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Chronic pain after surgery


What is chron­ic post-sur­gi­cal pain? How com­mon is it? How is it treat­ed? Pro­fes­sor Julie Bruce & Pro­fes­sor Stephan Schug explain

What is chron­ic post-sur­gi­cal pain?

Let’s start with some def­i­n­i­tions – acute post­op­er­a­tive pain is the pain expe­ri­enced imme­di­ate­ly after an oper­a­tion, usu­al­ly last­ing for days or some­times weeks – this is entire­ly nor­mal and expect­ed. The sur­gi­cal inci­sion and sur­round­ing area can be inflamed and ten­der – again this is fair­ly nor­mal and is impor­tant for wound heal­ing, where tis­sues and mus­cles repair them­selves after injury.

Chron­ic pain is nor­mal­ly con­sid­ered to be pain that per­sists or keeps com­ing back for more than three months or for longer than the expect­ed heal­ing time. Chron­ic pain that devel­ops after an oper­a­tion is often known as ‘chron­ic or per­sis­tent post-sur­gi­cal pain’.

Know­ing when pain becomes chron­ic after surgery is espe­cial­ly dif­fi­cult because many peo­ple have had their surgery to treat a painful con­di­tion, such as a painful her­nia or a long-stand­ing back prob­lem. Is the pain sim­ply a con­tin­u­a­tion of the old pain, or is it new? And, even if it is new, is it relat­ed to the surgery?

Some­times it is obvi­ous that some­thing has changed – nerve dam­age after an oper­a­tion for her­nia repair can be quite dif­fer­ent from the dis­com­fort felt before the oper­a­tion. Anoth­er exam­ple is per­sis­tent tin­gling nerve pain in the chest wall after heart bypass surgery, which is very dif­fer­ent from angi­na pain expe­ri­enced before heart surgery.

Some­times it is very dif­fi­cult to tell the pains apart, espe­cial­ly if the orig­i­nal pain (that the oper­a­tion was done to treat) was not in fact helped by the surgery. How­ev­er, these are the fea­tures that can allow doc­tors to tell if you have chron­ic post-sur­gi­cal pain:

  • The pain devel­ops after a sur­gi­cal operation
  • The pain lasts for at least three months after the operation
  • Your pain is not thought to be from oth­er caus­es, such as an infec­tion or cancer
  • Your pain is not the same as the pain from the orig­i­nal condition.

Sur­gi­cal fol­low-up can be lim­it­ed to one post­op­er­a­tive appoint­ment, thus a fol­low-up clin­ic at approx­i­mate­ly 8 weeks, to deter­mine sur­gi­cal ‘suc­cess’. Patients are then dis­charged and man­aged by the pri­ma­ry care team.

What type of pain is it?

The type of pain can depend on the oper­a­tion itself, because the painful symp­toms often relate to the dis­tri­b­u­tion of nerves in the area of the oper­a­tion. For exam­ple, after groin her­nia repair surgery, peo­ple have report­ed pain down the front and inside of the thigh, or in the tes­ti­cles. This may relate to poten­tial irri­ta­tion of nerves in the groin dur­ing sur­gi­cal repair of the hernia.

We now under­stand more about nerve pain or ‘neu­ro­path­ic pain’ which can arise from nerve injury. Typ­i­cal char­ac­ter­is­tics and descrip­tions of neu­ro­path­ic pain include stab­bing, tin­gling, numb­ness, altered sen­sa­tions and prob­lems with sen­si­tiv­i­ty. It is not always pos­si­ble to avoid nerve dam­age dur­ing an oper­a­tion, espe­cial­ly dur­ing can­cer surgery when removal of the tumour takes priority.

Treat­ment of chron­ic post-sur­gi­cal pain

Treat­ment does not depend upon what sort of surgery you have had but rather on the mech­a­nism that results in you hav­ing the per­sis­tent pain. For exam­ple, not every­one who suf­fers pain fol­low­ing a mas­tec­to­my will have the same ‘type’ of pain or for the same under­ly­ing rea­son. The treat­ment will depend on the char­ac­ter­is­tics of the pain and also the pos­si­ble rea­son for the pain devel­op­ing and not on the fact that the sur­gi­cal oper­a­tion hap­pened to be a mastectomy.

