Preoperative Chronic Pain Research Articles

2852 Long Term Follow up of Carbon Dioxide Laser Vaporisation Versus Harmonic Scalpel Excision in the Treatment of Superficial Endometriosis: A Randomised Controlled Trial

Study Objective To evaluate if excision of endometriosis (rAFS stages I-III) with the harmonic scalpel, is superior to carbon dioxide laser vaporisation in terms of symptoms over a 3 year period. Design This was a randomized double blind controlled trial. Setting Set at a Tertiary referral unit. Patients or Participants 116 patients found to have endometriosis at laparoscopy were randomized in to the study. Interventions The study was powered for superiority, and patient's randomized with a 1:1 allocation into receiving treatment either with laser or harmonic scalpel. Data was analyzed using SPSS version 21. The primary outcome measure was the visual analogue scale (VAS) score for chronic pelvic pain score at 6 months. Secondary outcomes included core EHP-30, HADS anxiety and depression score and VAS scores for chronic pelvic pain, dysmenorrhoea, dyschezia and dyspareunia, up to 3 years. Measurements and Main Results Pre operative chronic pelvic pain (VAS) for the laser and harmonic groups were 57.1 (IQR: 28.1-75.6) and 50.6 (IQR: 0-75.0) respectively, and at 6 months 43 (IQR: 0-66.5) and 30 (IQR: 0-60.7). The difference between the two were not statistically significant, p=0.228. At 12 months the chronic pelvic pain VAS scores for laser and harmonic groups were 50 (IQR: 20-74.7) and 13.1 (IQR: 0-49.0) respectively. The difference between the two was significant, p Conclusion Excision of endometriosis with harmonic is effective at improving chronic pelvic pain up to 3 years. This does not appear to be the case with CO2 laser vaporisation. In terms of most secondary outcomes laser performs as well as harmonic at 6 months but the trend is in favor of harmonic up to 3 years.

Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery.

Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway. This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway. There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04). We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

55. Ending opioid addiction following spine surgery

BACKGROUND CONTEXT Opioid addiction is the number one health care issue in the United States with spinal ailments the leading medical condition associated with opioid addiction. Patients with chronic pain syndrome and opioid addiction going for spine surgery are at high risk for several poor outcomes, including life-long use of opioids. Current evidence-based methods to optimize patients prior to spine surgery have been: (1) transition from opioids to nonopioid medications, (2) cardiovascular exercise program, (3) smoking cessation, (4) alcohol cessation, and (5) psychotherapy to treat mood and maladaptive pain behavior. PURPOSE The authors hypothesized that an initiation of an interdisciplinary “prehab” protocol utilizing all five aforementioned modalities prior to spine surgery in patients with chronic pain syndrome and opioid addiction would optimize postoperative outcomes, including decreased pain and opioid consumption. STUDY DESIGN/SETTING Prospective and retrospective review of patients with and without an interdisciplinary “prehab” program prior to spine surgery. PATIENT SAMPLE Eighty-nine patients with and 85 patients without prior to spine surgery. OUTCOME MEASURES Opioid usage, visual analog scale (VAS) for axial pain and radiculopathy, EQ-5D, QALY, PHQ-9, pain castrophizing scale (PCS), and chronic pain acceptance questionnaire (CPAQ). METHODS A review from 2013 to 2017 at a single institution was performed on patients undergoing spine surgery. Inclusion criteria were patients undergoing spine surgery who had preoperative chronic pain syndrome and opioid addiction. Two cohorts were investigated which included patients going for spine surgery with and without a multidisciplinary prehab protocol. The protocol was the initiation of a multidisciplinary task team to preoperatively optimize patients with opioid addiction and chronic pain syndrome going for spine surgery. Collaboration was between the spine surgery division, pain management, pharmacy, psychiatry, psychology, primary care, physical therapy, and nutritionist. Patients in the prehab cohort underwent a preoperative optimization checklist: patients were transitioned off of opioids with utilization of nonopioid medications; patients who were smokers were enrolled in an smoking cessation program; patients who had alcohol dependence had a behavioral medicine consult with psychology; patients who were obese (BMI >35) were enrolled in a multidisciplinary weight loss program through monitored cardiovascular exercising and nutritionist consultation; and all patients had a consultation with behavioral medicine for their chronic pain syndrome to forge healthy relationships with their pain. RESULTS Demographics and case breakdown (surgery type performed) were similar between cohorts. A significantly greater amount of patients receiving were opioid-free following spine surgery compared to patients without (8% vs 72%, respectively, p CONCLUSIONS A multidisciplinary “prehab” program for patients with opioid addiction and chronic pain syndrome going for spine surgery is efficacious at reducing opioid addiction and pain, improving quality of life and depression, and forging a healthier relationship with pain. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Prevalence and Clinical Implications of Chondral Injuries After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

