid use after elective abdominal surgery may not be sufficient for improving pain management or the quality of recovery compared to non-high-intensity use. Our results strengthen the argument for a multimodal approach that does not rely so heavily on opioids.

Relationship between Postoperative Pain and Sociocultural Level in Major Orthopedic Surgery

Background

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are associated with moderate to severe postoperative pain (POP). POP is theoretically predictable and may be influenced by sociocultural differences. This study aimed to identify the relationship between POP and the sociocultural level of the patient undergoing THA or TKA.

Methods

Prospective study, involving informed-consenting adults conducted through consulting patient's clinical processes, preoperative and postoperative questionnaires. Demographic and anthropometric data, type of surgery, ASA classification, sociocultural level of the patient, and POP were assessed.

Results

95 patients, all Caucasian and natural from the north of the Portugal, were included. Younger women undergoing TKA reported higher levels of POP. In females, the ASA 3 physical condition was also associated with higher mean pain intensity. Patients with preoperative chronic pain, without depression diagnosis, and unsatisfied with the current profession showed higher levels of reported POP. Retirees, with lower school degree, reported higher levels of minimal pain.

Conclusions

Job satisfaction, type of surgery, body mass index, presence of chronic pain, and the absence of depression were identified as the main predictors of pain after THA or TKA.

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background

Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.

Methods

A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.

Results

One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.

Conclusions

Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.

Trial registration

Clinical Trial NCT02886221. Registered 1 September 2016.

Acute Pain Burden and Opioid Dose Requirements after Cesarean Delivery in Parturients with Preexisting Chronic Back Pain and Migraine

Introduction

Preexisting chronic pain has been reported to be a consistent risk factor for severe acute postoperative pain. However, each specific chronic pain condition has unique pathophysiology, and it is possible that the effect of each condition on postoperative pain is different.

Methods

This is a retrospective cohort study of pregnant women with preexisting chronic pain conditions (i.e., migraine, chronic back pain, and the combination of migraine + chronic back pain), who underwent cesarean delivery. The effects of the three chronic pain conditions on time-weighted average (TWA) pain score (primary outcome) and opioid dose requirements in morphine milligram equivalents (MME) during postoperative 48 hours were compared.

Results

The TWA pain score was similar in preexisting migraine and chronic back pain. Chronic back pain was associated with significantly greater opioid dose requirements than migraine (12.92 MME, 95% CI: 0.41 to 25.43, P=0.041). Preoperative opioid use (P < 0.001) was associated with a greater TWA pain score. Preoperative opioid use (P < 0.001), smoking (P=0.004), and lower postoperative ibuprofen dose (P=0.002) were associated with greater opioid dose requirements.

Conclusions

Findings suggest women with chronic back pain and migraine do not report different postpartum pain intensities; however, women with preexisting chronic back pain required 13 MME greater opioid dose than those with migraine during 48 hours after cesarean delivery.

Low Incidence of Opioid-Induced Respiratory Depression Observed with Oliceridine Regardless of Age or Body Mass Index: Exploratory Analysis from a Phase 3 Open-Label Trial in Postsurgical Pain

INTRODUCTION

Advanced age and obesity are reported to increase the risk of opioid-induced respiratory depression (OIRD). Oliceridine, an intravenous opioid, is a G-protein-biased agonist at the µ-opioid receptor that may provide improved safety. The recent phase 3 ATHENA open-label, multicenter study evaluated postoperative use of oliceridine in patients with moderate-to-severe acute pain. This exploratory analysis of the ATHENA data examined the incidence of OIRD in older (≥ 65 years) and/or obese (BMI ≥ 30 kg/m2) patients and analyzed risk factors of OIRD.

METHODS

Patients aged ≥ 18 years with a score ≥ 4 on an 11-point numeric pain rating scale (NPRS) received IV oliceridine as needed via bolus dosing and/or patient-controlled analgesia (PCA). OIRD occurring within 48 h of last dose of oliceridine was defined using two established definitions: (1) naloxone use, (2) respiratory rate < 10 breaths per minute and/or oxygen saturation < 90%.

RESULTS

A total of 724 surgical patients with a mean age of 54.5 ± 15.9 years and a mean NRS score of 6.2 ± 2.1 were included in this analysis; 33.3% (241/724) were ≥ 65 years of age and 46.3% (335/724) had BMI (body mass index) ≥ 30 kg/m2. The overall OIRD incidence was 13.7% with no patients requiring naloxone. The OIRD incidence was similar in the elderly and younger adults' cohorts [10.8 vs. 15.1%, OR 0.68 (0.42, 1.1), p = 0.11], and in obese and non-obese groups [14.0 vs. 13.4%, OR 1.06 (0.69, 1.62), p = 0.80]. In patients that were both elderly and obese (n = 120), the incidence was 10.8%. The multivariate analysis identified baseline NRS ≥ 6 [OR 1.6 (1.0, 2.4), p = 0.0499], PCA administration [OR 1.9 (1.2, 3.1), p = 0.005], and concomitant use of benzodiazepines and/or gabapentinoids [OR 1.6 (1.0, 2.6), p = 0.045], as being associated with OIRD.

CONCLUSIONS

Postoperative oliceridine use in patients with advanced age and/or increased BMI was not associated with increased risk of OIRD.

Chronic Breast Pain Prior to Breast Cancer Surgery Is Associated with Worse Acute Postoperative Pain Outcomes

Acute postoperative pain is associated with adverse short and long-term outcomes among women undergoing surgery for breast cancer. Previous studies identified preexisting pain as a predictor of postoperative pain, but rarely accounted for pain location or chronicity. This study leveraged a multinational pain registry, PAIN OUT, to: (1) characterize patient subgroups based on preexisting chronic breast pain status and (2) determine the association of preexisting chronic pain with acute postoperative pain-related patient-reported outcomes and opioid consumption following breast cancer surgery. The primary outcome was a composite score comprising the mean of pain intensity and pain interference items from the International Pain Outcomes Questionnaire. The secondary outcome was opioid consumption in the recovery room and ward. Among 1889 patients, we characterized three subgroups: no preexisting chronic pain (n = 1600); chronic preexisting pain elsewhere (n = 128) and; chronic preexisting pain in the breast with/without pain elsewhere (n = 161). Controlling for covariates, women with preexisting chronic breast pain experienced more severe acute postoperative pain and pain interference (β = 1.0, 95% CI = 0.7-1.3, p < 0.001), and required higher doses of opioids postoperatively (β = 2.7, 95% CI = 0.6–4.8, p = 0.013). Preexisting chronic breast pain may be an important risk factor for poor pain-related postoperative outcomes. Targeted intervention of this subgroup may improve recovery.

