The Influence of Type of Anesthesia, Perioperative Pain, and Preoperative Health Status on Chronic Pain Six Months After Thoracotomy-A Prospective Cohort Study.

BACKGROUND: Chronic post-thoracotomy pain (CPP) has a high incidence. However, less is known about risk factors and the influence of different analgesia therapies. METHODS: In this prospective cohort study, patients either received standardized epidural analgesia or began an oral analgesic protocol with controlled-release oxycodone immediately postoperatively. Patients answered a baseline questionnaire on the day before surgery and a follow-up questionnaire six months postoperatively. The questionnaire included Short-Form 12, the Neuropathic Pain Scale, and descriptive questions for CPP. Pain protocols of all patients were examined. Logistic regression was used to analyze the risk factors related to CPP. RESULTS: One hundred seventy-four patients were enrolled; data of 131 patients were available after the six-month follow-up period. Fifty-one patients (39%) had CPP six months postoperatively. Of these, more than 80% had impaired daily activity or ability to work, or reported sleeping disturbance due to CPP. The strongest predictive factors for the development of CPP were: thoracic pain for three months preoperatively (odds ratio [OR] = 3.54, 95% confidence interval [CI] = 1.69-7.40, P = 0.001), thoracic pain for 12 months preoperatively (OR = 2.73, 95% CI = 1.28-5.83, P = 0.009), and higher pain scores at rest in the first five postoperative days compared with patients without CPP (OR = 1.79, 95% CI = 1.24-2.57, P = 0.002). Neuropathic pain was present in 4.8% of patients. Patients with CPP had a reduced physical (P = 0.005) and mental health status (P = 0.03) six months after surgery compared with patients without CPP. CONCLUSIONS: Preoperative thoracic pain and higher pain scores in the first five postoperative days seem to be the strongest risk factors for the development of CPP. CPP patients reported poorer mental and physical health before and six months after surgery.

Correlates of satisfaction with pain treatment in the acute postoperative period: results from the international PAIN OUT registry.

Patient ratings of satisfaction with their postoperative pain treatment tend to be high even in those with substantial pain. Determinants are poorly understood and have not previously been studied in large-scale, international datasets. PAIN OUT, a European Union-funded acute pain registry and research project, collects patient-reported outcome data on postoperative day 1 using the self-reported International Pain Outcome Questionnaire (IPO), and patient, clinical, and treatment characteristics. We investigated correlates of satisfaction and consistency of effects across centres and countries using multilevel regression modelling. Our sample comprised 16,868 patients (median age 55 years; 55% female) from 42 centres in 11 European countries plus Israel, USA, and Malaysia, who underwent a wide range of surgical procedures, for example, joint, limb, and digestive tract surgeries. Median satisfaction was 9 (interquartile range 7-10) on a 0-10 scale. Three IPO items showed strong associations and explained 35% of the variability present in the satisfaction variable: more pain relief received, higher allowed participation in pain treatment decisions, and no desire to have received more pain treatment. Patient factors and additional IPO items reflecting pain experience (eg, worst pain intensity), pain-related impairment, and information on pain treatment added little explanatory value, partially due to covariate correlations. Effects were highly consistent across centres and countries. We conclude that satisfaction with postoperative pain treatment is associated with the patients' actual pain experience, but more strongly with impressions of improvement and appropriateness of care. To the degree they desire, patients should be provided with information and involved in pain treatment decisions.

Procedure-specific risk factor analysis for the development of severe postoperative pain.

BACKGROUND: Many studies have analyzed risk factors for the development of severe postoperative pain with contradictory results. To date, the association of risk factors with postoperative pain intensity among different surgical procedures has not been studied and compared. METHODS: The authors selected precisely defined surgical groups (at least 150 patients each) from prospectively collected perioperative data from 105 German hospitals (2004-2010). The association of age, sex, and preoperative chronic pain intensity with worst postoperative pain intensity was studied with multiple linear and logistic regression analyses. Pooled data of the selected surgeries were studied with random-effect analysis. RESULTS: Thirty surgical procedures with a total number of 22,963 patients were compared. In each surgical procedure, preoperative chronic pain intensity and younger age were associated with higher postoperative pain intensity. A linear decline of postoperative pain with age was found. Females reported more severe pain in 21 of 23 surgeries. Analysis of pooled surgical groups indicated that postoperative pain decreased by 0.28 points (95% CI, 0.26 to 0.31) on the numeric rating scale (0 to 10) per decade age increase and postoperative pain increased by 0.14 points (95% CI, 0.13 to 0.15) for each higher score on the preoperative chronic pain scale. Females reported 0.29 points (95% CI, 0.22 to 0.37) higher pain intensity. CONCLUSIONS: Independent of the type and extent of surgery, preoperative chronic pain and younger age were associated with higher postoperative pain. Females consistently reported slightly higher pain scores regardless of the type of surgery. The clinical significance of this small sex difference has to be analyzed in future studies.