It is impor­tant that the health­care pro­fes­sion­al lis­tens to your sto­ry, per­forms a thor­ough exam­i­na­tion and allows you to give a full expla­na­tion of your symp­toms. The health­care pro­fes­sion­al then gains an under­stand­ing of the prob­lem and the impact the pain has on your dai­ly life. Patients often report find­ing this approach help­ful in itself. Often they feel that, in the past, their symp­toms have been dis­missed and not tak­en seri­ous­ly. Some­times, peo­ple have been told that the pain will go away soon after the oper­a­tion and this caus­es mis­trust and resentment.

The best treat­ment for the pain will depend upon the mech­a­nism caus­ing it. Treat­ments include: tri­cyclic anti­de­pres­sants, anti­con­vul­sants, painkillers, TENS (tran­scu­ta­neous elec­tri­cal nerve stim­u­la­tion) and injec­tions. Based on our clin­i­cal expe­ri­ence, nerve destruc­tion (periph­er­al nerve abla­tion) should not be used in the man­age­ment of chron­ic post-sur­gi­cal pain.

It is not always pos­si­ble to con­trol the pain and oth­er symp­toms ade­quate­ly. In such cas­es, a psy­chol­o­gy-based pain man­age­ment approach or phys­io­ther­a­py sup­port can help you to cope with your symp­toms and reduce the impact on your dai­ly life.

How com­mon is it?

A sur­vey asked over 5,000 patients attend­ing pain clin­ics across Scot­land and the north of Eng­land car­ried out in the late 1990s about their rea­sons for atten­dance. Twen­ty per cent of patients thought that surgery was one of the caus­es of their pain and, of these patients, half thought it was the only cause. Until this report was pub­lished, chron­ic pain after surgery was thought to be rare. This is pos­si­bly because few patients were asked about per­sis­tent pain after their operation.

On aver­age about 30 per cent of patients expe­ri­ence chron­ic pain after surgery, although this ranges from those with mild symp­toms to those with more severe pain. Over­all, only about five per cent of peo­ple report severe inten­si­ty pain, but five per cent is a sig­nif­i­cant num­ber when you con­sid­er the huge num­ber of oper­a­tions con­duct­ed across the UK and globally.

Are there risk factors?

We are begin­ning to under­stand more about risk fac­tors for chron­ic post-sur­gi­cal pain. As well as the impact on qual­i­ty of life for those affect­ed, chron­ic pain is dif­fi­cult and cost­ly to treat, so under­stand­ing more about who is at risk of devel­op­ing chron­ic pain after surgery is impor­tant as it may help in pre­vent­ing the condition.

Cer­tain groups of patients may be more at risk from pain after surgery than oth­ers. Women are more like­ly to expe­ri­ence chron­ic pain than men, although this is not always the case after surgery. Stud­ies sug­gest women are more like­ly to report more severe acute post­op­er­a­tive pain, but the evi­dence for chron­ic pain is less certain.

Younger patients do seem to be at greater risk of chron­ic post-sur­gi­cal pain than old­er patients – this has been found after many dif­fer­ent oper­a­tions. This find­ing might be explained by the fact that younger peo­ple are often more active and are work­ing, thus hav­ing per­sis­tent pain could have a greater impact on their dai­ly life com­pared to old­er peo­ple who are often less active. Or it may relate to nerve and tis­sue changes (how we react to pain) as we age.

Peo­ple with oth­er chron­ic pains are at greater risk of devel­op­ing chron­ic pain after surgery. This may include patients who suf­fer from such con­di­tions as chron­ic low back pain, Raynaud’s dis­ease, irri­ta­ble bow­el syn­drome, migraine, fibromyal­gia and oth­er con­di­tions. Changes in the ner­vous sys­tem may well lie behind many of these con­di­tions. There is grow­ing research on the genet­ics of pain, sug­gest­ing that some patients may be more sus­cep­ti­ble to pain con­di­tions than others.

