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Pain Medicine 2014; 15: 1222–1229 Wiley Periodicals, Inc.
ACUTE PAIN & PERIOPERATIVE PAIN SECTION Original Research Article Incidence of Chronic Postsurgical Pain (CPSP) after General Surgery
Christian J.P. Simanski, MD, PhD,*# Astrid Althaus, Dr Dipl Psych,†# Sascha Hoederath, MD,‡ Kerry W. Kreutz, MD,† Petra Hoederath, MD,§ Rolf Lefering, PhD,¶ Carolina Pape-Köhler, MD,** and Edmund A.M. Neugebauer, PhD†
Abstract
*Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke; †Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany; ‡Clinic of Surgery and Orthopaedics, Kantonales Spital Grabs, Grabs; §Clinic of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland; ¶Biometrics and Statistics, Institute for Research in Operative Medicine (IFOM); **Department of Abdominal, Vascular, and Transplant Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Cologne, Germany
Design. This is a prospective cross-sectional study at a university-affiliated clinic/level 1 trauma center. Patients were followed at least 1 year postoperatively. By surgical discipline, procedures were 50% orthopedic/trauma, 33% general (abdominal/ visceral), and 17% vascular.
Reprint requests to: Christian Johannes Paul Simanski, MD, Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstrasse 200, Cologne 51109, Germany. Tel: 0049-221-8907-13018; Fax: 0049-221-8907-3085; E-mail: [email protected]. #Both authors contributed equally. The authors declare no conflicts of interest in the publication of this study. Author’s contributions : CJPS, EAMN, KK, SH, and PH developed the study, design, and research. CJPS, EAMN, and RL supervised conduction of the study. CJPS, KK, SH, PH, and RL collected and managed the data. CJPS and AA drafted the manuscript, contributing equally. All other authors contributed substantially to its revision. CJPS takes responsibility for the paper as a whole. RL provided statistical advice on the study design and analyzed the data along with CJPS, KK, SH, CP-K, and AA. 1222
Objective. This study investigated the incidence and determinants of chronic postsurgical pain (CPSP) in a general surgical patient population.
Setting. All patients admitted during one year (N = 3020) were eligible. Exclusion criteria were cognitive impairment, communication/language barrier, nonoperative treatment, and refusal to participate. A CPSP questionnaire was completed. Step-by-step analysis followed with a 2nd questionnaire to detect CPSP with numeric rating scale (NRS) pain intensity ≥3. Finally, individual follow-up examinations were performed. Results. 911 patients responded (30.2%). 522 complained of pain intensity ≥3 on NRS (scale 0–10). The second step identified 214 patients with chronic pain (NRS ≥3, mean 29 months postoperatively). On final examination, 83 CPSP patients (14.8%) were identified. By surgical discipline, 28% were general, 15% vascular, and 57% trauma/orthopedic surgery. Most oftenly cited pain sites were joint (49.4%), incisional/scar (37.7%), and nerve pain (33.7%). By procedure, patients underwent pelvic surgery, colon surgery, laparoscopies, inguinal herniorrhaphies, arthroscopies, and hardware extractions. All patients in the “laborer” and “unemployed” categories reported chronic pain. Conclusion. Bias due to study design and/or heterogeneity of patients is possible, but there was a high CPSP rate after 2 years both generally and particularly in orthopedic/trauma (57%) patients. Both “major” and “minor” surgical procedures led to CPSP.
