BJA Advance Access published online on April 22, 2008
British Journal of Anaesthesia, doi:10.1093/bja/aen099
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Chronic post-surgical pain: 10 years on
Ninewells Hospital and Medical School, Dundee DD1 9SY and The Bute Medical School, University of St Andrews, St Andrews, KY16 9TS, Scotland
E-mail: w.a.macrae{at}dundee.ac.uk
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Abstract |
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 Top Abstract IntroductionHow much of a...What are the problems...MechanismsRisk factors and preventionPreventionConclusionsReferences |
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In the past ten years there has been recognition that chronic post-surgical pain is a significant problem. This is a complex area of research and although the quality of studies has improved many difficulties remain. Several recent publications have examined risk factors. Severe acute postoperative pain emerges as a factor that we may be able to influence. There is a need for education of the medical profession and the general public, so that effective measures are introduced and unnecessary and inappropriate operations minimized.
Keywords: pain, chronic; risk factors, prevention; surgery
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Introduction |
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TopAbstractIntroductionHow much of a...What are the problems...MechanismsRisk factors and preventionPreventionConclusionsReferences |
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The first paper on chronic post-surgical pain (CPSP) was published by Crombie and colleagues17 10 yr ago. Since then there have been several reviews.49 58 59 76 When the first review was written, it was noteworthy that the standard of research on outcomes after individual operations was often poor. For example, in one study looking at outcomes after hernia surgery, the methods section detailed how to perform the hernia repair but not how many patients were studied, for how long, or what outcome measures were used. Pain was often completely ignored. In the past 10 yr, there have been many excellent papers and it is heartening that in a recent review of inguinal hernia in the British Medical Journal, the authors state ‘chronic pain is the most common and serious long term problem after repair of an inguinal hernia’.37 This reflects an acceptance of chronic pain as an important outcome of surgery.
Recent research has shown a shift of emphasis away from mere number counting to the examination of risk factors and the possibility of prevention. There have been publications on this topic in general49 57 and on particular surgical procedures.1 7 11 22 28 42 68 72 81 84 101 What issues have emerged and what has recent research shown us? This paper will not attempt to cover the same ground as the initial reviews, but will draw on recent publications to highlight areas of interest and controversy. There will be an emphasis on risk factors and aspects of the problem that could lead to a reduction in the number of patients suffering chronic pain after surgery. It will ask more questions than it answers, in the hope of stimulating debate and further research.
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How much of a problem is chronic post-surgical pain? |
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TopAbstractIntroductionHow much of a...What are the problems...MechanismsRisk factors and preventionPreventionConclusionsReferences |
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The incidence of CPSP varies from operation to operation and between studies, but what is clear is that it is common. Table 1 shows the approximate incidence of chronic pain after some common operations, together with data on the numbers of operations performed in the UK and the USA. It is difficult to obtain accurate figures for numbers of operations performed, as the classification of operations for statistical purposes is different from the classifications used in studies of CPSP. The figures for numbers of operations in the UK are estimates based on Hospital Episode Statistics.33 In the UK, the total number of operations in 2005–6 was around 7 million, but this includes many procedures that are not true surgical operations, such as endoscopies and normal deliveries of babies, or operations that are unlikely to be associated with CPSP, such as cataract operations. The figures for individual operations in the USA in 1994 are taken from Rutkow.93 In the USA, the total number of operations performed in 1994 was approximately 22 629 000.113 Rutkow’s paper reported that the 10 most frequently performed operations in the USA increased from 5.7 million in 1983 to almost 8 million in 1994, an increase of 38%. The pattern and type of surgery will have changed since then, but the trend is likely to be similar. There is a wide variation in the figures for incidence of CPSP for several reasons, including differences in surgical techniques, study design, patient populations, and definitions. It is interesting that the first paper on the most common operation, Caesarean section, was not published until 2004.72
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These figures are estimates, but they give some insight into the magnitude of the problem and clearly there is a large population at risk. Taking just the seven operations listed above for each country and assuming the best case scenario, using the lowest figures for incidence for each operation there could be more than 41 000 cases in the UK and 394 000 in the USA each year. If we assume the worst case figures above, it could be as many as 103 000 in the UK and 1.5 million in the USA. This is a major public health issue: it affects large numbers of patients, has important economic consequences,6 97 and has a significant effect on quality of life.29 54 98 Chronic pain after surgery is usually, in part at least, neuropathic, and this makes it hard to treat; prevention is therefore of great importance.
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What are the problems in the research? |
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There are several problems that arise when investigating CPSP. The first is definition; the original review of the subject59 discussed this and proposed a working definition.
- The pain should have developed after a surgical procedure.
- The pain should be of at least 2 months duration.
- Other causes for the pain should be excluded, for example, continuing malignancy (after surgery for cancer) or chronic infection.
- In particular, the possibility that the pain is continuing from a pre-existing problem should be explored and exclusion attempted. (There is an obvious grey area here in that surgery may simply exacerbate a pre-existing condition but attributing escalating pain to the surgery is clearly not possible as natural deterioration cannot be ruled out.)
Unfortunately, few studies use a definition and where one is used, it differs from study to study.84 Another problem related to definition is the diversity of the syndromes. Using breast surgery as an example, patients complain of a range of unpleasant symptoms after operations, tingling, numbness, sensitivity, and swelling and pain.82 106 The type of pain also varies: phantom pain,23 52 neuropathic pain caused by damage to the intercostobrachial nerve,114 or scar pain.41 Patients often find it difficult to differentiate between the symptoms, for example, after amputation some patients cannot easily separate phantom pain, stump pain, and other unpleasant sensations.34
Research in this area is usually carried out on large populations, using questionnaires. We rely on the patients’ reports of their symptoms and feelings, and there are several studies that show how unreliable patients’ memories are for pain after surgery.71 107 Clinical data are difficult to obtain in this type of study, mainly because of the expense of conducting individual interviews and examinations. This means that in some cases the quality and reliability of the data is open to question.
One puzzling feature of CPSP relates to the incidence found in studies compared with the number of patients seen in Pain Clinics. Clinics known to have a special interest in this problem see large numbers of patients, but some doctors working in Pain Clinics report that they do not see many patients with CPSP. If the figures described above are correct, then Pain Clinics should be seeing large numbers of these patients. It is interesting to note that studies on outcomes after surgery, in which chronic pain is the main measure studied, find a higher incidence than those in which it is not. Is it that patients do not mention it unless they are asked? Do the studies overestimate the incidence? If the incidence is as high as the studies suggest, what is happening to these patients? Are they being treated appropriately in primary care or are they simply suffering in silence and being ignored?
