chronic pain after surgery” (chronic post surgical pain=cpsp)how to prevent it? - prof. a. husni...
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CURRICULUM VITAE
Name : Prof. dr. A. Husni Tanra, Sp.An-KICPlace, Date of Birth : Sengkang, January 29, 1943Address : Hertasning Street E7/ 15 Makassar, 90222
South Sulawesi, IndonesiaEmail : [email protected] : MD : 1975 in Hasanuddin University, Faculty of Medicine, Makassar, South
Sulawesi, Indonesia. Ph.D : 1981 in University of Hiroshima, School of Medicine, Hiroshima City, Japan. Visiting scholar : 1987 – 1988 in Multidiciplinary Pain Center in Departement of
Anesthesiology, School of Medicine, University of Washington, Seattle USA. Lemhanas KSA VIII : in 2000Organization :
Member of the Indonesian Doctors Association Member of Indonesian Society of Anesthesiologist and Reanimation Member of The Asian and Oceanic Society of Regional Anesthesia (AOSRA) Member of The World Association for Study of Pain (IASP) Past President of Indonesian Pain Society (IASP chapter Indonesia)
“Chronic Pain After Surgery” (Chronic Post Surgical Pain=CPSP)
How to prevent it?
Andi Husni TanraChairman of ISAPM
(Indonesia Society of Anesthesiology for Pain Management)
1 st National meeting “Indonesian Society of Anesthesiology for Pain management” (ISAPM)
INTRODUCTION *Good Pain, is an alarm symptom, tell us
that something wrong in our body Acute Pain or Inflammation pain. Pain with nociception
*Bad pain, is a disease entity is a disease of nervous system Chronic Pain. Pain without nociception
Chronic pain is a pain that persists beyond normal tissue healing time, which is assumed to be three – six months.
What is Chronic Pain After Surgery?1) Chronic Pain After Surgery or Chronic
Post Surgical Pain is a new emerging disease “a disease of nervous system” Intractable pain after surgery Persistent pain after surgery
2) Is a common disease after surgery but under recognized ( about 1% of total surgery)
3) Affects million patients world wide a “silent epidemic” disease. (in us 40 million surgical cases/year) incidence in US = 400.000 pts
Pain Clinics in UK, See a Lot of Chronic Pain After Surgery and Trauma!
5130 chronic pain patients in 10 pain clinics in the UK post surgery: 22.5% post trauma: 18.7%
So, about 2000 chronic pain patients, due to surgery and trauma, in UK.
(Crombie et al. Pain Clin 1992; 5: 436-7)
Definition for CPSP (Chronic Post-Surgical Pain).Based on four criteria, namely:
1. Pain developed after surgical procedure.2. It was at least 2 months duration.3. Other causes for the pain had been
excluded.(e.g. continuing malignancy, infection, etc )
4. An attemp had been made to explore and exclude the possibility that the pain was cotinuing from a pre-existing problem.
(Macrae and Davies 1999)
Predisposing factors to develope CPSP.
1. The type of surgery.2. Postoperative pain
intesity. (under-treatment of postoperative pain).
3. Psychological factor.4. Genetic factors.
1. The Type of Surgery, Common surgeries which may develope to CPSP are:
1.Limb amputation2.Thoracic surgery3.Breast surgery4.Herniorrhapy5.Cholicystectomy
1. CPSP; After limb amputationTwo type of pain syndrome
Stump pain Phantom pain
The incidence of phantom pain varies from 50% - 85%
About 40% of amputees having severe phantom pain
Prevalence of phantom pain After trauma was 12% Due to cancer was 48%
Phantom Limb Pain is a ‘Pain Memory’!
In 57% of subjects with phantom pain, this resembled preamputation pain. “… somatosensory inputs of sufficient intensity and duration can produce long-lasting changes in central neural structures”
Katz&Melzack, Pain 1990;43:319
2. CPSP; After thoracic surgery Pain after thoracotomy is fairly common. Incidence up to 50% Damage to intercostal nerve has been
assumed to be the main cause of chronic pain.
Sternotomy also showed almost similar results, the incidence was 28 %.
This suggest a more comlicated aethiology of chronic pain after post thoracotomy.
Even endoscopic surgery may not able to prevent CPSP.
3. CPSP; After breast surgery Several type of pain syndrome; Phantom pain (13-24%
Pain in the scar ( 11-57%) Pain in the arm (12- 51%)
Incidence of pain at one or
more these sites is 50 % Damage to intercostobrachial
nerve is considered the main cause.
Carpenter ‘s found only a lumpectomy developed chronic pain.
4. CPSP; After herniorrhapy Incidence of chronic pain after hernia
repair was 0- 37%. Cunningham* et al found that
Pain at 12 months was 65% 12% moderate to severe pain
Pain at 2 years was 54% 11% moderate to severe pain
Incidence of chronic pain after transperitoneal laparascopic hermorrhapy 15% at 9 m follow-up
* Cunningham et al. Pain in the post-repair patient. Ann Surg 1999;224:598-602
5. CPSP After Cholecystectomy Difficult to investigate because most
patient have pain before surgery and persist after cholecystectomy.
