Specific Pain Conditions

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Post-Surgical Chronic (Persistent) Pain

Persistent postsurgical pain is pain that persists after the expected healing time following surgery.  It is estimated to occur in 10-50% of people who have had surgery.  Approximately 10% of these patients report severe pain.

The cause of persistent postsurgical pain is not completely understood but is thought to include injury or damage to tissue and/or peripheral nerves during surgery.  Patients thought to be predisposed to developing this syndrome include those with a prior history of chronic pain, a history of anxiety or depression, pre-operative pain or an extenstive, complicated surgery.

Most persistent postsurgical pain is neuropathic in nature.  Treatment typically includes nonopioids for mild to moderate pain, opioids for moderate to severe pain and anticonvulsants.  In some cases, nerve blocks can be used to reduce pain sensations.  Non-drug techniques such as relaxation and distraction can also be utilized in addition to medication.

Resources:  Kehlet, H, Jensen TS, Wolff, CJ.  Persistent postsurgical pain: risk factors and prevention, Lancet, 2006, 367(9522):189-198; http://pain-topics.org/ (accessed May 8, 2011)

Examples of common surgeries that can result in persistent postoperative are listed below.  

Phantom Pain

• Types
  • Phantom Limb Pain
  • Phantom Limb Sensation
  • Stump Pain

Post-Mastectomy Pain

• Incidence:  thought to be as high at 65% (Smith, Bourne, Squait, et al, 1999). 
• Cause:  most commonly thought to be due to damage to intercostal nerves in the breast and underarm area.  Other possibilities are the development of a neuroma following surgery.
• Onset:  can occur immediately or up to 6 months following surgery.  . 
• Symptoms:   include numbness, pain with movement of the arm and shoulder on the side of the surgery, allodynia and dysesthesias.   The pain range from mild to severe is usually described as a burning or continuous ache.

Post-Thoracotomy Pain

• Incidence
• Cause
• Onset
• Symptoms

Complex Regional Pain Syndrome (CRPS)

Complex regional pain syndrome (CRPS) is a central and autonomic nervous system disorder that results in chronic pain that most often affects the arms, legs, hands, or feet.  Without proper diagnosis and treatment, it can spread to other parts of the body resulting in lifelong chronic pain. There are two types

• Type I (formerly known as reflex sympathetic dystrophy)
• Type II (formerly known as causalgia)

Causes:

The cause of CRPS is not well understood.  Type I can result from tissue injury, such as a IV catheter insertion, trauma (sprain or fracture) or surgery, and Type II has a clear association with nerve injury. The precipitating injury can minor, and approximately 1 in 3 patients can’t recall being injured.   

Onset: 

Ranges from hours, days or weeks of the injury. 

Symptoms: 

The primary symptom is debilitating pain over the affected area.  It is frequently described as burning and often seems out of proportion to the severity of the injury. Other signs and symptoms include:

• Extreme sensitivity to touch
• Changes in skin color (e.g. very pale, red or bluish), temperature (extreme hot or cold), and texture (e.g. thin or shiny)  
• Excessive diaphoresis
• Swelling
• Weakness and decreased function of the limb that can lead to muscle atrophy and contractures
• Abnormal nail and hair growth

Treatment: 

A combination of therapies is usually required and may include. 

• PO/topical medications ranging from NSAIDs to adjuvants (e.g., antidepressants, anticonvulsants, corticosteroids) and opioids.
• Sympathetic nerve blocks, IV lidocaine or ketamine infusions  
• Implanted spinal cord stimulators or pain pumps.
• Physical therapy
• Psychological counseling

Data from American Pain Foundation (APF) Pain Community, Fall 2008; http://www.rsds.org/  Feinberg, SD. Complex Regional Pain Syndrome, AJN, 2000; 100:23-24.