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Mechanisms |
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The mechanisms of CPSP are complex and ill understood. Different mechanisms will be responsible for different pain syndromes even after the same operation, for example, phantom pain, stump pain, and back pain after lower limb amputation.99 Clearly, many of the syndromes are neuropathic and result from changes in the nervous system after injury. Surgery should be seen as an injury, obviously in most cases necessary and performed for good reason, but nonetheless an injury. Castillo and colleagues12 have shown that the incidence of chronic pain after lower limb trauma is similar to that which occurs after many operations. An understanding of the types of changes that occur in the nervous system after disease and injury is important, but the subject is immensely complicated.115 However, a basic appreciation of the mechanisms is useful for several reasons. First, if injury is responsible for initiating the changes in the nervous system, then it is likely that subsequent surgery may make it worse, by further winding up the nervous system.117 Given the complexity of the changes, it is unlikely that simple treatments such as nerve blocks will produce long-term benefit. A multidimensional approach, involving the psychological dimension and physical and pharmacological treatments, will probably be required. An appreciation of the complexity of the mechanisms will also help to guide future research.
Many patients who suffer pain after surgery assume that something went wrong or the surgeon made a mistake. This is clearly not the case, and education of patients and doctors about the problem of CPSP would help patients come to terms with their problem. Patients who attribute blame for their chronic pain report more behavioural disturbance and distress, a poor response to treatments, and have lower expectations of the success of future treatments.18 Turk and Okifuji111 found that patients’ beliefs that they were injured led to lower pain thresholds and tolerance, general deconditioning, and reduced activity. Removing the climate of blame would help patients and doctors. It seems that chronic pain after surgery is an inevitable consequence of surgery in a proportion of cases, like wound infection. If this was accepted and CPSP discussed openly and included in the information given to patients before operations much subsequent grief could be avoided.
Nerve injury and chronic pain
One area that deserves special mention is nerve injury. It is usually assumed that nerve injury is the cause of most neuropathic post-surgical pain syndromes, but what do we mean by nerve injury? Clearly, peripheral nerve injury is an important factor in the aetiology of neuropathic pain, but is there a simple relationship between damage to peripheral nerves and CPSP? Damage to the intercostal nerve is assumed to be an important cause of chronic pain after thoracotomy. Richardson and colleagues90 found a point prevalence of post-thoracotomy neuralgia of 22% at 2 months and 14% at 12 months. An interesting series of papers from Nottingham investigated this topic; the first showed that all patients who have rib retraction during thoracotomy sustain intercostal nerve damage.91 The damage occurs at several levels and can be caused by spreading the ribs, as a result of direct pressure, ischaemia, and stretching. The second study confirmed that neuropathic pain was common and caused significant morbidity.61 Neuropathic pain was associated with more severe chronic pain, was more persistent, and caused greater impact on patients’ lives. Surgical technique influenced the incidence. In the third study, the authors carried out neurophysiological tests on the nerves before the operation and before closing the chest and then examined the patients at 6 weeks and 3 months after operation. The authors did not find an association between nerve injury measured at the time of thoracotomy and chronic pain or altered sensation at 3 months follow-up.60 This suggests a more complicated aetiology for neuropathic post-thoracotomy pain than injury to the intercostal nerve alone.
In the case of pain after mastectomy, Carpenter11 has stated ‘the generally accepted risk factor of damage to the intercostobrachial nerve is mostly anecdotal’. In Carpenter’s study, two patients who had only a lumpectomy, with no axillary dissection, developed post-mastectomy pain syndrome102 as well as four women in whom the intercostobrachial nerve was spared. Several studies on breast surgery have studied the effect of preserving the intercostobrachial nerve. In a prospective randomized, controlled trial, Abdullah and colleagues2 studied the effect of preserving or sacrificing the intercostobrachial nerve during axillary clearance. They found that, for a variety of reasons, it was not always possible to preserve the nerve. Although there was a significant difference in pain, numbness, and altered sensations at discharge, at 3 months, there was no significant difference between the groups, although as expected the incidence of sensory deficit was less in the preservation group. At 3 months, symptoms had worsened in both groups, particularly in the group whose nerves were preserved. Two patients with objective sensory loss had no symptoms whereas eight patients with sensory symptoms had no objective sensory deficit. Other studies have shown similar results.94 108 In a study of 38 patients with ipsilateral arm pain after mastectomy, Vecht and colleagues114 found that only eight of the patients could be diagnosed as having post-surgical pain. All had axillary node dissection. The authors identified eight other causes in the remaining 30 patients. It is interesting that studies of symptoms after breast and axillary surgery show a higher incidence of numbness than pain. In a study of patients who had undergone axillary dissection, but no radiotherapy, chemotherapy, and had no evidence of recurrence, 70% of patients reported numbness and only 30% reported pain.36 Polinsky82 reported that 81% of patients who underwent axillary surgery complained of numbness, but only 22–32% reported pain, depending on the type of surgery. In a study comparing psychophysical examination of patients with post-mastectomy pain with patients who had similar surgery but no pain, Gottrup and colleagues30 found that patients in both groups showed decreased sensitivity to thermal and pinprick stimuli on the affected side. Pressure pain threshold on the affected side was decreased in the pain group, but not in the pain-free group. The main finding was that repetitive pinprick stimulation around the scar in the pain group produced increased evoked pain intensity, sometimes called wind-up hyperalgesia. The magnitude of the evoked pain correlated with spontaneous pain intensity. The authors concluded that this indicated central sensitization.
Damage to nerves during surgery is obviously an important cause of chronic pain after surgery, but from the discussion above it is clear that this is a complex issue. Merely avoiding the sectioning of major nerve trunks is not sufficient to prevent CPSP and sectioning nerves clearly does not always result in chronic pain. It is not possible to perform operations without injuring elements of the nervous system at some level.
Three questions emerge: first, what level of nerve injury is required to induce the changes that result in neuropathic pain? Secondly, can damage to tissues other than nerves cause neuropathic pain? Lastly, what is the relative contribution of central and peripheral changes in the nervous system?