Arround 40% of patients complain pain -related after cholecystectomy.
Incidence of chronic pain varying from 3% =20%
Laparascopic cholecystectomy. Incidence of chronic pain is lower than open
cholecystectomy.
The incidence of CPSP varies with the surgical procedures.
Limb amputation 0 – 81 % Thoracotomy 0 – 50 % Mastectomy 13 –
24 % Herniorrhaphy 0 – 37 % Cholecystectomy 3 – 56
% H. Kehlet world congress on pain 2005
CPSP; After other surgeries Symphatectomy Total hip replacement 28%
(Nikolajsen) Cardiac surgery Rectal amputation Vasectomy Dental extraction Histerectomy 14 % (Brandsborg) Cesarian Section 12% (Nikolajsen) Etc.
Predisposing factors to develope CPSP.
1. The type of surgery.2. Postoperative pain
intesity. (under-treatment of postoperative pain).
3. Psychological factor.4. Genetic factors.
Postoperative pain intensityClinical studies have demonstrated that
the development of chronic pain postoperatively is associated with the intensity of acute pain experienced.
Laboratory research showed that neuropathic pain may appear within hours of nerve injury and persist for weeks to months thereafter.
• Kalso E, et al Pain after thoracic surgery . Acta Anesthesiolo Scand 1992; 36: 96-100.
• Peter , et al Somatic and psychosocial predicts long term outcome after surgical inetrvetion. Ann Surg 2007; 245: 487- 94.
2. Postoerative pain intensity
After surgery some changes in the NS may occur:
1. Peripheral sensitization2. Constant bombardment of the
CNS with noxious input.3. Central Sensitization, what we
called “wind-up” “Recruitment”
ASIC/BNC
1.Peripheral sensitization
2. Constant Bombardment of the CNS
TO BRAIN
Dorsal HornPain Neuron + +
+
C
IN
A-delta
+Mediated in part by NMDA receptor on the dorsal horn pain neuron
A-beta
_ _
0
IN
IN = interneuron; NMDA = N-methyl-D-aspartate.Woolf CJ, et al. Science. 2000;288:1765-1769.
3. Central Sensitization Central sensitization refers to enhanced
excitability of dorsal horn neurons and is characterized by:
1. increased spontaneous activity2. An increase in responses evoked by C fibers3. Enlarged receptive field area
Windup is progressive increase in the magnitude of C-fiber evoked responses of dorsal horn neurons produced by repetitive activation of C-fibers.
Recruitment During ongoing activation after
injury, the receptive fields of these neurons
expand, leading to spread of pain.
progressive increase in response of second order neurons to repetitive C-fiber input
4. “Wind-Up”
Mendel and Wall, 1965
Now is appreciated that “wind-up” is a crucial factor for chronic pain after surgery
wind-up
NMDA unblockedNMDA blocked (AP5)
Stimulus frequency applied toC-fiber nerve endings
Act
ion
pote
ntia
l dis
char
ge in
Seco
nd o
rder
spi
nal n
euro
ns 60
50
40
30
20
10
02 4 6 8 1
012
14
Ongoing activation after injury, the receptive fields of these neurons expand, leading to spread of pain.
Recruitment
Even Peripheral Changes of CRPS are Result of Central Sensitization!
So, the main cause neuro-plasticity after surgery or trauma are
Tissue damage Nerve damage
PERIPHERAL ACTIVITY
CENTRAL SENSITIZATION
Decreased threshold to peripheral
stimuli
Increased spontaneous
activityExpansion ofreceptive
field
Hyperalgesia AllodyniaTissue damagePrimary Hyperalgesia
Nerve damage
Spontaneous pain
Secondary Hyperalgesia
Consequences of Unrelieved of Postoperative Pain
Myocardialischaemia
Increasedsympathetic
activity
MyocardialO2
consumption
GI effectsShallow
breathingIncreasedcatabolicdemands
Anxietyand fear
Peripheral/central
sensitisation
GI motilityAtelectasishypoxaemiahypercarbia
Poor woundhealing/muscle
breakdown
Sleeplessness,
helplessness
Neuro-plasticity
Delayed recovery Pneumonia
Weaknessand impaired
rehab.
Psycho-logicaldistress
Chronic
pain
Under treatment of Postoperative pain
GI = gastrointestinal
Predisposing factors to develope CPSP.
1. The type of surgery.2. Postoperative pain
intesity. (under-treatment of postoperative pain).
3. Psychological factor.4. Genetic factors.
3.Psychological factors There are consistent relationship between
preoperative anxiety and acute postoperative pain.
Psycholocical factors include: anxiety extroversion depression educational level attitudes to medication, ect.
Postoperative pain is influenced by exaggerated negative beliefs and responses.
Postoperative pain is consistenly found to be the risk factor for CPSP across many study.