Background: Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited. Purpose: To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID). Study Design: Case-control study; Level of evidence, 3. Methods: Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS. Results: There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m2. A total of 493 (77.8%) patients had no evidence of chondral damage, 92 (14.5%) patients had partial-thickness chondral defects, and 49 (7.7%) patients had full-thickness chondral defects. There were statistically significant differences in the Hip Outcome Score (HOS)–Activities of Daily Living, HOS–Sports Subscale, modified Harris Hip Score, pain, and satisfaction (P < .01) among the 3 groups. Patients with grade IV chondromalacia experienced the poorest outcomes and lowest percentage of achieving the PASS. Predictors for achieving any PASS threshold included preoperative alpha angle (odds ratio [OR], 0.96; P = .016), absence of preoperative limping (OR, 7.25; P = .002), absence of preoperative chronic pain (OR, 5.83; P = .019), primary hip arthroscopic surgery (OR, 0.17; P = .050), patients who self-identified as runners (OR, 2.27; P = .037), and Tönnis grade 0 (OR, 2.86; P = .032). Male sex (OR, 2.49; P = .015) was the only predictor of achieving any MCID threshold. Conclusion: Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.

Early Hip Arthroscopy for Femoroacetabular Impingement Syndrome Provides Superior Outcomes When Compared With Delaying Surgical Treatment Beyond 6 Months

Background: There is literature on the association between chronic preoperative pain and worse outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). However, there are few data on whether there is an optimum window that provides the best midterm surgical outcomes. Purpose: To assess the outcomes of hip arthroscopy for FAIS according to timing of surgical intervention. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing arthroscopic intervention for FAIS with a minimum 2-year follow-up were included. All patients completed the Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales for pain and satisfaction. Patients were stratified by preoperative symptom duration. We compared 3 to 6 months of symptoms with other subsequent time frames (>6-12, >12-24, and >24 months). Clinically significant outcome was determined with the minimal clinically important difference and patient acceptable symptomatic state. Results: A total of 1049 patients were included (mean ± SD: age, 32.3 ± 12.4 years; follow-up, 30.8 ± 6.7 months). Patients undergoing surgery at 3 to 6 months of symptoms had no significant differences in outcome when compared with those in the >6- to 12-month group except for the iHOT-12 (P = .028). Patients with symptom duration of >12 to 24 months and >24 months had worse outcomes across all measures (P < .001). Surgery within 3 to 6 months of symptoms was predictive for achieving the minimal clinically important difference on the HOS-ADL (odds ratio [OR], 1.81; 95% CI, 1.20-2.73) and HOS-SS (OR, 1.90; 95% CI, 1.11-3.17), as well as the patient acceptable symptomatic state on the HOS-ADL (OR, 1.85; 95% CI, 1.34-2.56) and HOS-SS (OR, 1.58; 95% CI, 1.14-2.18), when compared with the other groups. In multivariate regression analysis, symptom duration was predictive of visual analog scale for pain (β = 3.10; 95% CI, 1.56-4.63; P < .001) and satisfaction (β = −4.16; 95% CI, −6.14 to −2.18; P < .001). Conclusion: Among patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) was associated with superior postoperative outcomes when compared with patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making regarding delay of surgery. These findings should be confirmed in a prospective study.

