Predictors of Persistent Postsurgical Pain After Hysterectomy-A Prospective Cohort Study

Changes in spatial bodily pain distribution one year after benign hysterectomy with emphasis on prevalence and risk factors for de novo and persistent pelvic pain- a prospective longitudinal multicenter study

BACKGROUND

The objectives were to determine the prevalence of de novo and persistent pelvic pain after benign hysterectomy and to assess risk factors.

METHODS

A Swedish prospective multicenter study of 440 women undergoing benign hysterectomy was conducted between October 2011 and March 2017. Measures of pain, the spatial extent of bodily pain, and pain sensitivity were assessed using a self-reporting questionnaire, Margolis's patient pain drawing, and quantitative sensory testing of pain thresholds for pressure, heat, and cold, respectively. Quality of life was evaluated by EQ-5D-3L and SF-36. Psychological distress was assessed by the Hospital Anxiety and Depression Scaleand the Stress-Coping Inventory. Logistic regression models were used to assess risk factors, and the outcome was presented as an adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

Preoperatively, 18.0% of the women reported no bodily pain, 41.5% had pelvic pain, either as the only location (7.0%) or along with pain in other locations (34.5%), and 40.5% had non-pelvic pain only. Postoperatively, 6.2% developed de novo pelvic pain and 16.4% had persistent pelvic pain. De novo pelvic pain developed exclusively in women who preoperatively had non-pelvic pain only. Risk factors for de novo pelvic pain were a long hospital stay (aOR 1.50 (95%CI) 1.02-2.21)), high preoperative pain intensity (aOR 1.25 (95%CI 1.01-1.62)) and a high number of pain areas (aOR 1.15 (95%CI 1.05-1.27)), along with anxiety (aOR 10.61 (95%CI 1.84-61.03)) and low EQ-5D-3L health index (aOR 0.02 (95%CI 0.00-0.31)). Risk factors for persistent pelvic pain were lower age (aOR 0.89 (95%CI 0.81-0.97)), higher number of pain areas (aOR 1.08 (95%CI 1.02-1.14)), and a higher frequency of preoperative pain (aOR 12.75 (95%CI 2.24-72.66)).

CONCLUSION

Although hysterectomy appeared to be reasonably effective in curing pelvic pain, a non-negligible proportion of women developed de novo pelvic pain or had persistent pelvic pain. De novo pelvic pain seemed to affect only those who preoperatively had widespread bodily pain. Women at risk for de novo and persistent pelvic pain after hysterectomy could be identified preoperatively.

TRIAL REGISTRATIONS

The study was retrospectively registered in ClinicalTrial.gov (NCT01526668) on 01/27//2012.

Catastrophic Cognition Is a Stronger Predictor Than Emotional Factors of Acute Postoperative Pain in Patients With Traumatic Orthopedic Injuries

BACKGROUND

Both cognitive (pain catastrophizing [PC]) and emotional factors (anxiety, depression, and optimism) play vital roles in acute postoperative pain (APOP) management among patients with traumatic orthopedic injuries (TOIs). It remains uncertain if these psychological factors independently or collectively impact APOP in patients with TOIs, and the underlying mechanisms by which various psychological factors impact APOP in patients with TOIs are also ambiguous.

PURPOSE

The aims of the current research were to analyze the effects of PC and emotional factors (anxiety, depression, and optimism) on APOP in patients with TOIs and explore the potential mechanisms by which PC and emotional factors influence APOP based on a hypothetical moderated mediation pathway mediated by pain-related fear.

METHODS

This was an observational cross-sectional study.

RESULTS

PC was a significantly positive predictor of APOP regardless of coexistence with emotional factors. TOI patients who had higher PC had more severe APOP (β = 0.57, standard error [SE] = 0.005, p < .01, adjusted R2 = 0.78; β = 0.84, SE = 0.003, p < .01, adjusted R2 = 0.77, respectively). Furthermore, when positive and negative emotions coexisted (adjusted R2 = 0.74), anxiety levels were a significant positive predictor of APOP (β = 0.71, SE = 0.009, p < .01) and optimism was a significant negative predictor of APOP (β = -0.24, SE = 0.008, p < .01). Pain-related fear played a mediating role in the association between the level of PC (effect = 0.044, 95% confidence interval [CI] = 0.027 to 0.062), anxiety (effect = 0.102, 95% CI = 0.075 to 0.137), and APOP in patients with TOIs. Optimism moderated the strength of the relationship between PC (95% CI = -0.020 to -0.010), anxiety (95% CI = -0.045 to -0.003), and APOP mediated by pain-related fear.

CONCLUSIONS

Clinical staff should assess the level of PC and emotional factors to identify TOI patients at high risk for APOP, subsequently facilitating the optimization of pain management and efficient utilization of nursing resources through early discussion.