Patient educationInformation influences the pain experience
after surgery. In one study, that good preoperative
information resulted in; post-operative pain declining rapidly lower pre-operative anxiety and more satisfaction with post-operative
pain management.
* (Burke, S and Shorten, G.D. when pain after surgery doesn’t go away. Biochemical Society transactions 2009. vol 37, part 1 )
Predisposing factors to develope CPSP.
1. The type of surgery.2. Postoperative pain
intesity. (under-treatment of postoperative pain).
3. Psychological factor.4. Genetic factors.
4. Genetic factorsSome diseases may be markers for
developing CPSP, include ; 1. Fibromyalgia Syndrome2. Migraine/headache3. Irritable Bowel Syndrome4. Irritable Bladder Syndrome5. Raynaud’s Syndrome
We must be warning the possibility for developing CSPS in these patients.
2 Studies on CPSP found many patients with a history of IBS, backpain or headache.
How to prevent CPSP ?Since Chronic Post Surgical Pain;
is common cause suffering reduced Quality of Life difficult to treat
Prevention is very important
Preventing chronic pain after surgeryPossible strategies for
1. Avoid unnecessary surgery, Avoid to wish to have surgery for reasons other than
ilness or disability ( cosmetic surgery, sterilization).
2. Modify surgical technique Minimal invasive technique, laparascopic or endoscopic surgery or nerve sparing.
3. Aggressive multimodal analgesia or Aggressive treatment of early inflammatory pain.
If surgery can not be avoided2 things can be done for preventing
Using minimal invasive surgical techniques . (the role of surgeon)
Agressive Perioperative multimodal Analgesia ( the role of anesthesiologist)
Agressive Multimodal Analgesias
Jin et al. J Clin Anesth;13:524, 2001 Kehlet et al. Anesth Analg;77:1048. 1998Woolf CJ, Science, 288:1765-1768, 2000
Optimal effect can be achieved when combined with LA - Epidural
- Nerve block- Infiltration
Cox-2 agents
Opioids
Multimodal
NSAIDs
Gabapentinoid
NorAdr & 5HT antagonists
NMDA antagonists
Parecoxib
IbuprofenKetamine
Tramadol
Pain free andStress free
iv
iv
iviv
iv
iv
Clinical evidenceMultimodal analgesia using a continuous
paravertebral block + acetaminophen and parecoxib has less pain during the first 96 h post-operatively, and had a lesser incidence of CPSP 10 weeks after breast surgery.(Iohom, G., Abdallah, H,. Et al. (2006) Anesth. Analg. 103, 995-1000)
The peri-operative use of anti-neuropathic agents, such as gabapentin and prgabaalin, has also been associated with improved long-term outcomes following mastectomy.
Fassoulaki A, et al. – Anesth Analg 2002;95(4):985-91. Reuben SS, et al. J Pain Symptom Manage 2004;27(2):133-9.
Clinical evidence* A Single dose of gabapentin administered
to patients before mastectomy decreases post-operative morphine consumption and pain during movement.
* Gabapentin, as part of a multimodal analgesic regimen, decreased the incident of CPSP at 10 weeks after breast surgery.
* (Burke, S and Shorten, G.D. when pain after surgery doesn’t go away. Biochemical Society transactions 2009. vol 37, part 1 )
Clinical evidence Studies have shown that effective peri-operative
analgesia using epidural analgesia reduces acute and chronic pain in thoracotomy and major abdominal surgery.
Obata H, et al. –Can J. Anaesth 1999;46(12):1127-32 Senturk M, et al. – Anesth Analg 2002;94(1):11-5 Lavand’homme P, et al. – Anesthesiology 2005;103(4):813-20
For thoracic insertion at Th 4-5-6
For upper abdominal at Th 8-9-10 For lower abdominal at Th 11-12-L1
1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
+Local Anesthetic- Epidural- Nerve Block- Infiltration
Opioids
Paracetamol, NSAID, COXIB, Gabapentinoid,
2 agonist
Agressive Multimodal Analgesia
Lower Dose Reduced Side Effects
Optimal Analgesia
May Prevent CPSP
Treatment of CPSP depend on the symptoms Neurophatic pain
Tricyclic anti depressantsAnti-epileptic drugs;
Gabapentin and pregabalin are efficacious in the treatment of PHN and DPN but also may play a big role the treatment CPSP, particularly after mastectomy.
Nociceptive pain Paracetamol NSAIDs Opioid if necessary
conclusionCPSP is a new emerging disease but can
be a silent epidemic.Optimal perioperative management may
reduce the incidence of CPSP. Minimal invasive surgical
techniques Agressive perioperative multimodal
analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
This Concept is Not NewGW Crile proposed in 1913,that pain can cause ‘scars’ in the central nervous system, if the noxious stimuli of surgery have unsuppressed access to this system.
Crile, Lancet 1913;185:7
Some chronic pain patients after surgery and trauma.
in Pain clinic at Hiroshima University Hospital, Japan
Thank youvery much