Survivorship and Outcome of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Performed With Modern Surgical Techniques

Background: Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly growing field in sports surgery; however, factors associated with poor outcomes and identification of predictor models of inferior clinical outcomes is unclear. Purpose: To analyze predictors of clinical failure and inferior clinical outcomes among patients undergoing hip arthroscopy for treatment of FAIS. Study Design: Case-control study; Level of evidence, 3. Methods: Data were collected and analyzed from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS from a single fellowship-trained surgeon between January 2012 and November 2015. Baseline data, postoperative patient-reported outcomes, and rates of clinical failure and inferior clinical outcomes were recorded at 2 years postoperatively. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Inferior clinical outcome was defined as not reaching the minimal clinically important difference (MCID) or patient acceptable symptomatic state for Hip Outcome Score–Activities of Daily Living. A multivariate logistic regression analysis was used to identify significant predictors of clinical failure and inferior clinical outcome. Results: Out of 1161 eligible patients, 935 (80.5%) completed 2-year postoperative patient-reported outcomes. The mean ± SD age and body mass index were 33.3 ± 12.3 years and 25.4 ± 8.2 kg/m2, respectively. The overall clinical failure rate was 3.6% (n = 34), including 23 cases (2.5%) of revision hip arthroscopy and 11 cases (1.2%) of conversion to total hip arthroplasty. Predictors of clinical failure were lower preoperative International Hip Outcome Tool score (P = .016), chronic preoperative pain (P = .001), and chondromalacia in the affected hip (P = .04). The inferior clinical outcome group, consisting of those who failed to reach the MCID for Hip Outcome Score–Activities of Daily Living, included 256 patients (27.4%). Predictors of inferior clinical outcomes were Tönnis grade >1 (P = .01), workers’ compensation (P < .001), and increased body mass index (P = .02). Conclusion: This study demonstrates that 73% of all patients treated for symptomatic FAIS with primary hip arthroscopy and routine capsular closure achieved the MCID. Clinical failure is predicted by a number of modifiable and nonmodifiable factors, including chronic preoperative pain and presence of chondromalacia. The current study updates the midterm failure rates and outcomes achievable with hip arthroscopy for FAIS.

Predictors of Persistent Postoperative Pain at Minimum Two-years After Arthroscopic Treatment of Femoroacetabular Impingement

Objectives: To evaluate predictors for persistent postoperative pain following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesized that patients with chronic preoperative pain, smokers, and those with co-morbid mental health disease would have greater persistent postoperative pain. Methods: Patients undergoing hip arthroscopy for FAIS were identified in a prospectively collected database with a minimum of two-year follow-up with patient reported outcomes (PROs). Previous open hip surgery and diagnoses other than FAIS were excluded. Patients were grouped by VAS-Pain scores as limited (≤30) and persistent (&gt;30). Patient factors and outcomes were analyzed with univariate and correlation analyses to build a logistic regression to identify predictors of postoperative pain. Results: The limited pain (n=514) and persistent pain (n=174) groups totaled 688 patients (449 females). The persistent pain group was significantly older with a greater proportion of revision arthroscopy, worker’s compensation cases, smokers, hypertension, a history of a psychiatric diagnosis and preoperative narcotic use. Both collegiate sport participation [odds ratio (OR) -6.09 (95% CI: -1.23--30.3, p=0.027) and frequent running (OR -1.75, 95% CI: -1.09--2.81; p=0.021) decreased risk for pain. Smokers were 2.22 times more likely to have persistent pain (p=0.032; 95% CI: 1.07-4.46). A history of anxiety and depression is associated with 2.87 greater risk for persistent pain (p=0.030; 95% CI: 1.11-7.45). Conclusion: Independent predictors for persistent postoperative pain include current smoking and mental health history positive for anxiety and depression. Running as a primary form of exercise and high-level athletic participation are protective against persistent pain. Additional risk factors for increased pain include increased age, workers’ compensation claim, previous comorbid disease treated with surgery, and decreased preoperative PROs. Our analysis demonstrated significant improvements in both pain and functional PROs in both the limited pain and persistent pain groups; however, those with persistent pain demonstrated significantly inferior PROs.

Preoperational chronic pain impairs the attention ability before surgery and recovery of attention and memory abilities after surgery in non-elderly patients.