Patients who are more anx­ious and wor­ried about their oper­a­tion are at greater risk of acute and chron­ic post­op­er­a­tive pain – so exces­sive wor­ry and anx­i­ety is a risk fac­tor. Pre­op­er­a­tive prepa­ra­tion is vital; for exam­ple, a clear expla­na­tion about the oper­a­tion and recov­ery process set­ting out the risks and ben­e­fits is an essen­tial part of sur­gi­cal treat­ment. Many hos­pi­tals run pre­op­er­a­tive clin­ics where­by patients attend for tests in advance of their oper­a­tion. This is an oppor­tu­ni­ty for care­ful expla­na­tion and dis­cus­sion between the patient and health care team.

Final­ly, one of the strongest and most con­sis­tent risk fac­tors for post-sur­gi­cal pain is the sever­i­ty of acute post­op­er­a­tive pain in the days and weeks after an oper­a­tion. Treat­ment and ade­quate con­trol of acute pain imme­di­ate­ly after surgery is very impor­tant and may ‘damp­en’ the pain response, pre­vent­ing longer term symptoms.

More aware­ness needed

It is clear that chron­ic post-sur­gi­cal pain is com­mon, can be severe and may result in dis­tress and dis­abil­i­ty for patients. Look­ing at the whole spec­trum of chron­ic pain con­di­tions after surgery, it is very unlike­ly that the cause of the pain is some­thing that the sur­geon has done wrong. It seems more like­ly that this is the inevitable result of surgery in a cer­tain per­cent­age of patients – approx­i­mate­ly 30 per cent of patients expe­ri­ence chron­ic post-sur­gi­cal pain of vary­ing sever­i­ty in the first year after an operation.

If it were more wide­ly accept­ed that chron­ic pain can arise after surgery, some patients might decide against hav­ing oper­a­tions that aren’t entire­ly nec­es­sary. Sur­geons, who are undoubt­ed­ly try­ing to do the best for their patients, would also be reas­sured that pain is prob­a­bly not the result of sur­gi­cal error. Anoth­er ben­e­fit is that patients would have their pain acknowl­edged and would be treat­ed more sympathetically.

Over the last 30 years, there has been a huge increase in med­ical research inves­ti­gat­ing the char­ac­ter­is­tics and poten­tial caus­es of chron­ic pain after surgery – this has helped raise aware­ness amongst health­care pro­fes­sion­als and patients alike. There is still, how­ev­er, much more work to be done to improve our abil­i­ty to pre­vent peo­ple from devel­op­ing chron­ic pain after surgery and to make sure every­one affect­ed by this all too com­mon con­di­tion receives swift diag­no­sis and treatment.

Final­ly, let’s look at some exam­ples of dif­fer­ent operations…

Pain after her­nia surgery

Inguinal (groin) her­nia is a com­mon con­di­tion with an inci­dence of six per cent to 12 per cent in adult males. It affects men more often that women. The con­di­tion presents as a lump in the groin, due to a pro­tru­sion of intes­tine through a weak­ness in the abdom­i­nal wall in the groin. This lump can affect dai­ly activ­i­ties and is often, but not always, painful.

Surgery to repair inguinal her­nia is one of the most com­mon­ly per­formed oper­a­tions. Some sur­geons use key-hole or laparo­scop­ic surgery rather than an open inci­sion. A mesh is often used to repair the abdom­i­nal wall weak­ness, secured in places either using stich­es, glue or sta­ples. There is a small risk that the nerves in the groin can become irri­tat­ed or inflamed by the implant or inter­nal stiches.

Chron­ic pain after inguinal repair surgery is now a well-recog­nised con­di­tion – it is one of the most wide­ly report­ed sur­gi­cal con­di­tions with hun­dreds of arti­cles report­ing preva­lence of up to and around 30 per cent. Approx­i­mate­ly 5 to 10 per cent of patients report pain after their her­nia oper­a­tion that inter­feres with dai­ly liv­ing. There is now guid­ance rec­om­mend­ing that it is safe for sur­geons to ‘watch and wait’ with some patients who have a small pain-free lump, as long as the her­nia doesn’t impact too much on their dai­ly activities.

