Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer

Abstract

IMPORTANCE Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain.OBJECTIVE To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery.DESIGN, SETTING, AND PARTICIPANTS This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day. INTERVENTIONSThe control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating. MAIN OUTCOMES AND MEASURESAverage and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications. RESULTS Duringpostoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η 2 p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η 2 p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%]women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η 2 p = 0.09 [0.004 -0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5 [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed.CONCLUSIONS AND RELEVANCE Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer.

Local Anesthetic Infusion for Improving Pain From Head and Neck Cancer Surgery

“…In all, we applaud the work by Gostian and colleagues, and we join them in seeking better characterization and treatment options following head and neck cancer surgery.…”

“…To the Editor With great anticipation we read the recent article titled “Postoperative Pain Treatment with Continuous Local Anesthetic Wound Infusion in Patients with Head and Neck Cancer: A Nonrandomized Clinical Trial.” Of primary importance, the authors should be singularly commended for pursuing treatment alternatives away from standard opioid administration. As we join a number of institutions following the example of Gostian and colleagues, we felt it prudent to specify details that may limit clinical application of the specific technique described to optimize future efforts.…”

“…This tool may not be appropriate because we are not aware that the questionnaire is validated or used for postsurgical pain, specifically with the manifestations of acute pain being altered so close to surgery. Despite the authors’ assurances to the contrary, placing the surgical drain and the catheter in different locations within a continuous fascial space would leave concern for suctioning the anesthetic. In the discussion, the authors discuss the potential training benefit of acute pain blocks, but the prospective trial did not track outcomes beyond 4 days (even with discontinued catheters) to investigate the entire course of recovery.…”

Local Anesthetic Infusion for Improving Pain From Head and Neck Cancer Surgery—Reply

“…In Reply We thank Drs Rahman and Mendelsohn for their interest in our recent study . The performance of a neck dissection has been shown to be associated with great and potentially long-lasting pain and is therefore also listed in the German S3 guideline for acute postoperative pain as a surgical procedure with expected high pain levels.…”

“…The catheter was inserted in the surgical field as far away from the drain as possible to minimize aspiration through the drain . In our opinion, complete aspiration of the agent by the drainage is also not consistent with the emphasized positive effects of local pain therapy in the first 2 days.…”