Incidence of CPSP After General Surgery Key Words. Risk Factors; Pain Management; Chronic Post-Surgical Pain (CPSP); Persistent Pain; Prospective Study
Introduction The development of chronic postsurgical pain (CPSP) appears to be a multifactorial process. It is influenced by physical, psychological, genetic, and social factors [1,2]. Numerous studies have investigated the process of “how acute pain becomes chronic” after various interventions [2–4]. Multiple surgical procedures within a single peripheral nerve distribution lead to high incidence of CPSP [2,3]. Patients complain of CPSP in 5–65% after thoracotomy [5,6], 30–50% after cardiac surgery [7,8], 5–63% after hernia surgery [9,10], 11–57% after mastectomy [11,12], and 30–85% after amputations [13]. Quoted rates of incidence for CPSP vary widely, depending on study design, single or multi center participation, clinic level of care, surgical expertise, etc. Severe acute postoperative pain seems to be a risk factor for the development of chronic pain [3,4]. In more than 115,000 patients, Gerbershagen et al. found that very high pain intensity on the first postoperative day was reported after “minor” interventions, e.g. appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, as well as after major orthopedic surgery [14]. Analysis of the literature confirmed high incidence rates of CPSP after these procedures [15–17]. In many studies patients were recruited from tertiary centers with specialized surgeons, or pain intensities were measured only on the first postoperative day [14]. It is thus possible that the results exhibit bias, and do not reflect actual CPSP incidence. In addition, it is important to examine such rates in the general surgical departments of primary and secondary care centers, since in our nation at least, patients are generally treated there and not in specialized surgical centers [18,19]. The aim of this study was to determine the incidence of chronic postoperative pain (CPSP) in a general surgical patient population of an academic university-affiliated hospital, and to analyze this data for specific contributing factors.
hospital, the questionnaire was modified. The study was approved by our local ethics committee. All patients were treated under the conditions of the Helsinki II declaration and all subjects provided informed consent to participate. Exclusion criteria were cognitive impairment, communication/language barrier in non-native speakers, non-operative treatment, and refusal to participate. To clarify whether the pain reported on the first questionnaire (mean 19 months post OP, Range: 13–26 months; SD ± 3.5 months) required further investigation (numerical rating scale NRS ≥3; scale 0–10), and whether it appeared related to surgery, a second analysis was performed by examining patient charts and performing telephone interviews (Figure 1). Thus, we differentiated patients treated operatively versus non-operatively, and whether a nonexistent, possible, or definite connection between the surgical intervention and current pain symptoms was present. Patients with possible or definite chronic pain related to surgery were invited to return to our clinic where a follow up examination was performed to assess the symptoms of CPSP (mean 29 months post OP, Range: 24–35 months; SD ± 3.5 months). Definition of CPSP We defined CPSP similarly to Macrae [20]: 1) Pain that develops after surgery, 2) where other etiologies have been ruled out, and 3) exacerbation of a pre-existing problem as cause for the pain has been ruled out. Unlike Macrae, we defined CPSP as postoperative pain lasting longer than 12 months, according to recommendations of other sources [21]. Evaluation Evaluation of the questionnaires, telephone interviews, and physical examinations was primarily descriptive. Percentages refer to the total number of patients with pain requiring intervention, i.e. with intensities on VAS/NRS ≥3 (scale 0–10 where 0 = no pain, 10 = maximum imaginable pain) [22]. Differences in frequency were tested with the Fisher’s exact test, and ranking with the Mann-Whitney U test (P < 0.05). Analysis was carried out using the SPSS software package (version 17.0, SPSS Inc., Chicago, Ill., United States).
Patients and Methods For this cross-sectional study, we included all 3,020 patients admitted to our facility (vascular, abdominal/ visceral, orthopedic/trauma) over a one year period (1st August until 31st July). Relative to surgical speciality, the patient distribution was 50% undergoing or thopedic/trauma, 33% abdominal/visceral, and 17% vascular procedures. Development of the Questionnaire The questionnaire was tested for comprehensiveness, clarity, and completion time with a first draft in our clinic during a pilot phase of the study. After extensive discussions by the “integrated acute pain working group” of our
Standardized Pain Measurement, Documentation, and Therapy An independent “study nurse” explained the study background and benefits of the routine daily pain measurement and documentation procedures to all patients. The routine clinical documentation of pain intensity comprised assessments at least twice daily (morning and evening) using a visual analog scale (VAS, 0–10) at rest and with movement (0 = no pain, 10 = worst pain imaginable) [23]. Pain measurement on weight bearing was performed during physiotherapy or mobilization on the hospital floor, and included coughing, stair climbing, or standing for more than 30 minutes. The VAS pain intensity scores were documented by the responsible nursing staff on 1223
Simanski et al.
Time point of analysis (TP) All surgical patients n = 3020
TP O: Hospital stay
First Questionnaire n = 911
TP 1: Ø 19 months post OP
Pain NRS-pain intensity ≥3 pts. n = 522 Pain
Pain - unclear reason n = 16
n=337
CPSP n = 83 25.9%
No pain NRS-pain intensity
Pain Medicine 2014; 15: 1222–1229 Wiley Periodicals, Inc.
