Chronic postsurgical pain: a review
OA Version
Citation
Abstract
The problem of chronic post surgical pain is not a new one. For years now, it has gone underreported and remains a problem despite advances in surgical and anesthetic techniques. Recent studies have shown that rates can vary from 18-65% of surgical patients. These patients experience decreased quality of life and strain the healthcare both from an economic and resource aspect. Individually, many of the patients do not attain their presurgical quality of life and experience financial hardship. The majority of postsurgical pain issues arise through the process of central sensitization where, due to neuroplasticity, the body becomes hypersensitized to normal stimuli and the inhibitory pathways no longer function normally. This process starts with increased peripheral sensitization due to the tissue damage associated with surgical incisions. When this occurs, the neurons of the spinothalamic pathway in the spinal cord are overwhelmed and undergo modification.
The current methods and organization of treatment are lacking and do not meet the demand of surgical patients. Typically, patients selected for surgery are admitted, undergo the surgical procedure, and then receive outside help if pain management schemes become necessary. More often than not, in the past, this pain management scheme has heavily relied on opioid analgesics. However, due to the opioid epidemic and the adverse drug events heavily associated with opioid use, alternatives are required. New and more proactive strategies are required to reduce the incidence of chronic postsurgical pain. Several screenable risk factors have been identified that increase the risk of developing chronic postsurgical pain. Implementation of a pre-screening process that identifies at risk patients indicating them for more specific and complex pain management has shown good results. Additionally, better selected anesthetic techniques by the anesthesiologists in the pre and perioperative have been shown to help reduce the development of both peripheral and central sensitization. Techniques such as multimodal therapy can reduce opioid consumption and minimize adverse drug effects and increase the patient’s quality of life. Through utilizing different combinations of drugs, the entire pain pathway can become a target and more comprehensive analgesia can be achieved. Instead of the main analgesic target being the μ opioid receptors in the central pathway, drugs such as pregabalin, paracetamol, and ketamine can hit a variety of targets and better prevent central sensitization. By reviewing the literature on chronic postsurgical pain, I describe a complete understanding of the pain pathways. Furthermore, I look to understand the risk factors associated with the development and identify ways to specifically address the current issues in treatment. Finally, I look at current working models that have sought to address the many issues and highlight how they might be implemented at other hospitals and centers that perform surgeries.