Femoral Stem Subsidence and its Associated Factors after Cementless Bipolar Hemiarthroplasty in Geriatric Patients

Introduction

Early femoral stem subsidence has been a concern as a predictor of the beginning of implant loosening, especially on cementless hip arthroplasty implants. This study aimed to determine the factors that affect femoral stem subsidence and outcome following hemiarthroplasty in the geriatric population.

Materials and Methods

This is a retrospective study of 179 patients who underwent cementless bipolar hemiarthroplasty during the 2011-2019 period at an orthopaedic and traumatology hospital. Data on the patient's demography, pre-operative American Society Anaesthesiologist (ASA) score, body mass index (BMI), canal flare index (CFI), Dorr classification, and stem alignment were obtained. The primary outcomes were post-operative femoral stem subsidence, post-operative pain, and functional outcome using Harris Hip Score (HHS). Statistical analysis was conducted to identify risk factors associated with the primary outcome.

Results

The mean femoral stem subsidence was 2.16 ±3.4 mm. The mean post-operative Visual Analog Score (VAS) on follow-up was 1.38 ± 1. Mean HHS on follow-up was 85.28±10.3. American Society Anaesthesiologist score 3 (p = 0.011, OR = 2.77) and varus alignment (p=0.039, OR = 6.963) were related to worse stem subsidence. Otherwise, neutral alignment (p = 0.045 and OR = 0.405) gave protection against femoral stem subsidence. The female gender (p = 0.014, OR 2.53) was associated with postoperative pain onset. Neutral alignment had significant relationship with functional outcomes (p = 0.01; OR 0.33).

Conclusion

A higher ASA score and varus stem alignment were related to a higher risk of femoral stem subsidence. Meanwhile, neutral stem alignment had a protective effect on the femoral stem subsidence and outcome.

Risk factors for postoperative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND

Pars plana vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain. The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following PPV in a selected population of patients with non-painful eye disease, receiving regional anesthesia and moderate sedation with benzodiazepines, without use of narcotics.

METHODS

Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the etiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.

RESULTS

Eye pain (NRS>3) was present in three patients (0.7%) at operating room discharge, 59 (13.2%) at six and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at six hours. Scleral buckling was selected for eye pain at 24 hrs.

CONCLUSIONS

A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade.

The Predictors of Postoperative Pain Among Children Based on the Theory of Unpleasant Symptoms: A Descriptive-Correlational Study

PURPOSE

Postoperative pain (POP) is a common outcome of surgical interventions among children. Identifying POP contributing factors can help identify children who are at risk for POP and facilitate POP management. The aim of the study was to determine the predictors of POP based on the Theory of Unpleasant Symptoms.

DESIGN AND METHODS

This descriptive-correlational study was conducted in 2018-2019 on 153 children purposively recruited. Data were collected using a personal characteristics questionnaire, the Coping Strategies Questionnaire, the Child Pain Anxiety Symptoms Scale, and a Visual Analogue Scale for Pain. The SPSS software (v. 21.0) was used for data analysis.

RESULTS

Twelve participants were excluded and final data analysis was done on the data obtained from 141 participants. Most of participants were male (65.2%), underwent abdominal surgery (53.2%), and experienced POP (86.5%). Their age mean was 8.58±2.23. Linear regression analysis revealed that the physiological factors of heart rate, preoperative pain, and surgery duration as well as the psychological factors of anxiety and coping strategies were significant predictors of POP among children. All these factors collectively explained 34% of the total variance of POP. Situational factors (such as age, gender, and ethnicity) had no significant effects on POP.

CONCLUSIONS

Heart rate, preoperative pain, surgery duration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies.

PRACTICE IMPLICATIONS

The findings provide a better understanding about the predictors of POP and can be used to develop pain management among children.

Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens

INTRODUCTION

Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis.

AIM

The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair.

METHODS

A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation.

RESULTS

The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001).

CONCLUSION

The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.

Colorectal resection via natural orifice specimen extraction versus conventional laparoscopic extraction: a meta-analysis with meta-regression

BACKGROUND

Studies have shown differences in postoperative outcomes between two minimally invasive extraction methods for colorectal lesions-natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLS). The aim of this study was to discover the major differences in NOSES and CLS to refine current practice.

METHODS

Electronic databases were searched for articles comparing NOSES and CLS from inception till March 2020. Weighted mean differences (WMD) and odds ratio (OR) were estimated for continuous and dichotomous outcomes, respectively. Summary statistics were calculated using the DerSimonian and Laird random effects.

RESULTS

Twenty-one studies (15 on malignant disease, 4 on benign disease, 2 on both) were included in this meta-analysis, totalling 2378 patients (1079 NOSE, 1299 CLS). NOSE was associated with decreased: intraoperative bleeding (WMD: - 10.652 ml; 95% CI: - 18.818 ml to - 2.482 ml; p < 0.001), pain score (WMD: - 1.520; 95% CI - 1.965 to - 1.076; p < 0.001), time to flatus (WMD: - 0.306 days; 95% CI: - 0.526 to - 0.085 days; p < 0.001), length of hospital stay (WMD: - 1.048 days; 95% CI: - 1.488 to - 0.609 days; p < 0.001), and total morbidity (OR: 0.548; 95% CI: 0.387 to 0.777; p = 0.001). Subgroup analyses showed significant differences between malignant and benign lesions for intraoperative bleeding (p = 0.011) and pain score (p = 0.010). Meta-regression analyses showed an association between the American Society of Anaesthesiologists (ASA) physical status classification III with pain (p = 0.03) and ASA III with time to flatus (p = 0.04).

CONCLUSIONS

This meta-analysis and meta-regression demonstrated that NOSES had better postoperative outcomes compared to CLS. More comprehensive reviews should be conducted on the long-term outcomes specific to the extraction site to better inform clinical practice.