ACUTE PAIN & PERIOPERATIVE PAIN SECTION Original Research Article Incidence of Chronic Postsurgical Pain (CPSP) after General Surgery
Christian J.P. Simanski, MD, PhD,*# Astrid Althaus, Dr Dipl Psych,†# Sascha Hoederath, MD,‡ Kerry W. Kreutz, MD,† Petra Hoederath, MD,§ Rolf Lefering, PhD,¶ Carolina Pape-Köhler, MD,** and Edmund A.M. Neugebauer, PhD†
Abstract
*Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke; †Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany; ‡Clinic of Surgery and Orthopaedics, Kantonales Spital Grabs, Grabs; §Clinic of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland; ¶Biometrics and Statistics, Institute for Research in Operative Medicine (IFOM); **Department of Abdominal, Vascular, and Transplant Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Cologne, Germany
Design. This is a prospective cross-sectional study at a university-affiliated clinic/level 1 trauma center. Patients were followed at least 1 year postoperatively. By surgical discipline, procedures were 50% orthopedic/trauma, 33% general (abdominal/ visceral), and 17% vascular.
Reprint requests to: Christian Johannes Paul Simanski, MD, Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstrasse 200, Cologne 51109, Germany. Tel: 0049-221-8907-13018; Fax: 0049-221-8907-3085; E-mail: [email protected]. #Both authors contributed equally. The authors declare no conflicts of interest in the publication of this study. Author’s contributions : CJPS, EAMN, KK, SH, and PH developed the study, design, and research. CJPS, EAMN, and RL supervised conduction of the study. CJPS, KK, SH, PH, and RL collected and managed the data. CJPS and AA drafted the manuscript, contributing equally. All other authors contributed substantially to its revision. CJPS takes responsibility for the paper as a whole. RL provided statistical advice on the study design and analyzed the data along with CJPS, KK, SH, CP-K, and AA. 1222
Objective. This study investigated the incidence and determinants of chronic postsurgical pain (CPSP) in a general surgical patient population.
Setting. All patients admitted during one year (N = 3020) were eligible. Exclusion criteria were cognitive impairment, communication/language barrier, nonoperative treatment, and refusal to participate. A CPSP questionnaire was completed. Step-by-step analysis followed with a 2nd questionnaire to detect CPSP with numeric rating scale (NRS) pain intensity ≥3. Finally, individual follow-up examinations were performed. Results. 911 patients responded (30.2%). 522 complained of pain intensity ≥3 on NRS (scale 0–10). The second step identified 214 patients with chronic pain (NRS ≥3, mean 29 months postoperatively). On final examination, 83 CPSP patients (14.8%) were identified. By surgical discipline, 28% were general, 15% vascular, and 57% trauma/orthopedic surgery. Most oftenly cited pain sites were joint (49.4%), incisional/scar (37.7%), and nerve pain (33.7%). By procedure, patients underwent pelvic surgery, colon surgery, laparoscopies, inguinal herniorrhaphies, arthroscopies, and hardware extractions. All patients in the “laborer” and “unemployed” categories reported chronic pain. Conclusion. Bias due to study design and/or heterogeneity of patients is possible, but there was a high CPSP rate after 2 years both generally and particularly in orthopedic/trauma (57%) patients. Both “major” and “minor” surgical procedures led to CPSP.