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Risk factors and prevention |
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Ideally, if you want to prevent an event, you would wish to understand the causes and reasons for its occurrence. It is not necessary to have a complete understanding of causation however. John Snow was not only a pioneer in the field of Anaesthetics, but also in Epidemiology. In 1854, there was a cholera outbreak in London. Snow traced the source of the outbreak to a water pump in Broad Street and when the handle was removed the epidemic declined. He knew nothing of the cholera bacterium, but suspected that the disease was water-borne. We may not understand the causes of CPSP in detail, but we can still try to develop strategies to reduce its incidence. Why some people develop chronic pain after surgery whereas others, who have had an identical operation and anaesthetic do not, is mysterious. The causation is complex and is obviously related to injury and change of function but psychosocial factors are also important. The incidence and severity of chronic pain after an operation is not directly related to the size of the operation. As stated by Brandsborg and colleagues7 ‘Several studies, however, have shown that surgery per se carries a significant risk for chronic or long-lasting pain. This is not only after major surgery such as amputation and thoracotomy, but also after minor procedures...’.
The risk factors can be broadly grouped into patient factors and medical factors. Each patient will bring their own genotype, medical history, past experiences, beliefs, and psychosocial circumstances to the problem. The environmental factors which then act on that patient will include type of surgery and anaesthesia, perioperative analgesia, and other treatments given.
Demographic factors
In both breast surgery and hernia repair, increasing age seems to reduce the risk of chronic pain. In breast surgery, younger patients tend to have larger tumours, with more postoperative and long-term pain.109 Smith and colleagues101 showed an incidence of chronic pain after mastectomy of 26% in those aged >70 yr, 40% in those between 50 and 69 yr of age, and 65% in those between 30 and 49 yr of age. Younger patients tend to have more severe pathology, poorer prognosis, and more recurrence51 121 and also a poor response to radiotherapy and chemotherapy.112 These may be contributory factors. Using adjusted models of risk, Poleshuck and colleagues81 found the probability for developing chronic pain after breast cancer surgery decreased by 5% with each year of increasing age. Poobalan and colleagues83 reported similar findings for pain after hernia surgery. Whether other demographic factors, such as employment, housing, and marital status, are important is controversial.83 101 Age and employment may affect the levels of activity which could confound the issue.
Psychosocial factors
There are many publications on the influence of psychosocial factors on acute postoperative pain. Munafo and Stevenson66 found a consistent relationship between preoperative anxiety and acute postoperative pain across 12 studies. Taenzer and colleagues105 showed that after elective gall bladder surgery about half the variability in outcome measures could be predicted by measures such as anxiety, extroversion, depression, educational level, previous chronic pain history, and attitudes to medication. Katz and colleagues46 have shown that preoperative anxiety is a risk factor for pain up to 30 days after breast surgery. Several studies have shown that acute postoperative pain is influenced by catastrophizing (exaggerated negative beliefs and responses).32 75
There have been fewer studies on the influence of psychosocial factors on chronic pain after surgery and the results are contradictory. Katz and colleagues45 found that measures of depression and anxiety were comparable in those who did and did not have pain after thoracotomy. The number of patients in this study was small and the preoperative measures of anxiety and depression were administered the day before surgery, which might have influenced the results. In the study by Taenzer and colleagues,105 the authors point out that ‘a health professional wishing to identify a patient at risk for experiencing high levels of postoperative pain is best advised to consider the patient’s typical emotional reactions rather than his preoperative emotional status’. In a study of women who had surgery for breast cancer, Tasmuth and colleagues107 found increased levels of anxiety and depression before surgery, compared with healthy women. At 1 yr after surgery, anxiety levels had returned to normal in all patients, but in those with chronic pain, depression remained at a higher level. Jess and colleagues39 studied patients having laparoscopic cholecystectomy and found higher levels of neuroticism at 1 yr in those who had chronic pain, compared with those who did not. The preoperative neuroticism scores were not significantly different. The authors question whether the higher scores at 1 yr could be the result of the chronic pain rather than an aetiological factor.
Peters and colleagues78 studied the somatic and psychological predictors of long-term unfavourable outcomes after surgery. The most important somatic predictors of unfavourable outcome were duration of the operation (longer than 3 h) and severe postoperative pain. Fear of surgery was associated with more pain, poor global recovery, and quality of life at 6 months. Optimism was associated with better recovery and higher quality of life, but did not affect chronic pain nor physical functioning. Catastrophizing was neither a risk factor for chronic pain nor functional limitation in this study.
It is interesting that severe acute postoperative pain is consistently found to be a risk factor for chronic pain across many studies, but the psychological factors that seem to be risk factors for acute pain do not show the same association in CPSP. In the field of chronic pain in general, quality of life is more affected by cognitive factors, particularly pain catastrophizing, than by pain intensity.53 It seems likely therefore that psychosocial factors will be important in CPSP. We need further studies on the influence of psychosocial factors in CPSP, but this is a difficult area of study. The instruments used to measure the variables may need to be modified to suit the specific circumstances. For example, the implications of a total hip replacement for osteoarthritis are totally different from having a thoracotomy for lung cancer. Normative data for various types of surgery would be useful. The influence of psychosocial factors on outcome after surgery is important because it is possible that interventions may be able to help.40
Genetic factors
A paper on pain after cardiac surgery showed that patients often develop pains at two separate sites: in the leg, where the vein is harvested for grafting, and the chest.9 Devor19 wrote an interesting comment on this paper, pointing out that the incidence of pain in both sites concurrently was much higher than would be expected if the chances of developing pain at each site were independent. He suggested that this was evidence that certain people are predisposed to develop pain after nerve injury. This supposition is supported by animal work showing that genetic factors influence whether mice develop neuropathic pain after nerve injury.20 95 Further evidence for a genetic predisposition to chronic pain syndromes comes from Diatchenko and colleagues21 who showed an association between a genetic polymorphism and temporo-mandibular joint disorder.
Many clinicians working in this field suspect that there are certain conditions which may be markers for developing chronic pain after an injury. These conditions include fibromyalgia syndrome, migraine, irritable bowel syndrome (IBS), irritable bladder, and Raynaud’s syndrome, especially in those patients who also have burning hot feet at night. Two studies on chronic pain after hernia repair found many patients with a history of backache, IBS, or headache.16 120 In a study of women with pain after hysterectomy those with pain problems elsewhere than in the pelvis before the operation had an increased risk of CPSP.7 The most common sites were head, neck, shoulders, and low back, which is similar to the areas usually associated with pain in fibromyalgia.