Factors associated with chronic pain following breast reconstruction in Japanese women

Chronic pain after breast surgery including breast reconstruction is a major concern for patients. However, the factors associated with chronic pain after breast surgery are uncertain in Japanese population. The aim of this study was to identify patient-specific and medical/surgical factors that predict chronic pain after breast surgery in Japanese patients. The subjects were 189 Japanese women undergoing breast surgery including tissue expander/implant (TE/implant), deep inferior epigastric perforator (DIEP) procedures and mastectomy only. Pain was assessed at one year postoperatively using a validated survey instrument: the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with postoperative pain. Surveys were completed by 141 subjects. A younger age (p = .04) and bilateral procedures (p < .05) were both closely associated with the extent of increased postoperative pain at 1 year using the MPQ-Total pain rating. Compared to total mastectomy only, TE/implant procedures showed a significantly lower visual analog scale (VAS) (p = .04) and present pain index (PPI) (p = .03) scores. No factor related to chronic pain was also significantly related to the frequency of pain medication use postoperatively or the effect of social life of the patients. This study identified patients at risk for greater chronic pain after breast surgery. These findings will allow surgeons to improve patient comfort, reduce clinical morbidity and enhance patient satisfaction with their surgical outcome. Abbreviations: BMI: body mass index; CI: confidence interval; DIEP: deep inferior epigastric perforator flap; MPQ: McGill pain questionnaire; PPI: present pain index; SD: standard deviation; SF-MPQ-JV: Japanese version of the short-form McGill pain questionnaire; TE: tissue expander; VAS: visual analog scale.

The effect of surgical pain severity, preoperative opioid use and patient characteristics on postoperative opioid prescriptions and refills in orthopedic surgery

BACKGROUND

Excessive opioid prescriptions after orthopedic surgery are common. The purpose of this study was to examine the association between surgical severity, preoperative opioid use and patient characteristics with postoperative opioid prescriptions and refills.

METHODS

Seventy-nine patients undergoing orthopedic surgeries were reviewed. Surgical pain severity was categorized as mild (n = 25), moderate (n = 26) and severe (n = 28). Patients were also categorized as opioid naïve (n = 57), experienced (n = 16) and tolerant (n = 6). Postoperative and refill prescriptions were reviewed to determine morphine equivalent dose (MED) prescribed.

RESULTS

Mild, moderate and severe pain surgeries received a median (interquartile range) equivalent of 20 (0, 30), 53 (33, 80) and 60 (45, 80) oxycodone 5 mg tablets, respectively. Excessive opioid prescriptions (> 400 MED) were given to 37 (46%) patients. There was no difference in the total discharge MED between moderate and severe pain surgeries or between opioid naïve and opioid-experienced patients (p > 0.05). Variables associated with excessive postoperative opioid prescriptions on multivariate analysis-included severe pain surgery (odds ratio 7.7, 95% confidence interval 2 to 25; p < 0.01) and anesthetic block (odds ratio 4.5, 95% confidence interval 1.4 to 14; p < 0.01). Variables associated with opioid refill on multivariate analysis included an American Society of Anesthiologists Physical Status (ASA) score > I (odds ratio 11, 95% confidence interval: 1.3 to 92; p < 0.01) and preoperative pain VAS (odds ratio 1.2, 95% confidence interval 1.01 to 1.4; p = 0.02).

CONCLUSION

The adoption of opioid prescription guidelines is warranted to differentiate between surgical severities and decrease the range and size of postoperative opioid prescriptions.

Postoperative pain after colorectal surgery

PURPOSE

Postoperative pain is a keystone in perioperative programs, as pain negatively impacts recovery. This study aimed to evaluate pain after elective colorectal surgery and to identify risk factors for postoperative pain.

METHODS

This prospective cohort study comprised consecutive patients undergoing elective colorectal surgery within the Enhanced Recovery after Surgery (ERAS) perioperative program between March 2013 and April 2017. The numeric rating scale (NRS) was used to estimate maximum pain. Logistic regression was used to model associations with the type of surgery, age, gender, and comorbidities.

RESULTS

The cohort comprised 434 of 459 eligible patients. On the day of surgery to postoperative day 3, 50-64% of patients reported moderate to severe pain (NRS 4-10). Postoperative pain was similar for open and minimally invasive rectal surgery, while patients undergoing minimally invasive colonic surgery experienced more pain on the day of surgery and less pain on postoperative days 2 and 3 vs. open colonic surgery. Younger age was associated with more pain every postoperative day and by 0.7 NRS/10 years (95% CI 0.5-0.9, P < 0.001) on the day of surgery, while having diabetes type 2 was associated with less postoperative pain by - 1.3 NRS (95% CI - 2.4 to - 0.2) on the day of surgery.

CONCLUSIONS

The majority, and young patients in particular, experience moderate to severe pain after open and minimally invasive colorectal surgery, despite following ERAS perioperative program. There is a need for effective and individualized analgesia after colorectal surgery, since the individual pain response to surgery is difficult to predict.

Quality of postoperative pain management in Ethiopia: A prospective longitudinal study

Background

The annual number of surgical operations performed is increasing throughout the world. With this rise in the number of surgeries performed, so too, the challenge of effectively managing postoperative pain. In Africa, there are scanty data available that make use of multi-center data to characterize the quality of postoperative pain management. In this study using a longitudinal data, we have attempted to characterize the quality of postoperative pain management; among patients scheduled for major elective orthopedic, gynecologic and general surgery.

Methods

This prospective longitudinal study evaluated the quality of postoperative pain management in patients undergoing elective general, gynecologic, and orthopedic surgery. We quantified the prevalence of moderate to severe postoperative pain with the International Pain Outcome Questionnaire and the corresponding adequacy of treatment with the pain management index. At four time points after surgery, we estimated pain severity, its physical and emotional interference, and patient satisfaction.

Results

Moderate to severe postoperative pain was present in 88.2% of patients, and pain was inadequately treated in 58.4% of these patients. Chronic pain (β = 0.346, 95% CI: 0.212, 0.480) predicted patients’ worst pain intensity. Gender was not associated with the worst pain intensity or percentage of time spent in severe pain. Patient’s pain intensity did not predicted the level of satisfaction.

Conclusions

The prevalence of moderate to severe postoperative pain and its functional interference is high in Ethiopian patients. The treatment provided to patients is inadequate and not in line with international recommendations and standards.

TNF-α and sTNF-RII Are Associated with Pain Following Hip Fracture Surgery in Older Adults

Objective

To explore whether plasma inflammatory mediators on postoperative day 3 (POD3) are associated with pain scores in older adults after hip fracture surgery.

Design

Cross-sectional study.

Setting

Mount Sinai Hospital, New York, New York.

Subjects

Forty patients age 60 years or older who presented with acute hip fracture at Mount Sinai Hospital between November 2011 and April 2013.

Methods

Plasma levels of six inflammatory mediators of the nuclear factor kappa B pathway were measured using blood collected on POD3. Self-reported pain scores (i.e., pain with resting, walking, and transferring) were assessed at baseline (prefracture) and on POD3. Linear regression models using log-transformed data were performed to determine associations between inflammatory mediators and postoperative pain.

