Practical strategies for the prevention and management of chronic postsurgical pain

Abstract

Chronic postsurgical pain (CPSP) is a multifactorial condition that affects a significant proportion of patients undergoing surgery. The prevention and management of CPSP require the identification of preoperative risk factors to screen high-risk patients and establish appropriate perioperative pain management plans to prevent its development. Active postoperative pain management should be provided to prevent CPSP in patients with severe pain following surgery. These tasks have become important for perioperative team members in the management of CPSP. This review article provides a comprehensive overview of the latest research on the role of perioperative team members in preventing and managing CPSP. Additionally, it highlights practical strategies that can be employed in clinical practice, covering the definition and risk factors for CPSP, including preoperative, intraoperative, and postoperative factors, as well as a risk prediction model. The article also explores various treatments for CPSP, as well as preventive measures, including preemptive analgesia, regional anesthesia, pharmacological interventions, psychoeducational support, and surgical technique modification. This article emphasizes the importance of a comprehensive perioperative pain management plan that includes multidisciplinary interventions, using the transitional pain service as an example. By adopting a multidisciplinary and collaborative approach, perioperative team members can improve patient outcomes, enhance patient satisfaction, and reduce healthcare costs. However, further research is necessary to establish targeted interventions to effectively prevent and manage CPSP.

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

“…For CPSP, the female sex is a well-known associated factor (e.g. 7,16,95,103–105▪▪ ). Although many patients with CPSP are female, numerous studies (except those on breast surgery) were performed in males only.…”

“…However, the lack of significant reduction of CPSP by so-called preemptive anesthetic techniques and somehow ‘aggressive’, early postoperative pain management leads some authors to question the causal effect of acute postoperative pain and even its role in the transition to chronic pain 131 . It has to be considered that the lack of consistent evidence does not necessarily question the probable underlying mechanism but may highlight the need for patient stratification and more studies of high methodological quality 6,103,128 .…”

“…The effect of different anesthetic techniques such as propofol-based total intravenous versus inhalational anesthesia seems to be very limited, although theoretically helpful through the antagonizing effect of propofol on the N -methyl- d -aspartate (NMDA) receptor and possibly preventive in certain study populations 6,103,132 . While certain effects seem to make sense in a pathophysiological way and single studies show some effects of pharmacological interventions, a currently updated meta-analysis shows the disappointing fact that overall, the effects of most drugs (e.g.…”

“…The reduction of opioids in the intraoperative and postoperative setting seems to be a key factor in reducing the risk of CPSP. Potential, adverse mechanisms of perioperative opioids related to CPSP include induction of opioid tolerance, changes in the central reward system, facilitated central sensitization, and altered descending inhibition 6,103,111,128,141,142 . Here, ketamine has been one of the most promising drugs as it seems to be helpful in reducing postoperative analgesic consumption, for example in patients that were already using opioids preoperatively, and CPSP in some studies 133▪,143–146 .…”

“…Physical exercise before and after surgery has been shown to be beneficial for certain types of surgery with mixed evidence 83,150–153 . Still, it is considered an important part of a multimodal treatment 6,101,103,128 .…”