Pain after chest surgery

When you con­sid­er what is involved in sur­gi­cal­ly open­ing the chest (tho­ra­co­to­my), it is not sur­pris­ing that many patients suf­fer long-term pain after­wards. In order to gain access to the chest, the sur­geon has to either remove part of a rib or spread the ribs apart. This inevitably caus­es dam­age to bone and nerves lying along the ribcage.

Expe­ri­ence sug­gests that many of the worst pain syn­dromes may be caused by par­tial nerve injury – thus it may be that a ‘clean’ cut of the nerve has a bet­ter long-term out­come, although this can result in numb­ness and loss of sen­sa­tion. Although pain after chest surgery is fair­ly com­mon, the sever­i­ty of pain varies. In one study, 15 per cent of patients with chron­ic pain after chest surgery were suf­fi­cient­ly trou­bled to war­rant refer­ral to a pain clinic.

Pain after amputation

Pain after limb ampu­ta­tion is a well-recog­nised post-sur­gi­cal pain con­di­tion. After limb ampu­ta­tion, the pain can be either stump pain or phan­tom pain (pain felt in the limb that is no longer there). In stump pain, patients often report a ten­der spot on the stump and this has led many sur­geons to per­form fur­ther oper­a­tions to try and find the cause. Patients in the past have fre­quent­ly had fur­ther ampu­ta­tions in the mis­tak­en belief that this would cure the prob­lem. Such oper­a­tions rarely help stump pain and some­times make it worse or make it more dif­fi­cult for the patient to wear an arti­fi­cial limb.

Phan­tom limb is a feel­ing or sen­sa­tion that the limb is still there, this is nor­mal and does not require treat­ment. But phan­tom limb pain (pain in the limb which is no longer there) can affect between 50 to 85 per cent of amputees. It usu­al­ly starts in the first few weeks after surgery. Stud­ies sug­gest that painful phan­tom symp­toms can last between one hour and 15 hours a day and can vary between five days a month and 20 days. Pain sever­i­ty can also be very variable.

It is now acknowl­edged that chil­dren get phan­tom limb pain and that peo­ple born with­out limbs also suf­fer from it. Recent research has shown that part of the pain after ampu­ta­tion aris­es due to activ­i­ty in the brain itself and this under­lines the futil­i­ty of meth­ods of treat­ment aimed direct­ly at the stump.

Oth­er chron­ic post-sur­gi­cal pain syndromes

Oth­er oper­a­tions with known risks of chron­ic pain include vasec­to­my, joint replace­ment surgery, spinal surgery for back pain and breast surgery for can­cer treat­ment. Oth­er leaflets in this series dis­cuss strate­gies for the man­age­ment of chron­ic pain.


Pro­fes­sor Bruce is based at the War­wick Clin­i­cal Tri­als Unit, Uni­ver­si­ty of Warwick.

Pro­fes­sor Stephan Schug is based at the Uni­ver­si­ty of West­ern Aus­tralia, Perth, WA.

This leaflet is an update of a pre­vi­ous leaflet pub­lished by Dr Bill Macrae, now retired.

If you would like to know more about the sources of evi­dence con­sult­ed for this pub­li­ca­tion, please click here.

Chron­ic Pain after Surgery © Copy­right Julie Bruce & Stephan Schug. All rights reserved. Revised June 2019. To be reviewed June 2022. First pub­lished June 2015.

Comments

Pain after abdom­i­nal surgery for inter­nal large cyst above colosto­my stoma.

