Guest Editorial: Perioperative Pain Management in Orthopaedic Surgery: Editorial Comment

Abstract

Postoperative pain ranks at or near the top of the list of concerns for patients following orthopaedic surgery. Once considered little more than a nuisance, the symptom of pain has now reached the status of a “vital sign” [13]. Frequent assessment of a patient's pain is widely mandated by societies, its successful treatment judged by consumer groups, and evaluated as a measure to potentially guide reimbursement by government agencies [11]. This environment has accelerated perioperative pain-related research, resulting in a better understanding of its nature. Importantly, the last decade has seen a widespread acknowledgement that inadequately treated pain may be associated with a number of adverse outcomes, including the development of chronic pain, incomplete rehabilitation, and prolonged length of hospitalization [1, 4]. This realization has sparked innovations in the treatment of perioperative pain, including the development of protocols using a variety of techniques such as neuraxial, peripheral nerve [6] and local infiltration blocks [2] with or without catheters, as well as the development of novel intravenous, oral and local additive drugs and delivery systems [3, 7, 14]. Despite these innovations, no single intervention targeting one pain pathway has provided the “perfect result.” Therefore, more clinicians are promoting a combination of approaches targeting different steps in the pain cascade, widely known as “multimodal pain management” [10]. Over the years, a migration of the target area for pain control from the central nervous system to the actual site of surgery has occurred, with the goal to reduce unwanted side effects and complications of previous techniques. Although occupying an important role in perioperative pain management, reliance on opiod-based systemic medications is waning in light of frequently high rates of side effects, such as nausea, drowsiness and respiratory depression. These side effects hinder expedient and efficient rehabilitation [9]. Neuraxial techniques, such as epidural analgesia, addressed many of these concerns—gaining popularity among some practitioners and institutions in the process. Unfortunately, the advent of potent anticoagulants and the associated risk of hematoma formation has limited this approach [12]. Facilitated by the widespread use of ultrasound, peripheral nerve blocks are seen by many as an alternative to epidurals in the setting of potent anticoagulant use. However, peripheral nerve blocks are not without downsides. They are often accompanied by negative effects on motor strength and possibly rehabilitation. Trying to avoid the latter, some orthopaedic surgeons have promoted the use of periarticular injections or intraarticular infusions. Questions regarding the effectiveness and safety profiles of these treatments are still being investigated [15]. In light of these questions, clinicians and researchers continue to investigate the role of nonpharmacologic interventions on pain outcomes, and the impact pain management strategies may have beyond the alleviation of acute discomfort (Fig. 1).Fig. 1: Dr. Stavros G. Memtsoudis is shown.In this context, researchers are currently investigating the correlation between the impact of various acute pain management strategies and patient morbidity, mortality and the development of chronic pain syndromes. Previously elusive links between acute pain, its treatment and the immune system even have lead to investigations on the effect on cancer recurrence [5, 8]. Although perioperative pain management research has progressed, the collaboration between researchers and clinicians will continue to be vital for sharing new information and achieving further improvements. Embracing the notion that appropriate management of acute pain may influence long-term outcomes and survival in some orthopaedic populations should provide enough impetus to fuel future investment in this line of research for a long time to come.