Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.
Regional Anesthesia in the Prevention of Persistent Postsurgical Pain
1. To Block or Not to Block:
Prevention of Persistent
Postoperative Pain
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD
2. Persistent Postsurgical Pain
Financial Disclosures
Halyard Health, B Braun – Unrestricted
educational program funding paid to my
institution
The contents of the following presentation
are solely the responsibility of the speaker
without input from any of the above
companies.
14. Persistent Postsurgical Pain
What Regional Anesthesia Does
Mitigates maximal pain intensity after
surgery1
Decreases opioid consumption2 (maybe
less opioid-induced hyperalgesia)
Facilitates early mobility3
Avoids immobility which can produce
hyperalgesia and persistent pain4,5
1. Ilfeld BM. A&A 2011;113(4):904
2. Richman JM, et al. A&A 2006;102:248
3. Ilfeld & Mariano, et al. Pain 2010;150:477
4. Ohmichi Y, et al. Eur J Pain 2012;16:338
5. Guo TZ, et al. J Pain 2014;15:1033
15. Persistent Postsurgical Pain
Preventing PPSP
Primary prevention: avoid injury/surgery
Secondary prevention: early intervention
to prevent transition from acute to chronic
Gilron & Kehlet. CJA 2014;61:101
16. Persistent Postsurgical Pain
Chronic Pain after Thoracotomy
Incidence is approximately 50%
– 3-16% report pain as moderate-severe
Heterogeneity in study designs
Many contributing factors: patients,
surgical technique, pre- and postop pain
To date, no convincing evidence that PVB
decreases chronic pain after thoracotomy
Wildgaard & Kehlet. Eur J CTS 2009;36:170
17. Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
Survey of 479 women who underwent
breast surgery over a 4-year period
59% response rate
Prevalence of pain after >1 year postop:
– Mastectomy/reconstruction = 49%
– Mastectomy alone = 31%
– Augmentation = 38%
– Reduction = 22%
Wallace MS, et al. Pain 1996;66:195
18. Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
Secondary outcome of previously-published RCT
– Immediate postop pain less in PVB group (p<0.01)
Less pain in PVB group at 6 (p=0.029; n=60) and
12 mos (p=0.003; n=59)
Kairaluoma P, et al. A&A 2004;99:1837
19. Persistent Postsurgical Pain
Chronic Pain after Breast Surgery
Meta-analysis: 3 studies assessed this
outcome (n=167)
All PVB-GA vs. GA
At 6 mos, RR=0.16, 95%CI (0.02-1.13)
– No difference (crosses 1)
At 12 mos, RR=0.61, 95%CI (0.08-4.90)
– No difference (crosses 1)
Schnabel A, et al. BJA 2010;105:842
20. Persistent Postsurgical Pain
3 day infusion of ropivacaine vs. saline
At 12 months:
– 13% pain-induced dysfunction for ropivacaine
vs. 47% for saline (p=0.011)
– Mean BPI 1.6 ± 4.6 for ropivacaine vs. 5.9 ±
11.3 for saline (p=0.007)
Ilfeld BM, et al. Ann Surg Onc 2015;22:2017
21. Persistent Postsurgical Pain
Is the Infusion Long Enough?
Lavand’homme, et al. CORR 2014;472:1409
TKA
Patients
Normal
Persistent Pain
Neuropathic Pain
22. Persistent Postsurgical Pain
Overview
Risk Factors for Persistent Postsurgical
Pain (PPSP)
Potential Role of Regional Anesthesia and
Analgesia
Pharmacologic Interventions for PPSP
28. Persistent Postsurgical Pain
Pregabalin
1. Lavand’homme, et al. CORR 2014;472:1409
2. Buvanendran A, et al. A&A 2010;110:199
For TKA, incidence of PPSP may be as
high as 58% with 11% reporting
neuropathic symptoms1
Pregabalin may decrease neuropathic
PPSP after TKA2
– 0% vs. 9% (placebo) at 3 months (p=0.001)
– 0% vs. 5% (placebo) at 6 months (p=0.014)
31. Persistent Postsurgical Pain
Overview
We discussed:
– Risk Factors for Persistent Postsurgical
Pain (PPSP)
– Potential Role of Regional Anesthesia
and Analgesia
– Pharmacologic Interventions for PPSP