Postoperative Opioid Administration and Prescription Practices Following Hysterectomy in Two Tertiary Care Centres: A Comparative Cohort Study between Canada and Austria

Background: In light of the opioid epidemic, opioid-prescribing modalities for postoperative pain management have been discussed controversially and show a wide variation across geographic regions. The aim of this study was to compare postoperative pain treatment regimes. Methods: We performed a matched cohort study of women undergoing hysterectomy in Austria (n = 200) and Canada (n = 200). We aimed to compare perioperative opioid medications, converted to morphine equivalent dose (MED) and doses of non-opioid analgesic (NOA) within the first 24 h after hysterectomy, and opioid prescriptions at discharge between the two cohorts. Results: The total MED received intraoperatively, in the post-anaesthesia care unit (PACU) and during the first 24 h after surgery, was similar in both cohorts (145.59 vs. 137.87; p = 0.17). Women in the Austrian cohort received a higher MED intraoperatively compared to the Canadian cohort (117.24 vs. 79.62; p < 0.001) but a lower MED in the PACU (25.96 vs. 30.42; p = 0.04). The primary outcome, MED within 24 h in the postoperative ward, was markedly lower in the Austrian compared to the Canadian cohort (2.36 vs. 27.98; p < 0.001). In a regression analysis, only the variables "Country" and "mode of hysterectomy" affected this outcome. A total of 98.5% in the Canadian cohort were given an opioid prescription at discharge vs. 0% in the Austrian cohort. Conclusions: Our analysis reveals marked differences between Austria and Canada regarding pain management practices following elective hysterectomy; the significantly higher intraoperative and significantly lower postoperative MED administration in the Austrian cohort compared to the Canadian cohort seems to be significantly affected by each country's cultural attitudes towards pain management; this may have significant public health consequences and warrants further research.

Preoperative pain sensitivity and its correlation with postoperative acute and chronic pain: a systematic review and meta-analysis

BACKGROUND

Preoperative pain sensitivity (PPS) can be associated with postsurgical pain. However, estimates of this association are scarce. Confirming this correlation is essential to identifying patients at high risk for severe postoperative pain and for developing analgesic strategy. This systematic review and meta-analysis summarises PPS and assessed its correlation with postoperative pain.

METHODS

PubMed, Scopus, Cochrane Library, and PsycINFO were searched up to October 1, 2023, for studies reporting the association between PPS and postsurgical pain. Two authors abstracted estimates of the effect of each method independently. A random-effects model was used to combine data. Subgroup analyses were performed to investigate the effect of pain types and surgical procedures on outcomes.

RESULTS

A total of 70 prospective observational studies were included. A meta-analysis of 50 studies was performed. Postoperative pain was negatively associated with pressure pain threshold (PPT; r=-0.15, 95% confidence interval [CI] -0.23 to -0.07]) and electrical pain threshold (EPT; r=-0.28, 95% CI -0.42 to -0.14), but positively correlated with temporal summation of pain (TSP; r=0.21, 95% CI 0.12-0.30) and Pain Sensitivity Questionnaire (PSQ; r=0.25, 95% CI 0.13-0.37). Subgroup analysis showed that only TSP was associated with acute and chronic postoperative pain, whereas PPT, EPT, and PSQ were only associated with acute pain. A multilevel (three-level) meta-analysis showed that PSQ was not associated with postoperative pain.

CONCLUSIONS

Lower PPT and EPT, and higher TSP are associated with acute postoperative pain while only TSP is associated with chronic postoperative pain. Patients with abnormal preoperative pain sensitivity should be identified by clinicians to adopt early interventions for effective analgesia.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023465727).

Pain Sensitivity and Acute Postoperative Pain in Patients Undergoing Abdominal Surgery: The Mediating Roles of Pain Self-Efficacy and Pain Catastrophizing

BACKGROUND

Inadequately managed postoperative pain remains a common issue. Examining factors like pain sensitivity, pain catastrophizing, and pain self-efficacy can help improve postoperative pain management. While these factors have been identified as potential predictors of acute postoperative pain, their effects have been inconsistent. Few studies have explored the interactions between these factors.

AIM

To investigate the influence of preoperative pain sensitivity, pain catastrophizing, and pain self-efficacy on acute postoperative pain in abdominal surgery patients and to determine the mediating roles of pain catastrophizing and pain self-efficacy in the relationship between pain sensitivity and acute postoperative pain, as per the gate control theory.

METHODS

A total of 246 patients were enrolled in this study. General information was collected before surgery, and the Pain Sensitivity Questionnaire (PSQ), Pain Catastrophizing Scale (PCS), and Pain Self-Efficacy Questionnaire (PSEQ) were administered. After surgery, patients' average pain scores over the 24 hours were reported using the Numerical Rating Scale (NRS). Correlation analyses and a structural equation model were used to examine the relationships among these variables.

