Chronic Postsurgical Pain

Brief Overview: Chronic postsurgical pain is pain that persists beyond normal healing after surgery, typically defined as pain lasting ≥3 months post-op that cannot be explained by infection, recurrence, or other causes. It is often neuropathic in nature and may involve central sensitization.

Etiology:

  • Surgical trauma → nerve injury, inflammation, or scar tissue formation → peripheral and central sensitization.
  • Altered pain processing (wind-up, hyperalgesia).
  • Sometimes exacerbated by psychological distress or inadequate acute pain control.

Risk Factors:

  • Procedures that are more extensive and produce greater tissue damage
  • Excision or damage to nerves
  • High risk procedures: amputation, spine surgery, thoracotomy, breast surgery, hernia repair, hysterectomy, arthroplasty
  • Poorly controlled acute postoperative pain
  • Pre-existing pain conditions
  • Anxiety, depression
  • Younger age, female
  • Radiation therapy or chemotherapy in cancer patients
  • Repeated surgeries on the same site

Commonly Associated Conditions:

  • Neuropathic pain syndromes (allodynia, hyperalgesia)
  • Phantom limb pain (after amputation)
  • Fibromyalgia, chronic pain syndromes
  • Anxiety, depression, sleep disorders

Common Medications:

(Multimodal pain approach recommended)

  • Neuropathic pain agents: gabapentin, pregabalin, duloxetine, amitriptyline, nortriptyline
  • Analgesics: acetaminophen, NSAIDs
  • Topicals: lidocaine patches, capsaicin
  • Muscle relaxants (if spasms present)
  • Opioids: short-term role only; not recommended for long-term management of CPSP
  • Adjuncts: sleep aids, anxiolytics if comorbid insomnia/anxiety

Common Labs, Imaging, and Tests:

  • Primarily clinical diagnosis (pain >3 months after surgery, localized to surgical site).
  • Imaging (X-ray, MRI, CT) only if new structural pathology suspected (hardware failure, infection, recurrence).
  • Labs (CBC, ESR, CRP) if infection suspected.
  • Neuropathic pain questionnaires (DN4, PainDETECT) may help phenotype pain.

Common Symptoms:

  • Persistent pain localized to surgical site or nerve distribution
  • Neuropathic descriptors: burning, shooting, stabbing, tingling, numbness
  • Allodynia (pain from light touch)
  • Pain interfering with sleep, mood, or daily functioning
  • Reduced range of motion (from pain or scarring)

Common Treatments:

  • Non-Pharmacologic:
    • Physical therapy, graded exercise
    • Cognitive-behavioral therapy (CBT), relaxation techniques
    • Acupuncture, TENS, mindfulness
    • Scar massage/desensitization techniques
  • Pharmacologic:
    • Neuropathic pain meds (gabapentin, pregabalin, duloxetine, TCAs)
    • Topical agents (lidocaine, capsaicin)
    • Multimodal analgesics (acetaminophen, NSAIDs as needed)
    • Opioids only as short-term adjuncts if refractory
  • Interventional:
    • Nerve blocks, epidural injections
    • Radiofrequency ablation
    • Spinal cord stimulation in refractory cases

Physical Findings:

  • Tenderness over surgical site or scar
  • Sensory abnormalities (hypoesthesia, hyperesthesia, allodynia)
  • Pain with light touch or pressure along nerve distribution
  • Decreased range of motion (secondary to pain or scar contracture)

Potential Complications and Contraindications:

  • Complications:
    • Chronic disability and reduced quality of life
    • Sleep disturbance, depression, anxiety
    • Medication overuse and dependency
    • Limited mobility, deconditioning
  • Contraindications:
    • Long-term opioid monotherapy (ineffective for neuropathic pain, risk of dependence)
    • Repeated steroid injections without benefit
    • TCAs in elderly or patients with cardiac disease, glaucoma, urinary retention

General Health and Lifestyle Guidance:

  • Stay active with gentle exercise/PT to prevent stiffness and deconditioning. Ask your healthcare provider what exercises are recommended for you.
  • Practice scar desensitization/massage techniques if recommended
  • Use mindfulness, relaxation, and stress management strategies
  • Maintain healthy sleep routines
  • Maintain a balanced diet to support healing – ask your healthcare provider if there are any dietary recommendations for you
  • Avoid excessive alcohol
  • Smoking cessation (improves healing, reduces pain sensitization)
  • Join support groups or counseling if pain affects mood/function

Suggested Questions to Ask Patients:

  • How long after surgery did your pain continue?
  • How would you describe your pain (burning, stabbing, tingling, numbness)?
  • Is the pain localized to the surgical area, or does it radiate?
  • What activities worsen or improve your pain?
  • How does the pain affect your daily activities, sleep, or mood?
  • What treatments have you tried so far (medications, PT, injections)?
  • Did you have similar pain before surgery?

Suggested Talking Points:

  • CPSP is fairly common after major surgery, especially if nerves were affected.
  • It’s important to treat pain early – discuss pain management with your healthcare provider.
  • There are medications that can help nerve pain.
  • Physical therapy, stress reduction, and sleep hygiene are also important.
  • Most patients improve with a combined approach, but some may need interventional treatments.
  • Good communication with your care team helps tailor treatment to your specific needs. Always let your healthcare provider know about any new, worsening, or persistent symptoms.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.