PurposeThis study aimed to investigate the relationship of preoperative chronic pain and postoperative cognitive dysfunction (POCD) in non-elderly patients who underwent arthroscopic surgery.Materials and methodsThe pain intensity was estimated using visual analog scale, and the cognitive function was assessed by Syndrom Kurz Test. The effects of preoperative chronic pain on the cognitive scales were comparatively studied between the patients of observational group (OG, with chronic pain) and control group (CG, without chronic pain) pre- and postoperatively, and followed up for 3 months.ResultsA total of 57 non-elderly patients completed the study. Twenty-five patients (44%) with preoperative chronic pain were assigned to OG and 32 patients (56%) without chronic pain were assigned to CG. Preoperation chronic pain impaired the attention ability before surgery and caused less recovery of attention and memory abilities from 24 hours to 3 months after the surgery. Surgery procedures improved the attention and memory abilities and impaired the ability of numerical ability in CG patients. A postoperative pain relief in OG patients caused more recovery of cognition in addition to surgery procedure-mediated cognitive recovery. The incidence of POCD was ~3.5% and temporary at 24 hours after surgery, and disappeared at 2 weeks, 6 weeks and 3 months after the surgery.ConclusionThe incidence of POCD in non-elderly population who underwent arthroscopic surgery was low. Surgery improved the abilities of attention and memory, and impaired the ability of counting. The preoperative chronic pain distracted the attention before surgery, and reduced the recovery of attention and memory abilities during the follow-up period after the surgery in non-elderly patients.

Pre- and postoperative predictors of phantom limb pain

Phantom limb (PLP) as well as residual limb pain (RLP) are still a very significant problem after amputation and their causes are only partially known. Here we tested whether the predisposition for the frequency, duration and intensity of PLP and RLP is shared with other prior chronic pains and/or the presence of postamputation subacute pain. A week preoperatively we collected data using validated questionnaires, a pain diary and interviews on past chronic pain conditions, acute pain, depression, anxiety, pain interference, life control, social support and affective distress and pain ratings one day before the amputation in 52 patients scheduled for limb amputation. In the week postamputation and again three and 12 months thereafter, we collected data on postoperative wound pain, PLP, RLP and non-painful phantom sensation (PLS). Phantom and residual limb pain indices were calculated per patient, integrating the intensity, frequency and duration of past chronic pain, PLP, RLP and PLS into a single value to index the overall burden of pain. We report that acute and chronic pain long before but not on the day before the amputation and subacute pain postamputation significantly predicted up to half of the variance in the incidence and severity of PLP, RLP and PLS 12 months postamputation. Moreover, the severity of these painful sensations at 12 months postamputation was partially predicted by preamputation scores of depression and anxiety. These findings corroborate the hypothesis that chronic pain and non-painful sensations following limb amputation are strongly related to longstanding preoperative chronic pain and to subacute postoperative pain as well as to psychological factors before the amputation that may be inherited and/or acquired (learning- and memory-related). Furthermore, we also confirm that subacute pain postamputation comprises an additional risk factor for long-term painful sensations postamputation. Our results suggest that timely interventions might prevent the development of chronic pain.

C-reactive Protein Level on Postoperative Day One is Associated with Chronic Postsurgical Pain After Mastectomy.

BackgroundC-reactive protein (CRP) is an acute phase reactant released in response to inflammation or tissue injury. Inflammation is one of the pathogenic factors related to transition from acute postsurgical pain (APSP) to chronic postsurgical pain (CPSP). Although several risk factors are reportedly associated with CPSP, the effects of CRP levels on CPSP have not been examined.ObjectivesThe present study investigated the relationship between perioperative risk factors, including CRP levels on postoperative day one and CPSP, in patients undergoing mastectomy.MethodsPreoperative anxiety and depression levels were evaluated in female patients undergoing mastectomy under general anesthesia, with or without peripheral nerve block. Patients with chronic preoperative pain and/or preoperative breast pain were excluded. The intensity of postoperative pain was prospectively examined one and six days, and three and twelve months after surgery using a numerical rating scale (NRS).ResultsThe current researchers conducted univariate and multivariate linear regression analyses to explore risk factors for CPSP in 36 patients. Patient demographics, preoperative psychological states, and anesthetic managements showed no relationship with CPSP. On the other hand, pain intensity of APSP and CRP levels on postoperative day one was significantly associated with the pain intensity of CPSP.ConclusionsPostoperative CRP level is likely to be associated with the development of CPSP after mastectomy.

Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 270. Comparing posterior approach lumbar and neck surgery with and without multimodal methadone

Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 270. Comparing posterior approach lumbar and neck surgery with and without multimodal methadone

POSTOPERATIVE CHRONIC PAIN FOLLOWING MESH AND NON-MESH REPAIR OF PELPIC ORGAN PROLAPSE

(Objective) A FDA alert in 2011 warned about postoperative chronic pain following transvaginal mesh (TVM) for pelvic organ prolapse (POP). We studied cases with chronic pain after TVM, natural tissue repair (NTR) and laparoscopic salcocopopexy (LSC). (Methods) We retrospectively reviewed medical charts of patients who underwent POP operations in our hospital or were referred to us after POP operations in other hospitals between 2006 and 2016. Postoperative chronic pain was defined as persistent pain for more than three months following the first three months from the time of POP operations.Patients' characteristics and treatments were analyzed. (Results) In patients who underwent POP operations in our hospital, the rates of chronic postoperative pain after TVM, NTR and LSC were 12/2,457 (0.49%), 1/402 (0.26%) and 0/29 (0%), respectively. Another 8 patients were referred to us after POP operations in other hospitals. Thus, a total of 21 patients (15: TVM, 6: NTR) had either medications, surgical treatment or were referred to other doctors due to postoperative chronic pain. All of them were parous women aged 53 to 81 years old. Preoperative chronic pelvic pain was found in seven patients (33%), and another four patients (19%) had orthopedic diseases with chronic pain. The main locations of pain were; vagina 11, vulva 2, urinary bladder 2, urethra 1, coccyx 1, buttocks 1, anus 1, perineum 1 and groin 1. Nineteen patients had pharmacological treatment using tricyclic antidepressants, Ca2+ channel α2δ ligand and/or serotonin-noradrenalin reuptake inhibitor (SNRI); 9 (47%) of the patients showed a notable improvement. Three patients following TVM had surgical treatment; one with bladder mesh exposure was resolved with TURis, one with vaginal mesh exposure was resolved with mesh trimming, but one with tenderness on the mesh arm did not improve after a partial mesh removal. Four patients were referred to pain clinics. (Conclusions) Postoperative chronic pain can occur following both TVM and NTR therefore, attentive listening and proper medication are important as initial therapies. It is mandatory to examine the presence of mesh exposure in patients after using mesh. We should be careful about preoperative chronic pain, pelvic or elsewhere, as a risk factor for postoperative chronic pain.

Postoperative cognitive dysfunction in non-elderly patients with or without chronic pain

Objective Postoperative cognitive dysfunction (POCD) is a common complication with advanced age, perioperative pain and major surgery as risk factors. However, whether pre-operative long-term pain can influence postoperative cognitive status in non-geriatric population is unclear. This study aimed to investigate the relationship of preoperative chronic pain and POCD in non-elderly patients who underwent arthroscopic surgery. Methods An observational longitudinal cohort study of POCD was conducted in patients aged 18 to 59 years who underwent arthroscopic surgery in Huashan Hospital (Shanghai, China) between January 2016 and December 2016. Pain intensity was estimated by visual analog scale (VAS), cognitive function was assessed by Syndrom Kurz Test (SKT) and compared between observational group (OG, with chronic pain) and control group (CG, without chronic pain) pre- and post-operatively. Follow-up evaluations were conducted within 24 h, 2 weeks, 6 weeks and 3 months after surgery. Results Fifty-seven patients completed the follow-up. Twenty-five patients (44%) had preoperative chronic pain and 32 patients (56%) did not. OG patients had a worse performance of SKT than CG before surgery (P=0.010, 0.025, 0.010). Throughout the follow-up period, OG had lower scores than CG. OG patients had a pain relief postoperatively (P=0.001). Both OG and CG had an SKT score improvement. The incidence of POCD between two groups was similar at 24 h after surgery (4% vs. 3%). The incidence of POCD with or without chronic pain at follow-up point was 0. Conclusion The incidence of POCD in non-elderly population who underwent arthroscopic surgery was low. Preoperative chronic pain won’t deteriorate postoperative cognitive impairment, but pain diminishment can lead to cognitive function improvement. Key words: Postoperative cognitive dysfunction; Chronic pain; Non-elderly population

Interleukin-6 and leptin levels are associated with preoperative pain severity in patients with osteoarthritis but not with acute pain after total knee arthroplasty