Preoperative pain
Several studies on hernia repair have suggested that preoperative pain is a risk factor for CPSP.56 83 120 In a well-designed study specifically on this topic, Page and colleagues74 found that about a quarter of patients did not have pain at rest before their hernia repair, half had mild pain with the remainder having mild to moderate pain at rest. As expected more patients suffered pain on movement. A year after the operation, 25% had no pain at rest and only 22% no pain on moving. Some patients who were pain free before the repair suffered pain afterwards and 5% said that their day-to-day life was worse 1 yr after the surgery.
In a study of pain after amputation, Nikolajsen and colleagues71 found that preamputation pain was associated with an increased risk of stump and phantom pain, in the immediate postoperative period and at 3 months. Keller and colleagues50 showed that 48% of those taking narcotic analgesics before thoracotomy had chronic post-thoracotomy pain, compared with only 5% of those not taking narcotics.
Kroner and colleagues52 reported a correlation between breast pain before operation and phantom breast pain. Intensity of pain before total hip arthroplasty does not seem to correlate with chronic pain afterwards.68
Acute postoperative pain
Many studies have shown a correlation between severity of acute postoperative pain and CPSP. Kalso and colleagues43 were probably the first to show a link between acute postoperative pain and long-term pain after thoracotomy. Richardson and colleagues90 showed that severe postoperative pain was associated with chronic post thoracotomy pain and that regional anaesthetic techniques reduced the incidence. Katz and colleagues45 in a paper specifically studying risk factors showed that early postoperative pain was the only factor that significantly predicted long-term pain. More recent studies have confirmed the importance of the nociceptive input at the time of thoracotomy and the postoperative period.80
Postoperative pain is also a risk factor for pain after hernia surgery,1 surgery for breast cancer,81 total hip arthroplasty,68 and Caesarean section.72
Surgical factors
Although the size of the operation does not show a simple correlation with CPSP, the type of operation and how it is performed influences the incidence of CPSP. Peters and colleagues78 found more chronic pain and poorer outcomes in general, in operations lasting more than 3 h. This is not surprising as these patients will probably have had more serious pathology, complications, or other health issues affecting both the complexity of the operation and the outcome. Wallace and colleagues116 studied the incidence of pain after different types of breast surgery. The incidence varied from 53% for mastectomy with reconstruction by implant, to 31% for mastectomy only, to 22% for breast reduction. For hernia surgery, there appears to be no correlation between CPSP and different types of open repair, but less pain after laparoscopic repair.10 The reduction in chronic pain after laparoscopic repair is confirmed by two systematic reviews.1 84 Open cholecystectomy has a higher incidence of CPSP than laparoscopic cholecystectomy.103
The experience of the surgeon can affect morbidity and mortality.5 27 Tasmuth and colleagues106 studied chronic pain after breast surgery for cancer and found that patients who had their surgery in low volume, less experienced units suffered more CPSP than patients from high volume, specialist units. On the other hand, Courtney and colleagues16 showed no correlation between the grade of the surgeon and severe pain after hernia repair. Whether inpatient surgery is preferable to day-case surgery is controversial.16 83
Whether the condition for which the operation was performed influences the incidence of chronic pain is controversial. For lower limb amputation, the cause of the amputation does not affect the incidence of chronic pain afterwards.35 38 In the case of thoracotomy, Richardson and colleagues90 found a higher incidence of chronic pain after surgery for benign oesophageal disease than for lung cancer, but other studies have shown no difference.43 77 In hernia surgery, the type of hernia does not seem to influence the prevalence of chronic pain,16 but whether surgery for recurrent hernias carries a higher risk is controversial.10 16 83
Several studies have suggested that concomitant treatments, such as radiotherapy and chemotherapy, can increase the risk of chronic pain.100 106 109 Although other studies have not supported this,52 90 a rigorous recent study by Poleshuck and colleagues81 found that radiotherapy, independent of other variables, increased the risk of chronic pain after surgery for breast cancer.
Anaesthesia and analgesia
Most people working in this field believe that pain around the time of the operation sensitizes the nervous system119 and this hypersensitized state contributes to the development of chronic pain. It seems sensible then to try to reduce the nociceptive input to the spinal cord during and after the operation. Anaesthetic techniques that achieve this should show a reduction in both postoperative pain and chronic pain. Animal work has shown encouraging results, but Aida3 has pointed out that this is not easily translated into the clinical situation. In animal research, the subjects are healthy and have no pre-existing pain. The stimulus is usually to an extremity, with segmental somatic innervation only, for a short and circumscribed period. In our patients, the operation may be prolonged, over a large region of the body with complex innervation, and the pain may persist for days afterwards. If the pain breaks through the analgesic regimen at any time, even for a brief period, that may be enough to sensitize the nervous system, causing long-term problems and persistent pain. It is not surprising then that the evidence for the effect of different anaesthetic and analgesic regimens on chronic pain after surgery is confused. There are several papers that show benefit from regional anaesthesia, for example, after hysterectomy,7 Caesarean section,72 iliac crest bone harvesting,89 and thoracotomy.73 90 96 110 However, there are also studies that have not shown benefit.42 44 63 Several studies have looked at multimodal analgesic techniques and the use of drugs such as gabapentin,24 25 venlafaxine,88 and ketamine,47 118 but once again the results are not consistent. At one time, it was thought that delivering pre-emptive analgesia would reduce postoperative problems such as phantom pain,4 but subsequent studies have not confirmed this.47 69 70 Despite the conflicting evidence at present, it remains a reasonable hope that a multimodal approach, reliably delivered and tailored to the needs of individual patients for particular operations, will eventually reduce the incidence of CPSP.
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Prevention |
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TopAbstractIntroductionHow much of a...What are the problems...MechanismsRisk factors and preventionPreventionConclusionsReferences |
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Because post-surgical pain syndromes are usually hard to treat, prevention is important. At present, there is limited evidence for effective strategies and clearly there is a need for further research. Two strategies are obvious however.