Incidence of CPSP After General Surgery Key Words. Risk Factors; Pain Management; Chronic Post-Surgical Pain (CPSP); Persistent Pain; Prospective Study
Introduction The development of chronic postsurgical pain (CPSP) appears to be a multifactorial process. It is influenced by physical, psychological, genetic, and social factors [1,2]. Numerous studies have investigated the process of “how acute pain becomes chronic” after various interventions [2–4]. Multiple surgical procedures within a single peripheral nerve distribution lead to high incidence of CPSP [2,3]. Patients complain of CPSP in 5–65% after thoracotomy [5,6], 30–50% after cardiac surgery [7,8], 5–63% after hernia surgery [9,10], 11–57% after mastectomy [11,12], and 30–85% after amputations [13]. Quoted rates of incidence for CPSP vary widely, depending on study design, single or multi center participation, clinic level of care, surgical expertise, etc. Severe acute postoperative pain seems to be a risk factor for the development of chronic pain [3,4]. In more than 115,000 patients, Gerbershagen et al. found that very high pain intensity on the first postoperative day was reported after “minor” interventions, e.g. appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, as well as after major orthopedic surgery [14]. Analysis of the literature confirmed high incidence rates of CPSP after these procedures [15–17]. In many studies patients were recruited from tertiary centers with specialized surgeons, or pain intensities were measured only on the first postoperative day [14]. It is thus possible that the results exhibit bias, and do not reflect actual CPSP incidence. In addition, it is important to examine such rates in the general surgical departments of primary and secondary care centers, since in our nation at least, patients are generally treated there and not in specialized surgical centers [18,19]. The aim of this study was to determine the incidence of chronic postoperative pain (CPSP) in a general surgical patient population of an academic university-affiliated hospital, and to analyze this data for specific contributing factors.
hospital, the questionnaire was modified. The study was approved by our local ethics committee. All patients were treated under the conditions of the Helsinki II declaration and all subjects provided informed consent to participate. Exclusion criteria were cognitive impairment, communication/language barrier in non-native speakers, non-operative treatment, and refusal to participate. To clarify whether the pain reported on the first questionnaire (mean 19 months post OP, Range: 13–26 months; SD ± 3.5 months) required further investigation (numerical rating scale NRS ≥3; scale 0–10), and whether it appeared related to surgery, a second analysis was performed by examining patient charts and performing telephone interviews (Figure 1). Thus, we differentiated patients treated operatively versus non-operatively, and whether a nonexistent, possible, or definite connection between the surgical intervention and current pain symptoms was present. Patients with possible or definite chronic pain related to surgery were invited to return to our clinic where a follow up examination was performed to assess the symptoms of CPSP (mean 29 months post OP, Range: 24–35 months; SD ± 3.5 months). Definition of CPSP We defined CPSP similarly to Macrae [20]: 1) Pain that develops after surgery, 2) where other etiologies have been ruled out, and 3) exacerbation of a pre-existing problem as cause for the pain has been ruled out. Unlike Macrae, we defined CPSP as postoperative pain lasting longer than 12 months, according to recommendations of other sources [21]. Evaluation Evaluation of the questionnaires, telephone interviews, and physical examinations was primarily descriptive. Percentages refer to the total number of patients with pain requiring intervention, i.e. with intensities on VAS/NRS ≥3 (scale 0–10 where 0 = no pain, 10 = maximum imaginable pain) [22]. Differences in frequency were tested with the Fisher’s exact test, and ranking with the Mann-Whitney U test (P < 0.05). Analysis was carried out using the SPSS software package (version 17.0, SPSS Inc., Chicago, Ill., United States).
Patients and Methods For this cross-sectional study, we included all 3,020 patients admitted to our facility (vascular, abdominal/ visceral, orthopedic/trauma) over a one year period (1st August until 31st July). Relative to surgical speciality, the patient distribution was 50% undergoing or thopedic/trauma, 33% abdominal/visceral, and 17% vascular procedures. Development of the Questionnaire The questionnaire was tested for comprehensiveness, clarity, and completion time with a first draft in our clinic during a pilot phase of the study. After extensive discussions by the “integrated acute pain working group” of our
Standardized Pain Measurement, Documentation, and Therapy An independent “study nurse” explained the study background and benefits of the routine daily pain measurement and documentation procedures to all patients. The routine clinical documentation of pain intensity comprised assessments at least twice daily (morning and evening) using a visual analog scale (VAS, 0–10) at rest and with movement (0 = no pain, 10 = worst pain imaginable) [23]. Pain measurement on weight bearing was performed during physiotherapy or mobilization on the hospital floor, and included coughing, stair climbing, or standing for more than 30 minutes. The VAS pain intensity scores were documented by the responsible nursing staff on 1223
Simanski et al.
Time point of analysis (TP) All surgical patients n = 3020
TP O: Hospital stay
First Questionnaire n = 911
TP 1: Ø 19 months post OP
Pain NRS-pain intensity ≥3 pts. n = 522 Pain
Pain - unclear reason n = 16
n=337
CPSP n = 83 25.9%
No pain NRS-pain intensity