Results

Interleukin 18 (IL-18) was positively associated with POD3 resting pain score in the unadjusted model (β = 0.66, P = 0.03). Tumor necrosis factor α (TNF-α) and soluble TNF receptor II (sTNF-RII) were positively associated with POD3 resting pain score in the adjusted model (β = 0.99, P = 0.03, and β = 0.86, P = 0.04, respectively). Moreover, TNF-α was positively associated with POD3 walking pain score in the adjusted model (β = 1.59, P = 0.05). Pain with transferring was not associated with these inflammatory mediators.

Conclusions

These findings suggest that TNF-α and its receptors may influence pain following hip fracture. Further study of the TNF-α pathway may inform future clinical applications that monitor and treat pain in the vulnerable elderly who are unable to accurately report pain.

[High pain expectation and impairment from pre-existing pain are risk factors for severe postoperative pain : Results of a study using the Lübeck Pain Risk Questionnaire]

BACKGROUND

The intensity of postoperative pain is characterized by large interindividual variability. Furthermore, strong postoperative pain is known to influence physical recovery after surgery. High (preoperative) pain expectation and pre-existing pain, which are associated with pain-related disability (impairing pain) are risk factors for strong postoperative pain. They can be determined with the Lübeck Pain Risk Questionnaire used for the first time in this study. The aim of this study was to explore the hypothesis that patients with a combination of the characteristics (1) preoperative impairing pain and (2) high pain expectation are more likely to have strong postoperative pain. Patients with these characteristics represent a unique group of patients and are more likely to develop distinct postoperative pain and can therefore be characterized as a risk group.

MATERIAL AND METHODS

A total of 501 patients at the departments of general surgery, plastic surgery, trauma surgery and orthopedic surgery of the UKSH Campus Lübeck were included in this study. All underwent elective surgery. Study patients were 18 years and older. Those needing postoperative treatment in an intensive care unit were excluded from this study (n = 18). The characteristics "preoperative pain" and "pain expectation" were measured with the Lübeck Pain Risk Questionnaire the day before surgery. The primary outcome variable was the average postoperative pain intensity, which was measured with a numeric rating scale (NRS 0-10) and scores > 4 were defined as severe pain.

RESULTS

The NRS range for "preoperative pain" was subdivided as follows: "no pain" (NRS = 0), "functional pain" (NRS = 1-3), and "impairing pain" (NRS = 4-10); that for "pain expectation" as: "low expectation" (NRS = 0-4) and "high expectation" (NRS = 5-10). To determine these cut-off points, they were varied from > 1 to > 8 and those with highest effect size for strong postoperative pain were chosen. Patients with a high pain expectation had significantly stronger postoperative pain (p < 0.001) and significantly more often higher pain intensity than patients with a low expectation (53.3% vs. 20.6%, respectively, p < 0.001). Patients with pre-existing impairing pain had significantly stronger and more frequently higher postoperative pain than patients with pre-existing functional pain (43.4% vs. 18.4%, p < 0.05). Patients with a combination of the factors "preoperative impairing pain" and "high pain expectation" showed distinct postoperative pain with NRS > 4 significantly more often (59.4%, p < 0.001). These findings could be demonstrated for the departments general surgery, plastic surgery and trauma surgery.

CONCLUSION

The combination of both risk factors results in a unique risk group for the appearance of strong postoperative pain. This group can be economically determined in the daily clinical routine using the Lübeck Pain Risk Questionnaire. Further studies must be carried out to show if additional perioperative procedures can be profitable for the risk group identified with the Lübeck Pain Risk Questionnaire; however, patients falling outside the risk group must not be neglected because they too can develop severe postoperative pain.

Orthopedic Professionals' Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals

Pain is a challenge for orthopedic healthcare professionals (OHCP). However, pain studies examined the competencies of a single OHCP category, did not consider various pain management domains or barriers to optimal pain service, and are deficient across the Arabic Eastern Mediterranean region. We surveyed OHCP's recognition and knowledge of pain and perceived barriers to optimal pain service (361 OHCP, five hospitals). Chi square compared doctors' (n = 63) vs. nurses/physiotherapists' (n = 187) views. In terms of pain recognition, more nurses had pain management training, confidently assessed pediatric/elderly pain, were aware of their departments' pain protocols, and felt that their patients receive proper pain management. More doctors comfortably prescribed opiate medications and agreed that some nationalities were more sensitive to pain. For pain knowledge, more nurses felt patients are accurate in assessing their pain, vital signs are accurate in assessing children's pain, children feel less pain because of nervous system immaturity, narcotics are not preferred due respiratory depression, and knew pre-emptive analgesia. As for barriers to optimal pain service, less nurses agreed about the lack of local policies/guidelines, knowledge, and skills; time to pre-medicate patients; knowledge about medications; complexity of the clinical environment; and physicians being not comfortable prescribing pain medication. We conclude that doctors required confidence in pain, especially pediatric and geriatric pain, using vital signs in assessing pain and narcotics use. Their most perceived barriers were lack of local policies/guidelines and skills. Nurses required more confidence in medications, caring for patients on narcotics, expressed fewer barriers than doctors, and the complexity of the clinical environment was their highest barrier. Educational programs with clinical application could improve OHCPs' pain competencies/clinical practices in pain assessment and administration of analgesics.

Psychosocial Stress Delays Recovery of Postoperative Pain Following Incisional Surgery in the Rat

Psychosocial factors such as anxiety, depression and catastrophizing, commonly associated with established chronic pain, also may be associated with an increased risk of chronic postsurgical pain (CPSP) when present preoperatively. We used a repeat social defeat (RSD) paradigm to induce psychosocial stress in rodents prior to incisional surgery of the paw. Mixed effects growth curve models were utilized to examine resolution of mechanical hypersensitivity in rats for four weeks following surgery. Eight days following surgery, immunohistochemistry was conducted to examine glial activation as well as evoked neuronal activation in the spinal cord. Here we document that RSD resulted in reduced weight gain and increased depressive symptoms prior to surgery. Rats exposed to RSD displayed delayed resolution of mechanical hypersensitivity in the ipsilateral paw following surgery compared to non-defeated rats. Prior exposure to RSD significantly increased microglial activation and neuronal sensitization (pERK-IR) within the ipsilateral spinal cord. In conclusion, we found that chronic social stress alters the neurobiological response to surgical injury, resulting in slowed recovery. This model maybe useful for future interventional studies examining the mechanistic interactions between depression and risk of CPSP.

Osteopathic Manipulative Treatment in Surgical Care: Short Review of Research Publications in Osteopathic Journals During the Period 1990 to 2017

Background.