Effective management of postoperative pain
The evidence that severe postoperative pain is associated with a high incidence of CPSP is overwhelming. There is no proof of a causative link, however, and it is possible that some patients are more susceptible to both acute postoperative pain and CPSP. However, good perioperative analgesia should be part of a comprehensive programme of perioperative care48 for many reasons, ethical, humanitarian, and medical. As discussed above, the choice of anaesthetic and analgesic regimen that will best provide a safe and pain-free recovery from surgery is still evolving. Unfortunately, in many cases we are still failing to deliver the current best practice to many patients,31 64 often because of failure to implement changes into routine care.67 86 87 The reasons for this are complex, and clinicians, research workers, administrators, and policy makers will have to address a variety of issues, including lack of resources, technical problems, conflicting interests, and organizational and cultural barriers.85
Surgery as a risk factor
For CPSP, one risk factor is obvious, surgery. At present, the only certain way to reduce the number of cases of CPSP is to reduce the number of operations. Is this feasible? If we look at phantom pain, the best way to reduce the incidence would be to prevent amputations. Lower limb amputations are normally a result of vascular disease, often related to diabetes and smoking.13 Measures to reduce smoking and obesity are the best way therefore to prevent phantom limb pain. Obesity is a risk factor for many problems that can result in surgery such as osteoarthritis, certain types of cancer, gall bladder disease, and heart disease.8 Screening programmes to diagnose diseases early, for example, breast cancer, may result in less invasive surgery, with less postoperative morbidity.81 It is clear then that public health measures have an important role to play.
Are all operations necessary or appropriate? Chronic pain is common after hernia surgery.1 84 Page and colleagues74 recorded pain before and after inguinal hernia repair. They showed that patients with pain before the operation benefit from surgery, but some patients with no pain before hernia repair had significant pain afterwards. Watchful waiting has been shown to be safe26 and cost-effective104 in patients with asymptomatic inguinal hernias. It is a matter of debate whether surgery is appropriate in asymptomatic hernias and possibly some other operations as well.
Many patients with abdominal pain have visceral hyperalgesic syndromes. On investigation, no cause is seen on scans and endoscopies. Patients and their relatives often put surgeons under great pressure to do something, and eventually a laparoscopy or laparotomy may be performed.15 In some cases, this will be the start of a treadmill of operations, when the patient’s pain becomes worse, and then further surgery is demanded to rectify the problem, which of course only makes matters worse.117 The author has one patient with fibromyalgia, who reported that she had undergone 54 operations, mostly performed abroad. These included multiple laparotomies for abdominal pain and bilateral mastectomies for breast pain (no malignancy), followed by several operations because of continuing pain in the breast area. When asked why she persisted, she said she always believed the next operation would cure her!
Awareness of the risk of chronic pain is particularly relevant when patients wish to have surgery for reasons other than illness or disability, for example, male and female sterilization and some cosmetic surgery operations, which may be performed for aesthetic rather than medical reasons. Chronic pain after vasectomy has been the subject of several studies.55 62 65 These show an incidence of around 15%. A review article in 200314 examined the possible mechanisms in relation to changes that occur after vasectomy. It is disappointing then to find in a recent publication on sterilization the statement: ‘Whether a postvasectomy pain syndrome exists remains controversial’.79 The incidence of pain after breast augmentation operations has been reported to be 13% in a Norwegian study92 and varying from 21% to 50% depending on the type of operation according to Wallace and colleagues116 from California. This study also found an incidence of 22% after breast reduction surgery.116 Cosmetic surgery is widely advertised and easily available, but most of the websites of organizations offering breast augmentation and reduction operations do not mention chronic pain as a complication.
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Conclusions |
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TopAbstractIntroductionHow much of a...What are the problems...MechanismsRisk factors and preventionPreventionConclusionsReferences |
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Chronic pain after surgery is common. The standard of research has improved markedly in recent years, but much work remains to be done, particularly in the fields of mechanisms and risk factors. Improving the management of acute postoperative pain is one strategy which may prevent CPSP, but there are many technical, organizational, and cultural barriers to be overcome in order to achieve that improvement.
There is clearly a need for education of the medical profession and the general public about the problem. If patients and their doctors were aware of the risks, it might deter some patients from undergoing inappropriate and unnecessary operations.
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References |
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1 Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth (2005) 95:69–76.
2 Abdullah TI, Iddon J, Barr L, Baildam AD, Bundred NJ. Prospective randomized controlled trial of preservation of the intercostobrachial nerve during axillary node clearance for breast cancer. Br J Surg (1998) 85:1443–5.[CrossRef][Web of Science][Medline]
3 Aida S. The challenge of preemptive analgesia. Pain Clinical Updates (2005) XIII:1–4.
4 Bach S, Noreng MF, Tjellden NU. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Pain (1988) 33:297–301.[CrossRef][Web of Science][Medline]
5 Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med (2002) 346:1138–44.
6 Blyth FM, March LM, Cousins MJ. Chronic pain-related disability and use of analgesia and health services in a Sydney community. Med J Aust (2003) 179:84–7.[Web of Science][Medline]
7 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.[CrossRef][Web of Science][Medline]
8 Bray GA. Risks of obesity. Endocrinol Metab Clin North Am (2003) 32:787–804. viii.[CrossRef][Web of Science][Medline]
9 Bruce J, Drury N, Poobalan AS, Jeffrey RR, Smith WC, Chambers WA. The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study. Pain (2003) 104:265–73.[CrossRef][Web of Science][Medline]
10 Callesen T, Kehlet H. Postherniorraphy pain. Anesthesiology (1997) 87:1219–30.[CrossRef][Web of Science][Medline]
11 Carpenter JS, Sloan P, Andrykowski MA, et al. Risk factors for pain after mastectomy/lumpectomy. Cancer Pract (1999) 7:66–70.[CrossRef][Web of Science][Medline]
12 Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain (2006) 124:321–9.[CrossRef][Web of Science][Medline]
13 Chaturvedi N, Abbott CA, Whalley A, Widdows P, Leggetter SY, Boulton AJM. Risk of diabetes related amputation in South Asians vs Europeans in the UK. Diabet Med (2002) 19:99–104.[CrossRef][Web of Science][Medline]
14 Christiansen CG, Sandlow JI. Testicular pain following vasectomy: a review of postvasectomy pain syndrome. J Androl (2003) 24:293–8.
