Mechanisms Of Chronic Postsurgical Pain

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Most people expect to have some pain after an operation. This represents the same process within the organism as pain after any injury. The pain caused by an injury does not bear a simple relationship to the severity or "size" of the injury and in the same way the size of the operation does not neatly correlate to the severity of the chronic pain that follows. An example would be to compare vasectomy with total hip replacement or sternotomy. Vasectomy is an operation carried out for social rather than medical reasons, on fit men, and is minimally traumatic. However, in a proportion of men, the pain suffered after surgery can be severe and cause considerable disability. The prevalence of chronic pain after vasectomy varies between studies from 516 to 15 percent.17,18 In contrast, total hip replacement is a major operation on patients who have normally long-standing and painful pathology. This is a lengthy procedure that involves cutting and reaming bone, injury to muscles and other soft tissues, and a large incision which must inevitably cut some nerves. Nikolajsen et al.19 found a prevalence of chronic pain of 28 percent at 12-18 months following total hip arthroplasty, which caused sleep disturbance in 9 percent and moderate, severe, or very severe impact on daily life in 12 percent. In this group of 1048 patients, only one did not have pain prior to the operation, the majority had severe pain. After sternotomy, another traumatic procedure, about 28 percent of patients report chronic pain, with about 13 percent overall experiencing moderate or severe pain.20,21

In a recent paper, Peters et al?2 explored somatic and psychological predictors of outcome after surgery. This interesting study found that operations lasting more than three hours were associated with more chronic pain, as well as increased functional limitation, poor global recovery, and poorer quality of life at six months post-operatively. Fear of surgery and severe postoperative pain were also associated with a worse outcome. The authors suggest that the prolonged and intense nociceptive barrage may increase central sensitizations. Recent work on the role of the brain stem in influencing spinal cord amplification may help to explain the role of emotions and psychological factors.23

Clearly, the mechanisms involved in the etiology of chronic pain are complex and any operation has the potential to cause chronic pain, but changes in the nervous system are probably the most important factor.

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