A growing trend in surgical care is the investigation and incorporation of multimodal interventions into standardized programs. Additionally, manual therapies such as osteopathic manipulative treatment (OMT) are being used with patients in surgical care. Yet the scientific dialogue and the use of OMT in surgical care are currently insubstantial.

Objective.

The aim of this study was to present an overview of published research articles within the subject field of OMT in surgical care.

Method.

Summative review of peer-reviewed research articles published in osteopathic journals during the period 1990 to 2017. In total, 10 articles were identified.

Result.

Previous research has been conducted within the areas of abdominal, thoracic, gynecological, and/or orthopedic surgery with measured outcomes such as pain, analgesia consumption, length of hospital stay, and range of motion. Heterogeneity was identified in usage of osteopathic techniques, treatment duration, and occurrence, as well as in the treating osteopath’s experience.

Conclusion.

Despite the small number of research articles within this field, both positive measured effects as well as the absence of such effects were identified. Overall, there was a heterogeneity concerning surgical contexts, diagnoses, signs and symptoms, as well as surgical phases in current interprofessional osteopathic publications. In this era of multimodal surgical care, we argue that there is an urgent need to evaluate OMT in this context of care and with a proper research approach.

Anxiety and its predictive value for pain and regular analgesic intake after lumbar disc surgery - a prospective observational longitudinal study

BACKGROUND

Ongoing pain after surgery is a major problem and influences recovery and the quality of life of the patient. Associations between anxiety and their impact on postoperative pain after herniated disc surgery have been reported, but the results are inconsistent. The aim of the present longitudinal study was to evaluate the predictive value of preoperative anxiety for postoperative ongoing pain and prolonged analgesic intake after herniated disc surgery.

METHODS

106 patients with lumbar disc herniation were evaluated in the study. Anxiety was measured with the Generalized Anxiety Disorder 7-Item Scale (GAD-7) before surgery. Pain intensity was assessed on a numeric rating scale (NRS) at baseline, 6-weeks and 6-months after surgery. Regression analysis was performed to identify independent predictors of pain and regular utilization of analgesics up to 6 months after surgery while controlling for confounding variables.

RESULTS

42.5% of the patients were rated as anxiety cases (sum scores GAD-7 > 5), mean scores of anxiety showed mild to moderate symptom severity, and 43% suffered from chronic pain before surgery. Six months after surgery, 55.6% of the patients indicated pain levels of 4/10 (NRS) or higher and about 40% still took pain medication on a regular basis, regardless of their preoperative classification as anxiety-case (37.7% and 41.5%). The preoperative pain level was statistically significant for ongoing postsurgical pain in all four analyses (p < 0.001). With binary logistic regression analyses, preoperative pain intensity, but neither demographic factors nor preoperative anxiety, was identified as predictor for postoperative pain and need for analgesic medication up to 6 months after lumbar disc surgery.

CONCLUSION

We found no evidence for the presence of anxiety before disc surgery being a prognostic factor for ongoing pain and regular postoperative intake of analgesics. Only preoperative pain intensity was predictive for increased pain and continued need for analgesic medication up to 6 months after lumbar disc surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01488617 . Registered 6 December 2011.

Changes in Anxiety and Depression Are Mediated by Changes in Pain Severity in Patients Undergoing Lower-Extremity Total Joint Arthroplasty

BACKGROUND

Depression and anxiety are common comorbidities in chronic pain including osteoarthritis patients undergoing total joint arthroplasty (TJA). What is not clear is whether psychiatric comorbidity precedes the manifestation of painful states or represents a reaction to living with chronic pain and associated functional impairment. The objective of this research was to explore whether decreases in depressive and anxiety symptoms after lower-extremity TJA could be due to postsurgical reductions in pain.

METHODS

We conducted a secondary analysis of data from 1448 TJA patients enrolled in the Analgesics Outcome Study. Patients completed measures of pain intensity, functional status, and depressive and anxiety symptoms preoperatively and at 3 and 6 months postoperatively. Data were analyzed using a structural equation modeling approach.

RESULTS

We found that improvement in pain and physical function from baseline to 6 months postoperatively was associated with improvement in depression and anxiety symptoms. We also found that a change in overall body pain at 3 months after surgery significantly mediated changes in both the depression and anxiety scores at 6 months after surgery even when controlling for age, sex, baseline body pain, education, opioid use, and type of surgery.

CONCLUSIONS

Presurgical affective symptoms not only have an effect on change in postsurgical pain, whereby lower preoperative scores on depression and anxiety were associated with lower postsurgical pain, but also postsurgical decreases in pain were associated with lower levels of depression and anxiety after surgery. Taking these points into consideration may prove useful in working toward better outcomes for TJA.

Postoperative Pain Among Patients After Day-Case Surgery

Postoperative pain occurs at a high incidence after day-case surgery, with many patients reporting moderate to severe pain. A cross-sectional design was used in this study to estimate the prevalence of postoperative pain in the early postoperative period after day-case surgery and to determine whether there is a relationship between demographic and clinical variables. A convenient sample of 300 patients, aged between 18 and 80 years, was selected from all postoperative patients after day-case surgery over a period of 6 months. At the first 2 hr after surgery, about 70% of patients had either no pain or mild pain at rest and about 30% of patients had moderate to severe pain. About one third of these patients (103; 35.8%) reported mild pain, and about 43% of patients had moderate to severe pain on movement in the first 2 hr after surgery. Furthermore, 25.3% and 41.3% of the patients reported moderate to severe pain during the first 24 hr after hospital discharge at rest and on movement, respectively. Female patients had significantly higher pain scores than male patients (p < .001). Significant decrease in pain scores was reported in the first 2 hr after surgery (mean = 2.2, SD = 2) and within the first 24 hr after discharge (mean = 1.8, SD = 2.2, t(288) = 4.3, p =. 005) at rest. The prevalence of pain among postoperative patients after day-care surgery in Jordan is high. Young adult and female patients have higher pain scores after day-case surgery.

