Chronic Postoperative Surgical Pain

Question 1

A 36-year-old female patient is undergoing a right-sided mastectomy for breast carcinoma. She is a smoker and has a history of anxiety, but is otherwise well.

What is your plan for perioperative analgesia in this patient?

Answer 1

Preoperative:
* Oral paracetamol (1 g).
* Oral ibuprofen (400 mg).

Intraoperative:
* Regional anaesthesia e.g. serratus anterior plane block.
* Intravenous fentanyl boluses titrated to effect.
* Intravenous magnesium (2–4 g).

Postoperative:
* Regular paracetamol and ibuprofen (oral).
* Intravenous fentanyl boluses may be required in recovery.
* Oral morphine.
* Oral tramadol (50–100 mg) for rescue analgesia.
* Early assessment by the pain team/surgical team if the pain does not
settle.

Question 2

What are the risk factors for the development of chronic postsurgical pain in this patient?

Answer 2

• Younger age.
• Female.
• History of anxiety.
• Breast surgery (20%–50% incidence).
• Potential prolonged procedure.
• Risk of nerve damage during the procedure.
• Possibility of radiotherapy postoperatively.

Question 3

Three months following the initial surgery, this patient presents to the pain clinic with severe right-sided pain.

What factors might indicate that this patient has developed chronic post-surgical pain?

Answer 3

• According to the Macrae and Davies definition, the following factors would suggest that this patient has developed chronic post-surgical pain:
• Pain that has developed after a surgical procedure.
• At least 2 months duration.
• No other cause of pain is likely/other causes have been ruled out.
• Pain that does not pre-date the surgical procedure.

Question 4

What are the initial management options for this patient?

Answer 4

*Biopsychosocial approach

Physical:
* Acupuncture.
* Physiotherapy.

Psychological:
* Pain management programme.

Pharmacological:
* Antidepressant drugs e.g. amitriptyline.
* Anti-convulsants e.g. gabapentin, pregabalin.
* Weak opioids e.g. dihydrocodeine, tramadol.

Question 5

The patient is undergoing a breast reconstruction, and is worried about worsening of her pain.

What measures can be taken to reduce this risk?

Answer 5

• Repeated surgery is a risk factor for the development of chronic postsurgical pain, but the following interventions have been suggested to decrease its incidence:
• Perioperative gabapentin.
• Postoperative local anaesthetic wound infusions.
• Regional anaesthesia – paravertebral block.
• Perioperative ketamine infusion.
• Management of patient expectations and psychological strategies.