BackgroundIdentifying drivers of pain that can serve as novel drug targets is important for improving perioperative analgesia. Total knee arthroplasty (TKA) is associated with significant postoperative pain. Cytokines contribute to the pathophysiology of osteoarthritis (OA) and associated pain. However, the influence of perioperative cytokine levels after TKA surgery upon postoperative pain remains unexplored. MethodsWe designed a prospective observational study to profile three proinflammatory cytokines, interleukin-6 (IL-6), tumor necrosis factor α (TNFα), and leptin in serum, synovial, and cerebrospinal fluid of TKA patients perioperatively to determine associations between cytokine levels and pain. We characterized time-trajectories in cytokines pre- and post-surgery and explored their relationships to pain across gender. ResultsPreoperative pain, measured by functional pain disability scores (PDQ), was predictive of postoperative pain. There were no gender differences in severity of preoperative pain or acute postoperative pain. Serum IL-6, serum leptin, and synovial fluid leptin were positively correlated with body mass index and preoperative pain severity. Stratification of patients by gender revealed strong correlations between serum IL-6, leptin, and PDQ only in females, suggesting that females may be more sensitive to the nociceptive actions of these cytokines. Although serum IL-6 increased dramatically (and TNFα increased modestly) four hours after surgery and remained elevated at 72h; they were not associated with the severity of acute postoperative pain. ConclusionsOur data suggest that while preoperative chronic pain is predictive of the severity of acute postoperative pain in TKA patients, the pre- and post-operative inflammatory status does not predict postoperative pain.

59 - Outcome of Fusion vs Nonoperative Care in Degenerative Lumbar Scoliosis in Relation to Preoperative Chronic Pain Pattern and Disability: a Registry Study of 6796 Patients

BACKGROUND CONTEXT: Patients with degenerative lumbar scoliosis (DS) and predominant back pain (PBP) have been shown to have an inferior outcome after surgery. Studies comparing outcome according to preoperative pain predominance and treatment received are lacking.

Age and preoperative pain are major confounders for sex differences in postoperative pain outcome: A prospective database analysis.

ObjectivesCurrent literature is in disagreement regarding female sex as a risk factor for pain after surgery. We hypothesized, that sex differences exist but that they are influenced by certain factors. Here, we investigated the influence of sex for different clinically relevant postoperative pain (POP) outcome parameters and evaluated the role of assumed confounders for sex differences.MethodsFrom 1372 screened patients undergoing orthopedic surgery at the university hospital of Muenster between March 2010 and June 2011, 890 patients were included. The validated International Pain Outcomes questionnaire was used to assess the role of sex for several aspects of POP including pain severity, physical and emotional functional interference as well as the patient’s perceptions of the care they received on the first day after surgery. Assessed confounders were age, preoperative chronic pain, anesthetic technique employed and surgical procedure. All statistical analyses were performed with SPSS Statistics Software 22.ResultsLinear regression analysis demonstrated that sex was a statistically significant risk factor for “worst pain since surgery”. Additionally, significant sex differences in “time spent in severe pain”, “feeling anxious due to pain”, “feeling helpless due to pain” and “opioid consumption since surgery” could be identified. An univariate general linear model showed that “age” and “preoperative pain” were significant confounders for sex differences. Further descriptive subgroup analysis revealed consistent sex differences for several POP outcome variables especially in patients older than 50 years or patients with preoperative chronic pain. However, sex differences disappeared in younger patients and in patients without preoperative pain.DiscussionOur data confirmed that sex differences exist in pain intensity and frequency, pain interference with feelings and opioid consumption during the first 24 hours postoperatively. However, sex differences were significantly influenced by the factors “age” and “preoperative pain”. These findings may in part explain why clinical studies get different results related to sex differences and renders specific awareness in older women and female patients with preoperative chronic pain.

Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service.

To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital. 200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery. 51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood. Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.

Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement.

