Long-term pain and disturbed sensation after plastic surgery
-
Leiv Arne Rosseland
In this issue of the Scandinavian Journal of Pain, Kaasa et al. [1] present an important follow up study of women who had breast augmentation surgery 4 years earlier, with focus on persistent postoperative pain and somatosensory changes.
Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans [2]. Persistent pain after surgery has a prevalence of up to 50% and 2-10% of the patients suffer pain of moderate to severe intensity [3]. Genetic susceptibility and female gender increase the risk of chronic pain. Probably also the significant level of preoperative pain and inadequately treated acute postoperative pain increase the risk. However, we know too little about these risk factors and to what extent improved acute pain therapy may prevent persistent postsurgical pain. Neuropathic pain after surgical intervention is common and the last years there has been increasing focus on improving the surgical techniques [3]. Immune cells and inflammatory molecules play a role in acute and persistent pain after trauma or surgery [4, 5]. There is increasing focus on how drugs with anti-inflammatory and immunosuppressive effects may prevent the development of neuropathic pain after surgery [6, 7].
Prevalence studies are often based on the analyses of retrospective data in surgical registries as for instance the Swedish Hernia Register [8, 9] or the Danish Hysterectomy Database [10], but there are also prospective cohort studies [11]. The analyses from the Swedish Hernia Registry have introduced the concept of pain half life– the expected natural course of persistent postsurgical pain, which they estimated to about 6–7 years, indicating that chronic pain after inguinal hernia repair may diminish with time, although slowly [9]. The level of preoperative pain is an important covariate in the analysis of acute and chronic pain after surgery. All these trials will be more or less influenced by this confounder.
The 4 years follow-up study by Kaasa et al. [1] of women who had breast augmentation surgery, initially comprised 204 healthy patients between 20 and 45 years. They were randomized to receive an anti-inflammatory and immunosuppressive dose of methylprednisolone 125 mg, the COX-2 inhibitor parecoxib 40 mg, or placebo (double blind) at the time of surgery [12]. In contrast with many other studies on persistent postoperative pain, these patients did not experience pain before surgery. In a 1 year follow up the prevalence of non-evoked pain was 13% and evoked pain 20% [12]. They also found that acute postoperative pain and hyperesthesia at 6 weeks significantly increased the odds for pain after 1 year. Interestingly, methylprednisolone reduced hyperesthesia significantly, but not hypoesthesia from nerves that had been cut during surgery. Although there was a trend to less chronic pain in those who had received methylprednisolone, the trial was underpowered to show a statistically significant group difference in chronic pain after 1 year. 175 of the 204 patients participated in the 1-year follow up. Of these, 116 patients took part in the 4 years follow up presented in this issue [1].The observation of a close relation between hyper-aesthesia and chronic pain was reproduced in this 4 years follow-up study.
There are few data published about chronic pain after plastic surgery. Most reports are retrospective analyses and the registration of pain has not been systematic. The present authors have conducted these trials in a private clinic in cooperation with experts in pain research in a university clinic and this network has produced prospective data of high scientific quality, which is a significant achievement. The response rate after 1 year was above 80%, falling to 66% when the same patients were invited after 4 years. This may reduce the generalizability of the conclusions and illustrates one of the many difficulties in cohort studies.
However, the take home message in this study is that chronic postsurgical pain have declined but is still relatively common 4 years after surgery, and that hyperphenomena, like hyperesthesia in and around the surgical wound may be predictors of chronic pain.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2010.01.010.
Acknowledgement
This work was supported financially by a postdoctoral grant from Norwegian Research Council.