Factors Associated with Inadequate Pain Control among Postoperative Patients with Cancer

Postoperative pain is considered a major, complex and multidimensional problem that affects the clinical and functional outcomes of patients and may contribute to increased postoperative complications. The goal of this study was to determine the prevalence of inadequate pain control and to investigate the factors associated with inadequate pain control among postoperative cancer patients. A descriptive correlational, cross-sectional design was used. The study was conducted at four adult inpatient oncology departments at King Hussein Cancer Center, a nongovernmental, nonprofit, comprehensive hospital for treating cancer patients in Amman, Jordan. The convenience sample of 800 cancer patients selected comprised postoperative patients diagnosed with cancer and aged ≥18 years who were willing to participate and able to use the numeric rating scale. About 32.9% of patients had pain scores higher than 4/10 at rest, and 56.4% of patients had pain scores higher than 4/10 on movement. Data revealed that patients aged between 18 and 63 years (odds ratio [OR] = 0.196, p < .0005, and OR = 0.245, p < .0005) and chronic user patients (OR = 28.029, p < .0005, and OR = 10.332, p < .0005) had increased odds of poor pain control at rest and on movement, respectively. Administration of preemptive medications and of fentanyl and bupivacaine during the postoperative period was significantly associated with decreased odds of poor pain control. The intravenous route was associated with increased odds of poor pain control at rest and on movement (OR = 2.279, p = .016, and OR = 5.393, p = .012) compared with other routes, including combinations of the intravenous and oral or epidural route. Chronic use of pain medications and older age were predictors of inadequate pain control postoperatively. Administration of preemptive medications and of combinations of fentanyl and bupivacaine via the epidural route was associated with better pain control.

Time perspective as a predictor of acute postsurgical pain and coping with pain following abdominal surgery

BACKGROUND

The aim of this study was to predict acute postsurgical pain and coping with pain following surgery based on preoperative time perspectives. Time perspective is a basic dimension of psychological time. It is a tendency to focus on a particular time area: the past, the present and the future.

METHOD

Seventy-six patients completed measures of time perspective and pain 24 h before abdominal surgery. During the 3 days after surgery, measures of pain and coping with pain were completed.

RESULTS

We performed hierarchical regression analyses to identify predictors of acute postsurgical pain and how patients cope with it. These analyses suggested that a preoperative past-negative time perspective can be a predictor of postoperative pain level and catastrophizing after surgery.

CONCLUSION

The findings of our study indicate the importance of time perspective, especially the past perspective, in dealing with postoperative pain.

SIGNIFICANCE

Our research indicates that a preoperative past-negative time perspective is a significant predictor of acute postsurgical pain intensity and the strongest predictor of pain catastrophizing.

Prevalence of pain 6 months after surgery: a prospective observational study

Background

Pain after surgery is a major issue for patient discomfort and often associated with delayed recovery. The aim of the present study was to evaluate the prevalence of pain and requirement for analgesics up to 6 months after elective surgery, independent if new pain symptoms occurred after surgery or if preoperative pain persisted in the postoperative period.

Methods

A prospective observational single center cohort study was conducted between January 2012 and August 2013. Eligible patients were scheduled to undergo elective surgical interventions including joint (hip, knee arthroplasty), back (nucleotomy, spondylodesis), or urological surgery (cystectomy, prostatectomy, nephrectomy). Pain was assessed on an 11-point numerical rating scale (NRS) before, on postoperative day 2 and 6 months after surgery. Clinical information was collected with structured questionnaires and by telephone interview.

Results

Six hundred and forty-four patients gave informed consent, including 54.4 % men (mean age 62.2, SD 14.3). Higher preoperative pain scores were found in patients undergoing joint (mean 7.6; 95 % confidence interval [CI]: 7.2–8.0) and back surgery (mean 7.1, CI: 6.8–7.5) than in patients prior to urological surgery (mean 2.3; CI: 1.8–2.8). After 6 months, about 50 % of patients after joint or back surgery indicated pain levels ≥3/10, compared to 15.9 % of patients after urological surgery (p < .001). 35.3 % of the patients after joint surgery and 41.3 % after back surgery still use pain medication 6 months postoperatively, in contrast to 7.3 % of patients after urological surgery. 13.6 % of patients who underwent back surgery indicated the regular intake of opioids.

Conclusions

Our results reveal that a significant percentage of patients undergoing procedures in joint or back surgery still need pain medication up to 6 months postoperatively due to ongoing pain symptoms. Improved monitoring of pain management is warranted, especially after discharge from hospital, to improve long-term results.

Trial registration

Clinicaltrials.gov (Identifier: NCT01488617); date of registration December 6th 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0261-7) contains supplementary material, which is available to authorized users.

A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series

Background

Spine surgery candidates are commonly treated with long-term opioid analgesia. However, chronic opioid analgesia is associated with poor pain control, psychological distress, decreased functional status and operative complications. Therefore, our medical centre piloted an outpatient biopsychosocial interdisciplinary opioid reduction program for spine surgery candidates on chronic opioid analgesia.

Methods

Our case series reviews the outcomes of the first 5 interdisciplinary program completers. Data was collected on admission to the program, preoperatively at completion of the program, and 1 month postoperatively. We recorded changes in pain interference scores, physical functioning, and symptoms of depression and anxiety as captured by the Patient-Reported Outcome Measurement Information System (PROMIS-29) Profile.

Results

The mean duration of the preoperative opioid reduction program was 6–7 weeks. The mean morphine equivalent daily dose (SD) decreased from 238.2 (226.9) mg on admission to 157.1 (161.0) mg preoperatively and 139.1 (84.0) mg one month postoperatively. Similarly, the mean pain interference score (SD) decreased from 72.4 (5.1) on admission to 66.5 (6.9) preoperatively and 67.7 (5.4) one month postoperatively. The preoperative opioid dose and pain interference scores decreased in all 5 patients, but one month postoperatively increased in one patient related to a surgical complication. Pre- and postoperative depression, anxiety and fatigue improved in all patients. Satisfaction with participation in social roles, sleep disturbances, and physical functioning improved in most patients.

Conclusions

Pre- and post-operative pain improved despite the opioid dose being tapered. These preliminary data suggest that a short-term outpatient preoperative interdisciplinary biopsychosocial opioid reduction program is safe, feasible, and improves patient-centred outcomes.

Implications

Our preliminary data support the rationale for expansion of the opioid reduction program; opioid use and pain should be evaluated in all surgical candidates. These findings need to be replicated in larger studies.

Factors Associated with Acute Postoperative Pain Following Breast Reconstruction

INTRODUCTION

Post-mastectomy breast reconstruction has become an increasingly important component of breast cancer treatment. Unfortunately, some patients experience severe postoperative pain, placing them at risk for increased clinical morbidity and the development of disabling chronic pain. In an attempt to identify at-risk patients, we prospectively evaluated patient characteristics and medical/surgical variables associated with more severe acute post-reconstruction pain.

