In this episode of PodMD, Pain Medicine Physician and Interventional Pain Specialist Dr Akilan Velayudhan will be discussing the topic of management of post-surgical pain.
- Transcript
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Today I’d like to welcome to the PodMd studio Dr Akilan Velayudhan, an Australian-trained Pain Medicine Physician and Interventional Pain Specialist with an interest in spinal, nerve, joints and extremities pain.
Dr Velayudhan has experience in practising as a Pain Specialist working in a multidisciplinary team for over 10 years in Australian, UK and Canada. He is currently providing care in Bundoora, Epping, Werribee and surrounding areas in Victoria.
Dr Velayudhan has Fellowships from Royal College of Australian and New Zealand College of Anaesthetists, Royal College of Anaesthetists from U.K and Ireland. He is also a Fellow of Interventional Pain Practice from World Institute of Pain and in addition has Pain Fellowship from Australian and New Zealand College of Anaesthetists.
He strongly believes in a holistic approach in chronic pain management and uses various pharmacological and non-pharmacological strategies such as interventional therapy, physical therapy and psychological approach in the overall management of chronic pain.
Today, we’ll be discussing the topic of management of post-surgical pain.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Dr Akilan Velayudhan, thanks for talking with us on Pod MD today.
Akilan: Thank you very much for having me today and thanks for your time in listening.
The topic of today’s discussion is management of post-surgical pain. Can you describe for our listeners what is Post-Surgical Persistent Pain?
Akilan: Persistent post-surgical pain is defined as pain that persists for at least three to six months post-surgery. It is localised to the surgical field or to an innervation territory of nerves situated in the surgical field, or to a dermatome after surgery in the deep somatic or visceral tissues.
Question 1
How would a patient with post-surgical pain typically present?Akilan: Usually, there are a few criteria here. Firstly, the pain must develop after a surgical procedure. The pain is also of at least two months’ duration. Thirdly, other causes of pain have been excluded. Fourthly, the possibility that the pain is from a pre-existing condition has been excluded. To enable adequate identification, diagnosis, and therapy, persistent post-surgical pain is now included in the International Classification of Disease 11. It postulates a more global measure of the impact of pain on the quality of life for the individual. It also considers pain severity and encompasses three dimensions: one, pain intensity; two, pain-related distress; and three, pain-related functional interference.
Question 2
Who is at risk of getting persistent post-surgical pain?Akilan: Factors that indicate someone is at a high risk of getting persistent post-surgical pain include patient demographics, genetics, psychological factors, and surgical techniques. Regarding patient demographics, studies have shown older patients tend to have a lesser risk of developing persistent post-surgical pain compared to younger patients. This is opposed to the findings in other chronic pain states where increased age can predispose someone to higher rates of chronic pain. Turning attention now to the sex of the patient, female sex is considered a generalised risk factor for developing severe acute and chronic pain. Looking now to genetics, genetic studies have shown that the severity of post-surgical persistent pain is correlated with mutations in genes involving enzymes influencing pain inhibition. In terms of the psychological aspects, studies found negative cognitive-affective states, including perioperative depression, anxiety, pain catastrophising, and post-traumatic stress symptoms as predictors of the onset of persistent postsurgical pain. In terms of preoperative acute/chronic pain, what they found is that increased preoperative use of analgesics and an acute pain trajectory with constantly higher pain intensity scores carry the most risk of someone developing persistent post-surgical pain. When they looked at the surgical techniques, what they found is that some of the surgical procedures are inherently riskier regarding post-surgical pain. For example, it has been shown that 60% of patients developed persistent postsurgical pain after limb amputation, and following mastectomy, it has shown a 20 to 40% risk. With hernia repair, there is a 20% risk, and in patients with thoracotomy, it has been found to be around 20 to 40% risk of developing persistent post-surgical pain.
Question 3
How can you prevent or minimise the risk of developing post-surgical pain?Akilan: First and foremost is identifying patients who are at risk of developing persistent post-surgical pain, and this can be done, or rather facilitated, by using prehabilitation clinics or preoperative assessment clinics. Secondly, is using perioperative strategies. In terms of the perioperative strategies, surgical techniques have been shown to be helpful in minimising persistent postsurgical pain; however, the evidence is still insufficient, and it is mentioned that avoiding damage to the local nerves, minimising the duration of surgery, choosing minimally invasive procedures, or avoiding extensive surgery where possible, can all influence someone at risk of developing persistent post-surgical pain. Regarding the postoperative pain management strategies, the use of regional techniques such as nerve blocks with or without continuous local anaesthetic infusion catheters during or soon after surgeries has been shown to reduce the incidence. Finally, using Multimodal Analgesia during the perioperative period has been shown to be effective in preventing persistent post-surgical pain. Multimodal Analgesia uses medications with different mechanisms of action that may have a synergistic effect by modulating the pain signals at various points of the pain pathway. For example, using a combination of gabapentinoids, anti-inflammatory drugs, paracetamol, as well as regional anaesthesia.
Question 4
What are the treatment options?Akilan: The treatment options are mainly pharmacological and non-pharmacological. If you look at the pharmacological options, the current pharmacological therapies for the management of persistent postsurgical pain usually include anti-neuropathic agents such as gabapentinoids, tricyclic antidepressants, serotonin or norepinephrine reuptake inhibitors, and topical lignocaine or capsaicin, usually used as common anti-neuropathic agents. However, a 2017 meta-analysis of the available randomised controlled trials for pharmacological treatment revealed that most pharmacological interventions tested were in isolation and did not include multimodal or multidisciplinary treatment programmes. Moving to the non-pharmacological approach, I would say perhaps in patients who have not responded to pharmacological therapy, interventions such as nerve blocks, nerve ablations, and neural modulations can be used. Other non-pharmacological approaches may include using a psychological-based approach for people who have higher levels of anxiety and depression associated with pain. Some of the cognitive strategies can be used as an effective tool.
Question 5
Are there any warning signs a GP or their patient can look out for?Akilan: Patients having persistent pain around four to six weeks after surgery should trigger alarm bells for patients transitioning from acute to chronic persistent postsurgical pain.
Question 6
When should a GP refer?Akilan: I think any patient presenting or reporting pain post-surgery around four to six weeks, when you would have expected them to have recovered, should raise alarm bells for possibly transitioning from acute to chronic persistent postsurgical pain. I would say at this juncture, considering referring to a pain specialist for either a pharmacological approach or a non-pharmacological approach which would reduce the risk of neuroplasticity and thereby preventing peripheral or central sensitisation leading to persistent postsurgical pain.
Question 7
What role does the GP play in the treatment of the condition?Akilan: Early recognition and initiating pharmacological therapy, and a referral to a pain specialist for early intervention, is very crucial.
Question 8
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on management of post-surgical pain?Akilan: In terms of the take-home messages:
1. Chronic pain after surgery is a significant chronic problem that affects approximately 10% to 50% of patients worldwide.
2. Anyone reporting pain post-surgery beyond the normal tissue healing period of four to six weeks should raise suspicion of someone transitioning from acute to chronic pain.
3. Current treatments for chronic postsurgical pain remain contentious, and clinical trials often focus on individual, as opposed to multimodal, treatment strategies. Nevertheless, early referral to a pain specialist for a multimodal approach could possibly reduce the risk of developing persistent postsurgical pain.Thanks again for your time and the insights you’ve provided.
Akilan: Thanks again for your time.