References
[1] Kaasa T, Romundstad L, Stubhaug A. Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years. A prospective four-year follow-up study. Scand J Pain 2010;1:75–81.Search in Google Scholar
[2] Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333.Search in Google Scholar
[3] Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618–25.Search in Google Scholar
[4] Thacker MA, Clark AK, Marchand F, McMahon SB. Pathophysiology of peripheral neuropathic pain: immune cells and molecules. Anesth Analg 2007;105:838–47.Search in Google Scholar
[5] Hansson E. Long-term pain, neuroinflammation and glial activation. Scand J Pain 2010;1:67–72.Search in Google Scholar
[6] Marchand F, Jones NG, McMahon SB. Future treatment strategies for neuropathic pain. Handbook of experimental pharmacology; 2009. pp. 589–615.Search in Google Scholar
[7] Marchand F, Perretti M, McMahon SB. Role of the immune system in chronic pain. Nat Rev Neurosci 2005;6:521–32.Search in Google Scholar
[8] Franneby U, Sandblom G, Nordin P, Nyren O, Gunnarsson U. Risk factors for long-term pain after hernia surgery. Ann Surg 2006;244:212–9.Search in Google Scholar
[9] Sandblom G, Kalliomäki ML, Gunnarsson U, Gordh T. Natural course of long-term postherniorrhaphy pain in a population-based cohort. Scand J Pain 2010;1:55–9.Search in Google Scholar
[10] Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology 2007;106:1003–12.Search in Google Scholar
[11] Macdonald L, Bruce J, Scott NW, Smith WCS, Chambers WA. Long-term follow-up of breast cancer survivors with post-mastectomy pain syndrome. Br J Cancer 2005;92:225–30.Search in Google Scholar
[12] Romundstad L, Breivik H, Roald H, Skolleborg K, Haugen T, Narum J, Stubhaug A. Methylprednisolone reduces pain, emesis, and fatigue after breast augmentation surgery: a single-dose, randomized, parallel-group study with methylprednisolone 125mg, parecoxib 40mg, and placebo. Anesth Analg 2006;102:418–25.Search in Google Scholar
© 2010 Scandinavian Association for the Study of Pain
Articles in the same Issue
- Editorial comment
- Neuroinflammation explains aspects of chronic pain and opens new avenues for therapeutic interventions
- Review
- Long-term pain, neuroinflammation and glial activation
- Editorial comment
- Long-term pain and disturbed sensation after plastic surgery
- Original experimental
- Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years A prospective four-year follow-up study
- Editorial comment
- Trismus—An important issue in pain and palliative care
- Review
- Prevention and treatment of trismus in head and neck cancer: A case report and a systematic review of the literature
- Editorial comment
- Why would studies on furry rodents concern us as clinicians?
- Original experimental
- Co-administered gabapentin and venlafaxine in nerve injured rats: Effect on mechanical hypersensitivity, motor function and pharmacokinetics
- Editorial comment
- Why we publish negative studies – and prescriptions on how to do clinical pain trials well
- Effects of perioperative S (+) ketamine infusion added to multimodal analgesia in patients undergoing ambulatory haemorrhoidectomy
- Editorial comment
- Inguinal hernia surgery—A minor surgery that can cause major pain
- Sensory disturbances and neuropathic pain after inguinal hernia surgery
- Letter to the Editor
- Paravertebral block is not safer nor superior to thoracic epidural analgesia
Articles in the same Issue
- Editorial comment
- Neuroinflammation explains aspects of chronic pain and opens new avenues for therapeutic interventions
- Review
- Long-term pain, neuroinflammation and glial activation
- Editorial comment
- Long-term pain and disturbed sensation after plastic surgery
- Original experimental
- Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years A prospective four-year follow-up study
- Editorial comment
- Trismus—An important issue in pain and palliative care
- Review
- Prevention and treatment of trismus in head and neck cancer: A case report and a systematic review of the literature
- Editorial comment
- Why would studies on furry rodents concern us as clinicians?
- Original experimental
- Co-administered gabapentin and venlafaxine in nerve injured rats: Effect on mechanical hypersensitivity, motor function and pharmacokinetics
- Editorial comment
- Why we publish negative studies – and prescriptions on how to do clinical pain trials well
- Effects of perioperative S (+) ketamine infusion added to multimodal analgesia in patients undergoing ambulatory haemorrhoidectomy
- Editorial comment
- Inguinal hernia surgery—A minor surgery that can cause major pain
- Sensory disturbances and neuropathic pain after inguinal hernia surgery
- Letter to the Editor
- Paravertebral block is not safer nor superior to thoracic epidural analgesia
