Implications Of The Complexity Of Mechanisms

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Understanding the scale of the changes to the nervous system and the mechanisms that predispose to chronic pain after surgery is important for many reasons. It can change the climate of blame that exists when patients have pain after an operation. Because people expect the pain after injury or an operation to resolve as the injury heals, it is natural that they should imagine that something must have gone wrong with the operation if the pain persists. It is not possible to perform surgery without some damage to tissues, and therefore a hyperalgesic state will be induced after any operation, regardless of how it is done. Usually this will revert to normal as healing occurs, but not always. Whether a patient experiences chronic pain after surgery or not is therefore more likely to depend on the "set" of their nervous system than on precisely what the surgeon did. For patients who have chronic pain after surgery, it is inappropriate to assume that the surgeon has necessarily done anything wrong or that it is anyone's fault.

Patients who believe that someone was to blame for their chronic pain report more distress and behavioral disturbance, as well as poor response to treatments and lower expectations of future benefits.74 Cognitive mechanisms of symptom perception in chronic pain may be affected by a patient's belief that they were injured,75 leading to lower pain threshold and tolerance, decreased activity, and general deconditioning. It is therefore clear that removing the climate of blame would help both patients and surgeons. By accepting that chronic pain is, for a proportion of patients, an inevitable consequence of surgery, like a wound infection, and openly discussing it before surgery, much subsequent grief could be avoided.

The complexity also has implications for clinical practice. The extent of the changes in the nervous system suggests that pharmacological, psychological, and behavioral therapies may be more beneficial to patients than invasive treatments. Simplistic notions about treatment, for example simple nerve blocks, or further surgery are unlikely to help, and may well do harm, by causing further damage. If surgery has the potential to cause chronic pain, then caution is needed before embarking on operations. This is of particular relevance for cosmetic surgery, or for other procedures that are performed out of choice rather than need. It also raises important questions about surgery in conditions where the evidence for efficacy is lacking, for example some types of surgery for back pain, producing the post laminectomy syndrome.76

Lastly, acknowledging the complexity of chronic pain after surgery, especially the changes in the nervous system, should help to guide the directions of future research, in particular by taking into account the mechanisms that lead to the development of chronic pain.

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