RESULTS

NRS scores over 3 during the 24 hours post-surgery were reported by 21.54% of patients. Postoperative acute pain was found to be associated with pain sensitivity (rs = 0.463, p < .001), pain catastrophizing (rs = 0.328, p < .001), and pain self-efficacy (rs = -0.558, p < .001). A direct effect on postoperative acute pain was exerted by pain sensitivity (effect = 0.250, p = .001), along with indirect effects through: (A) pain catastrophizing (effect = 0.028, p = .001); (B) pain self-efficacy (effect = 0.132, p = .001); and (C) the chain mediation of pain self-efficacy and pain catastrophizing (effect = 0.021, p = .008).

CONCLUSIONS

The severity of postoperative acute pain can be predicted by pain self-efficacy and pain catastrophizing, and the connection between moderate pain sensitivity and postoperative acute pain severity is mediated by them. Therefore, intervention programs aimed at boosting pain self-efficacy and reducing pain catastrophizing can enhance postoperative pain outcomes for abdominal surgery patients.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Ocular Pain after Refractive Surgery: Interim Analysis of Frequency and Risk Factors

PURPOSE

To examine the frequency and risk factors for ocular pain after laser assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK).

DESIGN

Prospective study of individuals undergoing refractive surgery at 2 different centers.

PARTICIPANTS

One hundred nine individuals undergoing refractive surgery: 87% LASIK and 13% PRK.

METHODS

Participants rated ocular pain on a numerical rating scale (NRS) of 0 to 10 before surgery and 1 day, 3 months, and 6 months after surgery. A clinical examination focused on ocular surface health was performed 3 and 6 months after surgery. Persistent ocular pain was defined as an NRS score of 3 or more at both 3 and 6 months after surgery (patients), and this group was compared with individuals with NRS scores of < 3 at both time points (control participants).

MAIN OUTCOME MEASURES

Individuals with persistent ocular pain after refractive surgery.

RESULTS

The 109 patients who underwent refractive surgery were followed up for 6 months after surgery. Mean age was 34 ± 8 years (range, 23-57 years); 62% self-identified as female, 81% as White, and 33% as Hispanic. Eight patients (7%) reported ocular pain (NRS score ≥ 3) before surgery, with the frequency of ocular pain increasing after surgery to 23% (n = 25) at 3 months and 24% (n = 26) at 6 months. Twelve patients (11%) reported an NRS score of 3 or more at both time points and constituted the persistent pain group. Factors that predicted persistent pain after surgery in a multivariable analysis were (1) ocular pain before surgery predicated persistent pain after surgery (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.06-3.31), (2) symptom report of depression before surgery (Patient Health Questionnaire-9: OR, 1.3; 95% CI, 1.1-1.6; P = 0.01), (3) use of an oral antiallergy medication before surgery (OR, 13.6; 95% CI, 2.1-89.3; P = 0.007), and (4) pain intensity day 1 after surgery (OR, 1.6; 95% CI, 1.2-2.2; P = 0.005). There were no significant associations between ocular surface signs of tear dysfunction and ocular pain, P > 0.05 for all ocular surface signs. Most individuals (> 90%) were completely or somewhat satisfied with their vision at 3 and 6 months.

CONCLUSIONS

Eleven percent of individuals reported persistent ocular pain after refractive surgery, with several preoperative and perioperative factors predicting pain after surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Targeting Affective Mood Disorders With Ketamine to Prevent Chronic Postsurgical Pain

The phencyclidine-derivative ketamine [2-(2-chlorophenyl)-2-(methylamino)cyclohexan-1-one] was added to the World Health Organization's Model List of Essential Medicines in 1985 and is also on the Model List of Essential Medicines for Children due to its efficacy and safety as an intravenous anesthetic. In sub-anesthetic doses, ketamine is an effective analgesic for the treatment of acute pain (such as may occur in the perioperative setting). Additionally, ketamine may have efficacy in relieving some forms of chronic pain. In 2019, Janssen Pharmaceuticals received regulatory-approval in both the United States and Europe for use of the S-enantiomer of ketamine in adults living with treatment-resistant major depressive disorder. Pre-existing anxiety/depression and the severity of postoperative pain are risk factors for development of chronic postsurgical pain. An important question is whether short-term administration of ketamine can prevent the conversion of acute postsurgical pain to chronic postsurgical pain. Here, we have reviewed ketamine's effects on the biopsychological processes underlying pain perception and affective mood disorders, focusing on non-NMDA receptor-mediated effects, with an emphasis on results from human trials where available.