Despite the development of multimodal analgesia for postoperative pain management, opioids are still required for effective pain relief after knee arthroplasty. We aimed to identify the determinants of post-operative pain intensity and post-operative opioid requirement in this context. In this observational prospective study, we recorded patient characteristics, pre-operative pain intensity, anxiety and depression levels, sensitivity and pain thresholds in response to an electrical stimulus, and mu-opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) single-nucleotide polymorphisms. Multivariate linear regression models were used to identify predictors of post-operative pain at rest and opioid requirement. We included 109 patients. Pre-operative pain at rest (p=0.047), anxiety level (p=0.001) and neuropathic pain symptoms (p=0.030) were independently and positively associated with mean post-operative pain intensity adjusted for mean post-operative morphine equivalent dose (MED). Mean post-operative pain intensity at rest was lower (p=0.006) in patients receiving celecoxib and pregabalin in the post-operative period, with all other variables constant. Mean post-operative MED over 5days was low, but highly variable (78.2±32.1mg, from 9.9 to 170mg). Following adjustment for mean post-operative pain intensity, it was independently negatively correlated with age (p=0.004), and positively correlated with associated paracetamol treatment (p=0.031). No genetic effect was detected in our sample. Our findings suggest that clinicians could use the pre-operative pain profile, in terms of anxiety levels, neuropathic pain symptoms, and chronic pre-operative pain intensity, to improve the efficacy of pain management after knee surgery.

Chronic postsurgical pain in Europe: An observational study.

Chronic postsurgical pain (CPSP) is an important clinical problem. Prospective studies of the incidence, characteristics and risk factors of CPSP are needed. The objective of this study is to evaluate the incidence and risk factors of CPSP. A multicentre, prospective, observational trial. Twenty-one hospitals in 11 European countries. Three thousand one hundred and twenty patients undergoing surgery and enrolled in the European registry PAIN OUT. Pain-related outcome was evaluated on the first postoperative day (D1) using a standardised pain outcome questionnaire. Review at 6 and 12 months via e-mail or telephonic interview used the Brief Pain Inventory (BPI) and the DN4 (Douleur Neuropathique four questions). Primary endpoint was the incidence of moderate to severe CPSP (numeric rating scale, NRS ≥3/10) at 12 months. For 1044 and 889 patients, complete data were available at 6 and 12 months. At 12 months, the incidence of moderate to severe CPSP was 11.8% (95% CI 9.7 to 13.9) and of severe pain (NRS ≥6) 2.2% (95% CI 1.2 to 3.3). Signs of neuropathic pain were recorded in 35.4% (95% CI 23.9 to 48.3) and 57.1% (95% CI 30.7 to 83.4) of patients with moderate and severe CPSP, respectively. Functional impairment (BPI) at 6 and 12 months increased with the severity of CPSP (P < 0.01) and presence of neuropathic characteristics (P < 0.001). Multivariate analysis identified orthopaedic surgery, preoperative chronic pain and percentage of time in severe pain on D1 as risk factors. A 10% increase in percentage of time in severe pain was associated with a 30% increase of CPSP incidence at 12 months. The collection of data on CPSP was feasible within the European registry PAIN OUT. The incidence of moderate to severe CPSP at 12 months was 11.8%. Functional impairment was associated with CPSP severity and neuropathic characteristics. Risk factors for CPSP in the present study were chronic preoperative pain, orthopaedic surgery and percentage of time in severe pain on D1. Clinicaltrials.gov identifier: NCT01467102.

Pain on the first postoperative day after head and neck cancer surgery.

Postoperative pain within the first 24 h after head and neck cancer (HNC) surgery was assessed. Factors influencing postoperative pain were identified. In a prospective cohort single center study 145 HNC patients rated their pain on the first postoperative day using questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including numeric rating scales (NRS, 0-10) for the determination of patient's pain on ambulation, his maximal and minimal pain. QUIPS allowed a standardized assessment of patients' characteristics and pain-related parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistical analysis. One-third had already pain prior to the surgical intervention. Overall, the mean pain on ambulation, maximal pain and minimal pain were 2.55 ± 2.36, 3.18 ± 2.86, and 1.38 ± 2.86 (NRS), respectively. 53 % of the patients had maximal pain scores >3. Multivariate analysis revealed independent predictors for more postoperative pain on ambulation: intensity of chronic preoperative pain, usage of non-opioids on ward, and existence of pain documentation on ward. Intensity of chronic preoperative pain and usage of non-opioids on ward were independent risk factors for more maximal pain. Intensity of chronic preoperative pain was independently associated to more minimal pain. Concerning pain management side effects, the risk for drowsiness increased with longer time of surgery. Postoperative pain after HNC surgery is highly variable and seems often to be unnecessarily high. Many patients seem to receive less analgesia than needed or ineffective analgesic drug regimes.