Patients' perception of postoperative pain management: validation of the International Pain Outcomes (IPO) questionnaire.

UNLABELLED: PAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire-the International Pain Outcomes questionnaire-that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbach's alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbach's alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53-.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory. PERSPECTIVE: The International Pain Outcomes questionnaire provides an instrument for postoperative pain assessment and improvement of quality of care, which demonstrated good psychometric quality when translated into a variety of languages in a large European and Israeli patient population. This measure provides the basis for the first comprehensive postoperative pain registry in Europe and other countries.

Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures.

BACKGROUND: Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified. METHODS: This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared. RESULTS: The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia. CONCLUSIONS: Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.

Preoperative chronic pain in radical prostatectomy patients: preliminary evidence for enhanced susceptibility to surgically induced pain.

BACKGROUND AND OBJECTIVE: The aim of the study was to examine a possible relationship between the extent of preoperative chronic pain and the development of moderate-to-severe acute postoperative pain. METHODS: Eighty-four patients scheduled for radical prostatectomy were studied. Pain intensities after mobilization during the first 3 postoperative days were added to yield a total pain score (total pain score after mobilization, range 0-30). Pain was considered as moderate to severe at a total pain score after mobilization of 12 or higher. The preoperative severity of chronic pain disorders was measured using the Mainz Pain Staging System (I-III). Further possible preoperative risk factors for the development of intense postoperative pain that were examined included pain intensity, pain in the urological site, psychological distress (Hospital Anxiety and Depression Scale) and health-related quality of life (Short Form-12). RESULTS: Patients with moderate-to-severe preoperative chronic pain and those with higher Mainz Pain Staging System stages were significantly (P < 0.001) more likely to develop moderate-to-severe postoperative pain. Anxiety and depression scores as well as physical health (Short Form-12) were significantly associated with a total pain score after mobilization of at least 12. The development of postoperative pain was independent of the presence of preoperative pain in the urological site. CONCLUSION: This study demonstrated that higher degrees of preoperative chronic pain were associated with the development of more intense pain after radical prostatectomy. Preoperative psychological distress and reduced physical health were associated with a marked increase in postoperative pain intensity.

Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy.

BACKGROUND: Chronic post-surgical pain (CPSP) by definition develops for the first time after surgery and is not related to any preoperative pain. Preoperative pain is assumed to be a major risk factor for CPSP. Prospective studies to endorse this assumption are missing. METHODS: In order to assess the incidence and the risk factors for CPSP multidimensional pain and health characteristics and psychological aspects were studied in patients prior to radical prostatectomy. Follow-up questionnaires were completed three and six months after surgery. RESULTS: CPSP incidences in 84 patients after three and six months were 14.3% and 1.2%. Preoperatively, CPSP patients were assigned to higher pain chronicity stages measured with the Mainz Pain Staging System (MPSS) (p=0.003) and higher pain severity grades (Chronic Pain Grading Questionnaire) (p=0.016) than non-CPSP patients. CPSP patients reported more pain sites (p=0.001), frequent pain in urological body areas (p=0.047), previous occurrence of CPSP (p=0.008), more psychosomatic symptoms (Symptom Check List) (p=0.031), and worse mental functioning (Short Form-12) (p=0.019). Three months after surgery all CPSP patients suffered from moderate to high-risk chronic pain (MPSS stages II and III) compared to 66.7% at baseline and 82.3% had high disability pain (CPGQ grades III and IV) compared to 41.7% before surgery. CPSP patients scored significantly less favorably in physical and mental health, habitual well-being, and psychosomatic dysfunction three months after surgery. CONCLUSIONS: All patients with CPSP reported on preoperative chronic pain. Patients with preoperative pain, related or not related to the surgical site were significantly at risk to develop CPSP. High preoperative pain chronicity stages and pain severity grades were associated with CPSP. CPSP patients reported poorer mental health related quality of life and more severe psychosomatic dysfunction before and 3 months after surgery.

Risk factors for acute and chronic postoperative pain in patients with benign and malignant renal disease after nephrectomy.