15 Cole JA, Yeaw JM, Cutone JA, et al. The incidence of abdominal and pelvic surgery among patients with irritable bowel syndrome. Dig Dis Sci (2005) 50:2268–75.[CrossRef][Web of Science][Medline]
16 Courtney CA, Duffy K, Serpell MG, O’Dwyer PJ. Outcome of patients with severe chronic pain following repair of groin hernia. Br J Surg (2002) 89:1310–4.[CrossRef][Web of Science][Medline]
17 Crombie IK, Davies HTO, Macrae WA. Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic. Pain (1998) 76:167–71.[CrossRef][Web of Science][Medline]
18 DeGood DE, Kiernan B. Perception of fault in patients with chronic pain. Pain (1996) 64:153–9.[CrossRef][Web of Science][Medline]
19 Devor M. Evidence for heritability of pain in patients with traumatic neuropathy. Pain (2004) 108:200–1. author reply 202.[Web of Science][Medline]
20 Devor M, Raber P. Heritability of symptoms in an experimental model of neuropathic pain. Pain (1990) 42:51–67.[CrossRef][Web of Science][Medline]
21 Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet (2005) 14:135–43.
22 Dijkstra PU, Geertzen JH, Stewart R, van der Schans CP. Phantom pain and risk factors: a multivariate analysis. J Pain Symptom Manage (2002) 24:578–85.[CrossRef][Web of Science][Medline]
23 Dijkstra PU, Rietman JS, Geertzen JH. Phantom breast sensations and phantom breast pain: a 2-year prospective study and a methodological analysis of literature. Eur J Pain (2007) 11:99–108.[Web of Science][Medline]
24 Fassoulaki A, Melemeni A, Stamatakis E, Petropoulos G, Sarantopoulos C. A combination of gabapentin and local anaesthetics attenuates acute and late pain after abdominal hysterectomy. Eur J Anaesthesiol (2007) 24:521–8.[CrossRef][Web of Science][Medline]
25 Fassoulaki A, Triga A, Melemeni A, Sarantopoulos C. Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer. Anesth Analg (2005) 101:1427–32.
26 Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA (2006) 295:285–92.
27 Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L. Early mortality among medicare beneficiaries undergoing bariatric surgical procedures. JAMA (2005) 294:1903–8.
28 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.[CrossRef][Web of Science][Medline]
29 Galvez R, Marsal C, Vidal J, Ruiz M, Rejas J. Cross-sectional evaluation of patients functioning and health-related quality of life in patients with neuropathic pain under standard care conditions. Eur J Pain (2007) 11:244–55.[CrossRef][Web of Science][Medline]
30 Gottrup H, Andersen J, Arendt-Nielsen L, Jensen TS. Psychophysical examination in patients with post-mastectomy pain. Pain (2000) 87:275–84.[CrossRef][Web of Science][Medline]
31 Gramke HF, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital. Clin J Pain (2007) 23:543–8.[CrossRef][Web of Science][Medline]
32 Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain (2005) 21:439–45.[CrossRef][Web of Science][Medline]
33 Health Episode Statistics. (2007) Available from www.hesonline.nhs.uk.
34 Hill A. Phantom limb pain: a review of the literature on attributes and potential mechanisms. J Pain Symptom Manage (1999) 17:125–42.[CrossRef][Web of Science][Medline]
35 Houghton AD, Saadah E, Nicholls G, McColl L, Houghton AL. Phantom pain: natural history and association with rehabilitation. Ann R Coll Surg Engl (1994) 76:22–5.[Web of Science][Medline]
36 Ivens D, Hoe AL, Podd TJ, Hamilton CR, Taylor I, Royle GT. Assessment of morbidity from complete axillary dissection. Br J Cancer (1992) 66:136–8.[Web of Science][Medline]
37 Jenkins JT, O’Dwyer PJ. Inguinal hernias. Br Med J (2008) 336:269–72.
38 Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain (1985) 21:267–8.[CrossRef][Web of Science][Medline]
39 Jess P, Jess T, Beck H, Bech P. Neuroticism in relation to recovery and persisting pain after laparoscopic cholecystectomy. Scand J Gastroenterol (1998) 33:550–3.[CrossRef][Web of Science][Medline]
40 Johnston M, Vogele C. The benefits of psychological preparation for surgery: a meta-analysis. Ann Behav Med (1993) 15:245–56.
41 Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain (2003) 104:1–13.[CrossRef][Web of Science][Medline]
42 Kalliomaki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain (2008) 12:214–25.[CrossRef][Web of Science][Medline]
43 Kalso E, Perttunen K, Kaasinen S. Pain after thoracic surgery. Acta Anaesthesiol Scand (1992) 36:96–100.[Web of Science][Medline]
44 Katz J, Cohen L. Preventive analgesia is associated with reduced pain disability 3 weeks but not 6 months after major gynecologic surgery by laparotomy. Anesthesiology (2004) 101:169–74.[CrossRef][Web of Science][Medline]
45 Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain (1996) 12:50–5.[CrossRef][Web of Science][Medline]
46 Katz J, Poleshuck EL, Andrus CH, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain (2005) 119:16–25.[CrossRef][Web of Science][Medline]
47 Katz J, Schmid R, Snijdelaar DG, Coderre TJ, McCartney CJ, Wowk A. Pre-emptive analgesia using intravenous fentanyl plus low-dose ketamine for radical prostatectomy under general anesthesia does not produce short-term or long-term reductions in pain or analgesic use. Pain (2004) 110:707–18.[CrossRef][Web of Science][Medline]
48 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth (1997) 78:606–17.
49 Kehlet H, Jensen TS, Woolf C. Persistent postsurgical pain: risk factors and prevention. Lancet (2006) 367:1618–25.[CrossRef][Web of Science][Medline]
50 Keller SM, Carp NZ, Levy MN, Rosen SM. Chronic post thoracotomy pain. J Cardiovasc Surg (1994) 35:161–4.[Medline]
51 Kroman N, Jensen MB, Wohlfahrt J, Mouridsen HT, Andersen PK, Melbye M. Factors influencing the effect of age on prognosis in breast cancer: population based study. Br Med J (2000) 320:474–8.