METHODS

Women (N = 2207; one-week 82.8% response rate) undergoing breast reconstruction were assessed for pain experience, anxiety, depression, and sociodemographic characteristics prior to surgery. Pain assessments were made preoperatively and postoperative at 1-week using validated survey instruments including the McGill Pain Questionnaire-Short Form (MPQ-SF), Numerical Pain Rating Scale (NPRS), and BREAST-Q Chest and Upper Body scale. Depressive symptoms and anxiety severity were assessed by the Patient Health Questionnaire and Generalized Anxiety Disorders Scale, respectively. Mixed-effects regression modeling was used to examine the relationships between patient characteristics and medical/surgical factors and 1-week postoperative pain.

RESULTS

Younger age, bilateral reconstruction, and severity of preoperative pain, anxiety and depression were all associated with more severe acute postoperative pain on all the pain measures and BREAST-Q. Comparison of surgical procedure type indicated less severe postoperative pain for PTRAM, DIEP and SIEA reconstructive surgery compared to tissue expander/implant reconstruction.

CONCLUSIONS

This study identified patients at risk for greater acute postoperative pain following breast reconstruction. These findings will allow plastic surgeons to better tailor postoperative care to improve patient comfort, reduce clinical morbidity, and further enhance patient satisfaction with their surgical outcome.

Assessment of post-operative pain management among acutely and electively admitted patients - a Swedish ward perspective

RATIONALE, AIMS AND OBJECTIVES

Swedish health care is regulated to involve the patient in every intervention process. In the area of post-operative pain, it is therefore important to evaluate patient experience of the quality of pain management. Previous research has focused on mapping this area but not on comparing experiences between acutely and electively admitted patients. Hence, the aim of this study was to investigate the experiences of post-operative pain management quality among acutely and electively admitted patients at a Swedish surgical department performing soft-tissue surgery.

METHODS

A survey study design was used as a method based on a multidimensional instrument to assess post-operative pain management: Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP). Consecutive patients at all wards of a university hospital's surgical department were included. Data collection was performed at hospital discharge.

RESULTS

In total, 160 patients participated, of whom 40 patients were acutely admitted. A significant difference between acutely and electively admitted patients was observed in the SCQIPP area of environment, whereas acute patients rated the post-operative pain management quality lower compared with those who were electively admitted.

CONCLUSIONS

There may be a need for improvement in the areas of post-operative pain management in Sweden, both specifically and generally. There may also be a difference in the experience of post-operative pain quality between acutely and electively admitted patients in this study, specifically in the area of environment. In addition, low levels of the perceived quality of post-operative pain management among the patients were consistent, but satisfaction with analgesic treatment was rated as good.

[Fear and preoperative anxiety behaviour and pain intensity perceived after knee arthroscopy]

OBJECTIVE

The aim of this study was to investigate the short-term (24hours) association between postoperative pain and preoperative psychological variables (anxiety, pain catastrophizing and kinesiophobia) in a sample of knee arthroscopy ambulatory surgery.

METHODS

Observational cross-sectional study, conducted with 40 adult subjects who underwent knee arthroscopy in the surgical area of Cantoblanco Hospital (Hospital Universitario La Paz) in Madrid. The fear-avoidance beliefs and anxiety were assessed using validated questionnaires of pain catastrophizing, kinesiophobia and anxiety. Pre and post-surgical pain and perceived disability were evaluated by the Verbal Numeric Scale.

RESULTS

Mean age of the sample (22 men and 18 women) was 52.85±14.21 without significant differences between gender. No statistically significant data for the association between variables of kinesiofobia, anxiety and pain catastrophizing and the intensity of perceived pain by the postoperative knee arthroscopy patient were found. Length of surgery in our study has a correlation with the immediate post-surgical pain (r=0.468; P=.002) and there is a relationship between age and pain intensity at 24hours (r=-0.329; P=.038), and between age and perceived disability (r=-0.314; P=.049). An association between catastrophizing and kinesiophobia scales (r=0.337; P=.033) is obtained likewise.

CONCLUSIONS

In conclusion, preoperative fear-avoidance beliefs like pain anxiety or pain catastrophizing and kinesiophobia were not associated with acute postoperative pain in our study. Analyses of secondary pain related outcomes, however, indicated that reduced time of surgery may contribute to enhance clinical postoperative pain. If confirmed and replicated in larger samples, this may potentially enable clinicians to improve postoperative pain management in future patients.

Age as a predictor of rescue opioid administration immediately after the emergence of general anesthesia

BACKGROUND AND OBJECTIVES

While previous studies have shown that elderly patients require lower dosages of opioids, the literature suggests that pain is undertreated in the geriatric population, which may lead to postoperative pain and high rescue analgesia requirements. The purpose of this study is to determine whether elderly patients undergoing hip and knee arthroplasty require higher levels of postoperative rescue opioids than their younger counterparts early after emergence from anesthesia.

METHODS

Using a nonconcurrent retrospective cohort study design, patients who underwent hip or knee arthroplasty under general anesthesia at a tertiary academic hospital from 2007 to 2012 were identified. Demographic information and data regarding patients' anesthetic care were obtained from the institution's anesthesia information management system. To assess the presence of pain after the emergence of anesthesia, we used, as a proxy, opioid administration by the anesthesia provider after leaving the operating room and before the end of anesthesia care.

RESULTS

A total of 2731 patients met inclusion criteria, of which 487 (17.8%) received rescue opioids. Patients older than 80 years were less likely to receive opioids after leaving the operating room (odds ratio, 0.57; 95% confidence interval, 0.37-0.88; P = .01) and received 1.37 mg less of hydromorphone equivalent opioid compared to patients younger than the age of 50 years (95% confidence interval, 1.18-1.55; P < .001). The proportion of patients who received rescue opioids varied significantly between anesthesia providers from 0% to 38% (P < .001).

CONCLUSIONS

While elderly patients received lower doses of opioids intraoperatively, they were less likely to require rescue analgesia. The variability among providers in rescue opioid administration after emergence presents an opportunity for further research.

Setting expectations following endoscopic cubital tunnel release

BACKGROUND

The objective was to evaluate recovery characteristics of patients undergoing endoscopic cubital tunnel release (ECuTR) by determining the following: (1) return to work (RTW) times following ECuTR compared with RTW times of patients that underwent anterior transposition of the ulnar nerve (ATUN), (2) satisfaction rates and factors affecting satisfaction, (3) resolution rates of common preoperative complaints and findings, and (4) effect of preoperative ulnar nerve subluxation on postoperative outcomes.