AIMS: This longitudinal study was performed in order to analyze the incidence of and perioperative risk factors for the development of chronic postsurgical pain (CPSP) in patients after nephrectomy. METHODS: For baseline data acquisition, valid instruments were used for scoring sociodemographic, psychological, psychosocial, pain, pain treatment, and comorbidity factors: the Mainz Pain Staging System (MPSS) for pain chronicity, the Chronic Pain Grading Questionnaire (CPGQ), the Neuropathic Pain Scale (NPS), the Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF-12) for health-related quality of life, the Habitual Well-Being Questionnaire (HWBQ), the Symptom Check List (SCL-8) for detecting psychosomatic dysfunction, and the Weighted Illness Check List (WICL) for evaluation of comorbidities and their impact on activities of daily living. Pain intensities were recorded over the first 6 postoperative days after nephrectomy. A sample of 35 patients was followed up for 3 and 6 months. RESULTS: Patients with more intense postoperative pain during the first 6 days had significantly higher preoperative anxiety scores. The incidence of CPSP 3 and 6 months after nephrectomy was 28.6% and 8.6%, respectively. Preoperatively increased anxiety scores, reduced physical health-related quality of life (SF-12), multiple comorbid conditions, and increased comorbidity-related disability were significantly associated with the occurrence of CPSP after 3 months. These patients also reported more severe pain during the first week after surgery. Preoperative "current pain intensity" was significantly increased in CPSP patients. CONCLUSIONS: Our results demonstrate a multifactorial development of CPSP. This process may contribute not only to the occurrence of chronic postsurgical pain but also to the biopsychosocial impairment in these patients as often seen in other chronic pain populations.

Prevalence, severity, and chronicity of pain and general health-related quality of life in patients with localized prostate cancer.

AIMS: To analyze the prevalence and the severity spectrum of pain and its relationships to health-related quality of life and the bio-psycho-social consequences of pain among patients scheduled for radical prostatectomy. METHODS: Urological inpatients completed an epidemiological pain questionnaire extensively exploring pre-operative acute and chronic pains in 21 body regions. The severity of pain was determined using von Korff's Pain Grading (CPGQ). Pain chronicity was estimated employing the Mainz Pain Staging System (MPSS). Anxiety and depressive symptoms were identified with the HADS and the Habitual Well-Being Questionnaire (FW-7). Health-related quality of life was measured using the SF-12. Comorbidities and comorbidity-related interferences with daily activities were ascertained with the Weighted Illness Checklist (WICL). RESULTS: Eighty of 115 patients (69.6%) reported about pain during the last 3 months pre-operatively. 28.7% of the pain patients had pain related to urological disease. Severe dysfunctional pain was identified by pain Grades 3 and 4 of the CPGQ in 20% and 13.8%, respectively. Advanced pain chronicity characterized by pain Stages II and III of the MPSS was present in 38.8% and 11.3%. Patients with localized prostate cancer without pain complaints had significantly better health-related quality of life and habitual well-being and lower anxiety and depression scores and fewer comorbidities. Patients with cancer-related and non-cancer pain did not differ in pain chronicity, pain severity, pain intensities, anxiety, comorbidities and physical health (SF12-PCS). CONCLUSIONS: The high prevalence of severe and chronic pain in cancer patients before scheduled radical prostatectomy--combined with considerable disability effects and markedly reduced quality of life necessitate a short routine screening-analysis of the severity spectrum of pain and psychopathology. Patient self-rated pain chronicity staging and psychological distress analysis will allow a disorder severity-guided treatment and the prevention of suffering and additional new chronic post-surgical pain.

Assessing cognitive and psychomotor performance under long-term treatment with transdermal buprenorphine in chronic noncancer pain patients.

BACKGROUND: The therapeutic use of opioids has been associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but there are no data about the effect of long-term treatment with transdermal buprenorphine on driving ability. METHODS: Thirty patients suffering from chronic noncancer pain, who had been treated with stable doses of transdermal buprenorphine, included in a prospective trial and compared with 90 healthy volunteers (matched pairs). A computerized test battery, developed to assess the driving ability of traffic delinquents in Germany, was used. Attention reaction, visual orientation, motor coordination, and vigilance were evaluated. The data from 14 variables were assessed, and for each test, a relevant score was defined. As the primary end-point, the sum score of the three relevant scores was determined. A weaker statistical means to assess the patient's performance is to compare the test results to an age-independent control group. Individuals performing worse than the 16th percentile of this control group are considered to be unable to drive according to German law. RESULTS: According to tests that predict driving ability, patients receiving transdermal buprenorphine were shown to be noninferior to the control group. Driving ability, as defined as a result above the 16th percentile, did not differ significantly between the patients and the control group. CONCLUSION: Long-term use of transdermal buprenorphine for chronic noncancer pain does not impair driving ability, but because of the individual variability of test results, an individual assessment is recommended.