52 Kroner K, Knudsen UB, Lundby L, Hvid H. Long term phantom breast syndrome after mastectomy. Clin J Pain (1992) 8:346–50.[Web of Science][Medline]
53 Lame IE, Peters ML, Vlaeyen JW, Kleef M, Patijn J. Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity. Eur J Pain (2005) 9:15–24.[CrossRef][Web of Science][Medline]
54 Lame IE, Peters ML, Vlaeyen JWS, van Kleef M, Patijn J. Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity. Eur J Pain (2005) 9:15–24.[CrossRef][Web of Science][Medline]
55 Leslie TA, Illing RO, Cranston DW, Guillebaud J. The incidence of chronic scrotal pain after vasectomy: a prospective audit. BJU Int (2007) 100:1330–3.[CrossRef][Web of Science][Medline]
56 Liem MS, van Duyn EB, van der Graaf Y, van Vroonhoven TJ. Recurrences after conventional anterior and laparoscopic inguinal hernia repair: a randomized comparison. Ann Surg (2003) 237:136–41.[CrossRef][Web of Science][Medline]
57 Macrae WA. Can we prevent chronic pain after surgery? In: Postoperative Pain Management—Shorten G, Carr DB, Harmon D, Puig MM, Browne J, eds. (2006) Philadelphia: Saunders Elsevier. 259–64.
58 Macrae WA. Chronic pain after surgery. Br J Anaesth (2001) 87:88–98.
59 Macrae WA, Davies HTO. Chronic postsurgical pain. In: Epidemiology of Pain—Crombie IK, Linton S, Croft P, Von Korff M, LeResche L, eds. (1999) Seattle: International Association for the Study of Pain. 125–42.
60 Maguire MF, Latter JA, Mahajan R, Beggs FD, Duffy JP. A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery. Eur J Cardiothorac Surg (2006) 29:873–9.
61 Maguire MF, Ravenscroft A, Beggs D, Duffy JP. A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery. Eur J Cardiothorac Surg (2006) 29:800–5.
62 Manikandan R, Srirangam SJ, Pearson E, Collins GN. Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years. BJU Int (2004) 93:571–4.[CrossRef][Web of Science][Medline]
63 McCartney CJL, Brull R, Chan VWS, et al. Early but not long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology (2004) 101:461–7.[CrossRef][Web of Science][Medline]
64 McLeod G, Davies H, Munnoch N, Bannister J, MacRae W. Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures. Anaesthesia (2001) 56:75–81.[CrossRef][Web of Science][Medline]
65 McMahon AJ, Buckley J, Taylor A, Lloyd SN, Deane RF, Kirk D. Chronic testicular pain following vasectomy. Br J Urol (1992) 69:188–91.[Web of Science][Medline]
66 Munafo MR, Stevenson J. Anxiety and surgical recovery. Reinterpreting the literature. J Psychosom Res (2001) 51:589–96.[CrossRef][Web of Science][Medline]
67 Nagi H. Acute pain services in the United Kingdom. Acute Pain (2004) 5:89–107.[CrossRef]
68 Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H. Chronic pain following total hip arthroplasty: a nationwide questionnaire study. Acta Anaesthesiol Scand (2006) 50:495–500.[CrossRef][Web of Science][Medline]
69 Nikolajsen L, Ilkjaer S, Christensen JH, Kroner K, Jensen TS. Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower limb amputation. Lancet (1997) 350:1353–7.[CrossRef][Web of Science][Medline]
70 Nikolajsen L, Ilkjaer S, Jensen TS. Effect of preoperative extradural bupivacaine and morphine on stump sensation in lower limb amputees. Br J Anaesth (1998) 81:348–54.
71 Nikolajsen L, Ilkjaer S, Kroner K, Christensen JH, Jensen TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain (1997) 72:393–405.[CrossRef][Web of Science][Medline]
72 Nikolajsen L, Sorensen HC, Jensen TS, Kehlet H. Chronic pain after Caesarean section. Acta Anaesthesiol Scand (2004) 48:111–6.[CrossRef][Web of Science][Medline]
73 Obata H, Saito S, Fujita N, Fuse Y, Ishizaki K, Goto F. Epidural block with mepivacaine before surgery reduces long-term post-thoracotomy pain. Can J Anaesth (1999) 46:1127–32.[Web of Science][Medline]
74 Page B, Paterson C, Young D, O’Dwyer PJ. Pain from primary inguinal hernia and the effect of repair on pain. Br J Surg (2002) 89:1315–8.[CrossRef][Web of Science][Medline]
75 Pavlin DJ, Sullivan MJ, Freund PR, Roesen K. Catastrophizing: a risk factor for postsurgical pain. Clin J Pain (2005) 21:83–90.[CrossRef][Web of Science][Medline]
76 Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. Anesthesiology (2000) 93:1123–33.[CrossRef][Web of Science][Medline]
77 Perttunen K, Tasmuth T, Kalso E. Chronic pain after thoracic surgery: a follow-up study. Acta Anaesthesiol Scand (1999) 43:563–7.[CrossRef][Web of Science][Medline]
78 Peters ML, Sommer M, de Rijke JM, et al. Somatic and psychologic predictors of long-term unfavorable outcome after surgical intervention. Ann Surg (2007) 245:487–94.[CrossRef][Web of Science][Medline]
79 Peterson HB. Sterilization. Obstet Gynecol (2008) 111:189–203.[CrossRef][Web of Science][Medline]
80 Pluijms WA, Steegers MA, Verhagen AF, Scheffer GJ, Wilder-Smith OH. Chronic post-thoracotomy pain: a retrospective study. Acta Anaesthesiol Scand (2006) 50:804–8.[CrossRef][Web of Science][Medline]
81 Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following breast cancer surgery: a prospective study. J Pain (2006) 7:626–34.[CrossRef][Web of Science][Medline]
82 Polinsky ML. Functional status of long-term breast cancer survivors: demonstrating chronicity. Health Soc Work (1994) 19:165–73.[Web of Science][Medline]
83 Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WC. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg (2001) 88:1122–6.[CrossRef][Web of Science][Medline]
84 Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain (2003) 19:48–54.[CrossRef][Web of Science][Medline]
85 Powell AE, Davies HTO, Bannister J, Macrae WA. Chapter 169, Acute pain services and organizational change. In: Clinical Pain Management: Practice and Procedures in Pain Management—Nicholas MK, ed. (2008) 2nd Edn. London: Hodder Arnold.
86 Powell AE, Davies HTO, Bannister J, Macrae WA. Rhetoric and reality on acute pain services in the NHS: a national postal questionnaire survey. Br J Anaesth (2004) 92:689–93.