I found your arti­cle help­ful thank you. I have been suf­fer­ing sev­er neu­ro­path­ic and inter­nal scar tis­sue pain for the past three years after hav­ing had mul­ti­ple Inguinal Her­nia sur­gi­cal repairs. My sur­geon also believes that it’s pos­si­ble that my body is reject­ing the exten­sive amount of mesh that has been implant­ed as I also expe­ri­ence peri­od­i­cal sharp, stab­bing type pains. Even though my doc­tors have tried numer­ous types pain med­ica­tion, as well as nerve block­ers and Ket­a­mine infu­sions, for the most part, my pain lev­els are nev­er below a 7/10! Dis­trac­tions tend to help but I’m start­ing to get to the point where I feel as though the con­stant burn­ing across my abdomen is dri­ving me insane! Any new help would be appre­ci­at­ed thank you.

Pain has start­ed these last years in the area where I broke and oper­at­ed my left foot over ten years ago. The pain comes and goes. Dur­ing days when I notice my Qi is stagnated/stuck in me, I feel aches in my body much more. I can tell my Qi is stuck/not flow­ing in many ways.

I had a major back surgery done in Oct 2019. I had her­ni­at­ed and bulging discs since 1992 and had fell in 2017 which made my con­di­tion worse. Symp­toms include sci­at­i­ca, fluc­tu­at­ing numb­ness in left leg, pain in back, nar­row­ing of spine. I had a laminec­to­my in Oct 2019 and after surgery nerve pain in right foot toe. I twist­ed my ankle 4 times. I expe­ri­ence back pain and pain through­out my right foot, ankle has swollen a few times and toes. I loss sen­sa­tion to cold areas in cer­tain soot ontop of right foot. Xray and blood tests are nor­mal. An MRI with dye imag­ing of spine and MRI of ankle has been ordered

Hi there

I would like to ask you how do you feel after your pro­ce­dure regard­ing your back and sciatica

Con­stant pain under left rib cage 5 months after Colon Resec­tion surgery. Has not been diag­nosed as chron­ic pain . Had all kinds of tests run can’t find any­thing wrong. Sur­geon dis­missed it . Won’t give me any more pain meds. But still have bad pain every day !! It nev­er stops !

hi stel­la , i know how you feel i an the same , strange …me also 5 months after same op, i take over counter med , i also have tin­gle x ten­der sor­ness when i lie down 

just none stop

Since my her­nia op I always have pain also my sur­geon cut my abdo­min­is rec­tus and I lost a lot of blood and need­ed two blood trans­fu­sions and also looked preg­nant I spent months recov­er­ing he did admit he could have been more care­ful I was very unhap­py with the outcome

Linda bayley Roberts

I had a Elec­tive Bio­pros­thet­ic Tri­cus­pid Valve Replace­ment on 20/1020 and on 27/10/2020 I was fit­ted with a Dual Cham­ber Per­ma­nent Pace­mak­er. I was won­der­ing how long does the pain last. I’m still get­ting pains in my chest and my breast and 2 wks ago I was told that I have nerve end­ings dam­age in my hand and it com­ing from my neck

Hi Lin­da,

I’m sor­ry, we can­not give advice spe­cif­ic to your health, that can only come from your health­care pro­fes­sion­al. How­ev­er, please do con­tact our helpline, where our trained vol­un­teers will be able to lis­ten to you and advise you appro­pri­ate­ly if they are able. The tele­phone num­ber and email address is on our helpline page.

James, Pain Concern

I had an Enu­cle­ation of the pan­creas that was a neu­roen­docrine tumor. I had to have it done sur­gi­cal­ly due to the fact that it was on the head, so it couldn’t be done laparo­scop­i­cal­ly. It had now been 7 weeks post op. The inci­sion is healed on the out­side, but it is so ten­der to the touch, some­times just my shirt or sport bra touch­ing it is painful. Is this normal?

My daugh­ter had her appen­dix out near­ly 12 week­snow and was back in hos­pi­tal twice with pain in her side they said it was a bad blad­der infec­tion and kid­ney infec­tion back in again 4 weeks latwr told me bloods are fine s t scan clear ultra­sound clear sebd gome still has the pain nau­sea no appetite said it was mus­cu­lar pain

Comments are closed.

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