METHODS

A total of 172 cases in 148 patients undergoing ECuTR were prospectively enrolled including 56 women and 92 men. Kaplan-Meier analyses were performed to determine RTW time for ECuTR patients and for a cohort of 15 patients that underwent ATUN. Patients were evaluated for subjective and objective complaints preoperatively and postoperatively. Cases were grouped by Dellon's classification preoperatively and modified by Bishop's postoperatively.

RESULTS

Half of ECuTR patients returned to normal work within 8 days postoperatively versus 71 days following ATUN. Variables significantly negatively affecting RTW were male sex, manual labor, and worker's compensation status. Dellon's was the best predictor of postoperative satisfaction. Complete resolution of symptoms occurred in 86 % of patients for weakness, 81 % for pain, 79 % for numbness and tingling (N/T), 78 % for atrophy, 76 % for abnormal two-point discrimination, and 65 % for Wartenberg's. Preoperative ulnar nerve subluxation had no effect on outcome.

CONCLUSIONS

Improved RTW time following ECuTR versus ATUN indicates potential and substantial cost-saving implications with respect to reduced worker productivity loss. Patients with more severe preoperative Dellon's classification can expect less optimal results regarding postoperative satisfaction and resolution rates of N/T and pain.

Procedure-specific risk factor analysis for the development of severe postoperative pain

BACKGROUND

Many studies have analyzed risk factors for the development of severe postoperative pain with contradictory results. To date, the association of risk factors with postoperative pain intensity among different surgical procedures has not been studied and compared.

METHODS

The authors selected precisely defined surgical groups (at least 150 patients each) from prospectively collected perioperative data from 105 German hospitals (2004-2010). The association of age, sex, and preoperative chronic pain intensity with worst postoperative pain intensity was studied with multiple linear and logistic regression analyses. Pooled data of the selected surgeries were studied with random-effect analysis.

RESULTS

Thirty surgical procedures with a total number of 22,963 patients were compared. In each surgical procedure, preoperative chronic pain intensity and younger age were associated with higher postoperative pain intensity. A linear decline of postoperative pain with age was found. Females reported more severe pain in 21 of 23 surgeries. Analysis of pooled surgical groups indicated that postoperative pain decreased by 0.28 points (95% CI, 0.26 to 0.31) on the numeric rating scale (0 to 10) per decade age increase and postoperative pain increased by 0.14 points (95% CI, 0.13 to 0.15) for each higher score on the preoperative chronic pain scale. Females reported 0.29 points (95% CI, 0.22 to 0.37) higher pain intensity.

CONCLUSIONS

Independent of the type and extent of surgery, preoperative chronic pain and younger age were associated with higher postoperative pain. Females consistently reported slightly higher pain scores regardless of the type of surgery. The clinical significance of this small sex difference has to be analyzed in future studies.

Arthroscopic Resection Arthroplasty of the Radial Column for SLAC Wrist

Background Symptomatic advanced scapholunate advanced collapse (SLAC) wrists are typically treated with extensive open procedures, including but not limited to scaphoidectomy plus four-corner fusion (4CF) and proximal row carpectomy (PRC). Although a minimally invasive arthroscopic option would be desirable, no convincing reports exist in the literature. The purpose of this paper is to describe a new surgical technique and outcomes on 14 patients who underwent arthroscopic resection arthroplasty of the radial column (ARARC) for arthroscopic stage II through stage IIIB SLAC wrists and to describe an arthroscopic staging classification of the radiocarpal joint for patients with SLAC wrist. Patients and Methods Data were collected prospectively on 17 patients presenting with radiographic stage I through III SLAC wrist who underwent ARARC in lieu of scaphoidectomy and 4CF or PRC. Fourteen patients (12 men and 2 women) subject to 1-year follow-up were included. The average age was 57 years (range 41 to 78). The mean follow-up was 24 months (range 12 to 61). Arthroscopic resection arthroplasty of the radial column is described for varying stages of arthritic changes of the radioscaphoid joint. Midcarpal resection was not performed. Results The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 66 preoperatively and 28 at final follow-up. The mean satisfaction (0 = not satisfied, 5 = completely satisfied) at final follow-up was 4.5 (range 3 to 5). The pain level (on 0-10 scale) improved from 6.6 to 1.3. The total arc of motion changed from 124° preoperatively to 142° postoperatively following an ARARC. Grip was 16 kg preoperatively and 18 kg postoperatively. Radiographic stages typically underestimated arthroscopic staging. Although four of our patients appeared to be radiographic stage I, all were found to have arthritis involving some or all of the radioscaphoid articulation at the time of arthroscopy. Clinical Relevance Pain relief is rapid and remains consistent over time following ARARC. ARARC may be a viable surgical option for patients with SLAC wrist who desire a minimally invasive procedure. Radiographic stages underestimate the degree of arthritic change. Accurate staging requires arthroscopy. The indications and long-term outcome are not well defined; continued surveillance is warranted. Level of Evidence Level IV, Therapeutic study.

Predictors for moderate to severe acute postoperative pain after total hip and knee replacement

PURPOSE

The ability to identify and focus care to patients at higher risk of moderate to severe postoperative pain should improve analgesia and patient satisfaction, and may affect reimbursement. We undertook this multi-centre cross-sectional study to identify preoperative risk factors for moderate to severe pain after total hip (THR) and knee (TKR) replacement.

METHODS

A total of 897 patients were identified from electronic medical records. Preoperative information and anaesthetic technique was gained by retrospective chart review. The primary outcomes were moderate to severe pain (pain score ≥ 4/10) at rest and with activity on postoperative day one. Logistic regression was performed to identify predictors for moderate to severe pain.

RESULTS

Moderate to severe pain was reported by 20 % at rest and 33 % with activity. Predictors for pain at rest were female gender (OR 1.10 with 95 % CI 1.01-1.20), younger age (0.96, 0.94-0.99), increased BMI (1.02, 1.01-1.03), TKR vs. THR (3.21, 2.73-3.78), increased severity of preoperative pain at the surgical site (1.15, 1.03-1.30), preoperative use of opioids (1.63, 1.32-2.01), and general anaesthesia (8.51, 2.13-33.98). Predictors for pain with activity were TKR vs. THR (1.42, 1.28-1.57), increased severity of preoperative pain at the surgical site (1.11, 1.04-1.19), general anaesthesia (9.02, 3.68-22.07), preoperative use of anti-convulsants (1.78, 1.32-2.40) and anti-depressants (1.50, 1.08-2.80), and prior surgery at the surgical site (1.28, 1.05-1.57).

CONCLUSIONS

Our findings provide clinical guidance for preoperative stratification of patients for more intensive management potentially including education, nursing staffing, and referral to specialised pain management.