87 Rawal N. 10 years of acute pain services—achievements and challenges. Reg Anesth Pain Med (1999) 24:68–73.[Web of Science][Medline]
88 Reuben SS, Makari-Judson G, Lurie SD. Evaluation of efficacy of the perioperative administration of venlafaxine XR in the prevention of postmastectomy pain syndrome. J Pain Symptom Manage (2004) 27:133–9.[CrossRef][Web of Science][Medline]
89 Reuben SS, Vieira P, Faruqi S, Verghis A, Kilaru PA, Maciolek H. Local administration of morphine for analgesia after iliac bone graft harvest. Anesthesiology (2001) 95:390–4.[CrossRef][Web of Science][Medline]
90 Richardson J, Sabanathan S, Mearns AJ, Sides C, Goulden CP. Post-thoracotomy neuralgia. Pain Clin (1994) 7:87–97.
91 Rogers ML, Henderson L, Mahajan RP, Duffy JP. Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg (2002) 21:298–301.
92 Romundstad L, Breivik H, Roald H, Skolleborg K, Romundstad PR, Stubhaug A. Chronic pain and sensory changes after augmentation mammoplasty: long term effects of preincisional administration of methylprednisolone. Pain (2006) 124:92–9.[CrossRef][Web of Science][Medline]
93 Rutkow IM. Surgical operations in the United States. Then (1983) and now (1994). Arch Surg (1997) 132:983–90.
94 Salmon RJ, Ansquer Y, Asselain B. Preservation versus section of intercostal-brachial nerve (IBN) in axillary dissection for breast cancer—a prospective randomized trial. Eur J Surg Oncol (1998) 24:158–61.[CrossRef][Web of Science][Medline]
95 Seltzer Z, Wu T, Max MB, Diehl SR. Mapping a gene for neuropathic pain-related behaviour following peripheral neurectomy in the mouse. Pain (2001) 93:101–6.[CrossRef][Web of Science][Medline]
96 Senturk M, Ozcan PE, Talu GK, et al. The effects of three different analgesia techniques on long-term postthoracotomy pain. Anesth Analg (2002) 94:11–5. table of contents.
97 Smith BH, Hopton L, Chambers WA. Chronic pain in primary care. Fam Pract (1999) 16:475–82.
98 Smith BH, Torrance N, Bennett MI, Lee AJ. Health and quality of life associated with chronic pain of predominantly neuropathic origin in the community. Clin J Pain (2007) 23:143–9.[CrossRef][Web of Science][Medline]
99 Smith DG, Ehde DM, Legro MW, Reiber GE, del Aguila M, Boone DA. Phantom pain, residual limb, and back pain after lower extremity amputations. Clin Orthoped Relat Res (1999) 361:29–38.[CrossRef]
100 Smith J, Thompson JM. Phantom limb pain and chemotherapy in pediatric amputees. Mayo Clin Proc (1995) 70:357–64.[Abstract]
101 Smith WCS, Bourne D, Squair J, Phillips DO, Chambers WA. A retrospective cohort study of post mastectomy pain syndrome. Pain (1999) 83:91–5.[CrossRef][Web of Science][Medline]
102 Stevens PE, Dibble SL, Miaskowski C. Prevalence, characteristics, and impact of postmastectomy pain syndrome: an investigation of women’s experiences. Pain (1995) 61:61–8.[CrossRef][Web of Science][Medline]
103 Stiff G, Rhodes M, Kelly A, Telford K, Armstrong CP, Rees BI. Long-term pain: less common after laparoscopic than open cholecystectomy. Br J Surg (1994) 81:1368–70.[Web of Science][Medline]
104 Stroupe KT, Manheim LM, Luo P, et al. Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis. J Am Coll Surg (2006) 203:458–68.[CrossRef][Web of Science][Medline]
105 Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain (1986) 24:331–42.[CrossRef][Web of Science][Medline]
106 Tasmuth T, Blomqvist C, Kalso E. Chronic post-treatment symptoms in patients with breast cancer operated in different surgical units. Eur J Surg Oncol (1999) 25:38–43.[CrossRef][Web of Science][Medline]
107 Tasmuth T, Estlanderb AM, Kalso E. Effect of present pain and mood on the memory of past postoperative pain in women treated surgically for breast cancer. Pain (1996) 68:343–7.[CrossRef][Web of Science][Medline]
108 Tasmuth T, Kataja M, Blomqvist C, von Smitten K, Kalso E. Treatment-related factors predisposing to chronic pain in patients with breast cancer—a multivariate approach. Acta Oncol (1997) 36:625–30.[Web of Science][Medline]
109 Tasmuth T, von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol (1995) 6:453–9.
110 Tiippana E, Nilsson E, Kalso E. Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study. Acta Anaesthesiol Scand (2003) 47:433–8.[CrossRef][Web of Science][Medline]
111 Turk DC, Okifuji A. Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients. J Behav Med (1996) 19:435–53.[CrossRef][Web of Science][Medline]
112 Tutt A, Ross G. Commentary: much still to learn about relations between tumour biology, prognosis, and treatment outcome in early breast cancer. Br Med J (2000) 320:478–9.[Web of Science][Medline]
113 US Dept of Health and Human Resources. Health United States. 1996–7. Available from www.cdc.gov/nchs/hus.htm.
114 Vecht CJ, Van der Brand HJ, Wajer OJM. Post-axillary dissection pain in breast cancer due to a lesion of the intercostobrachial nerve. Pain (1989) 38:171–6.[CrossRef][Web of Science][Medline]
115 Villanueva L, Dickenson AH, Ollat H. The Pain System in Normal and Pathological States (2004) Seattle: IASP Press.
116 Wallace MS, Wallace AM, Lee J, Dobke MK. Pain after breast surgery: a survey of 282 women. Pain (1996) 66:195–205.[CrossRef][Web of Science][Medline]
117 Wilder-Smith OH, Tassonyi E, Senly C, Otten P, Arendt-Nielsen L. Surgical pain is followed not only by spinal sensitization but also by supraspinal antinociception. Br J Anaesth (1996) 76:816–21.
118 Wilson JA, Nimmo AF, Fleetwood-Walker SM, Colvin LA. A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation. Pain (2008) 135:108–18.[CrossRef][Web of Science][Medline]
119 Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science (2000) 288:1765–9.
120 Wright D, Paterson C, Scott N, Hair A, O’Dwyer PJ. Five-year follow-up of patients undergoing laparoscopic or open groin hernia repair: a randomized controlled trial. Ann Surg (2002) 235:333–7.[CrossRef][Web of Science][Medline]
121 Yildirim E, Dalgic T, Berberoglu U. Prognostic significance of young age in breast cancer. J Surg Oncol (2000) 74:267–72.[CrossRef][Web of Science][Medline]
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