Managing post-surgical pain is a priority for both the patient and doctor. Before surgery, it’s natural to have concerns about pain after the procedure, as well as the risks associated with medications to control the pain.
More than 45 million surgical procedures are performed in the United States each year. After major surgery, such as a hip or knee replacement, the patient will most likely experience post-surgical pain. It is estimated that acute post-surgical pain will develop into persistent post-operative pain in as many as 50% of patients.
Unfortunately, pain is inevitable following most types of surgery, and is an important part of the healing process. The pain immediately after surgery (acute pain) helps in the healing process by warming damaged tissue and inducing immobilization to allow appropriate healing. However, the negative effects of pain must be managed.
Post-surgical pain can be divided into acute pain and chronic pain.
Acute pain is experienced immediately after surgery (up to 7 days).
Chronic pain lasts more than 3 months.
Post-surgical pain is not just annoying or unpleasant, it differs in quality and location from a pain that is experienced before surgery. Women tend to be at higher risk for post-surgical pain, while older patients are at a reduced risk of developing chronic pain (with some exceptions like lumbar spinal stenosis).
Why is Pain Control Important?
In addition to keeping the patient comfortable, controlling post-surgical pain can help speed recovery. The proper control of post-surgical pain helps reduce the risk of developing complications following surgery, such as pneumonia and blood clots. Furthermore, controlling pain helps the patient accomplish tasks which are important to recovery, such as walking and deep breathing exercises.
What Causes Post-Surgical Pain?
Pain is both a psychological and sensory experience. Surgery, by nature, involves the cutting of tissues and nerves, which induces the injury response (inflammation and a heightened sensitivity to pain).
Doctors believe genetics also play a role in post-surgical pain, because only a proportion of patients who experience nerve damage during surgery actually develop chronic pain.
Pre-operative anxiety and pain are often associated with the development of post-surgical pain. Research has shown that multiple brain regions modulate pain. Furthermore, doctors have found that a patient’s emotions can influence the risk of developing persistent post-surgical pain.
The type of surgery, surgical technique, and experience of the surgeon also play a role in the development of post-surgical pain. The most common type of pain tends to be neuropathic pain rather than inflammatory pain, but both can be present in patients with post-surgical pain.
Surgeries lasting more than three hours and those involving the bones (orthopedic surgery) tend to cause more pain than other types of surgeries, and are therefore associated with an increase in chronic pain. However, some minor surgeries (classified as keyhole or laparoscopic) can also cause significant pain.
Some of the most painful surgeries include:
Open surgery on the heel bone. The skin around the heel is thin and does not have a lot of soft tissue. Surgery to attach screws to the bone can easily damage the nerves around the heel.
Spinal fusion. Surgery to fuse two or more vertebrae sometimes involves a bone graft (taking bone from the hip to put into the spine). Bone grafts can cause chronic pain following surgery.
Complex spinal reconstruction. The use of metal rods and screws to correct a curved spine or make the spine stable has the potential of affecting a high concentration of nerves and nerve endings in the spine, resulting in a great deal of post-surgical pain.
What are the Types of Post-Surgical Pain?
Although pain at the site of the incision is expected, there are often other areas of discomfort following surgery such as:
Muscle pain. There can be muscle pain in the neck, shoulders, back, or chest from lying on the operating table. Also, certain back surgeries are more likely to cause muscle spasms.
Throat pain. The throat may feel sore or scratchy if the surgery involved general anesthesia, due to a tube (endotracheal tube) inserted through the mouth into the trachea (windpipe) to help the patient breathe during surgery.
Movement pain. Doctors want you to sit up, walk, and cough after surgery. However, this may cause increased pain at or around the incision site.
Controlling pain is essential for recovery, because it’s important for patients to get up and move around after surgery. Movement is important because:
It lowers the risk for blood clots in the legs and lungs, as well as lung and urinary infections.
It allows the patient to recover more quickly and go home sooner.
How is Post-Surgical Pain Controlled?
Post-surgical pain is usually managed with prescription and over-the-counter pain-reducing medications (analgesics). The type and dose of medications depend on the type of surgery as well as the patient’s needs.
Following surgery is not the time to “tough it out.” Treating pain early is easier than treating it later, after it becomes chronic. If the patient waits until the pain becomes unbearable, it will require more medicine to control the pain. Doctors often recommend that patients start pain medication early instead of waiting until the pain becomes intolerable.
There are several types of pain treatments. The type of surgery will help determine which one best fits the patient’s needs. All pain treatments are relatively safe when administered properly; however, like any therapy, they are not entirely free of risk.
Opioids are powerful pain medications that diminish the perception of pain and are often critical for post-surgical pain. The use of opioids after surgery is intended as a short-term strategy to relieve pain while the body heals. The risk of becoming addicted to short-term pain medication after surgery is minimal, but there is a risk of abuse. Another risk is a possible prolonged recovery if the patient avoids taking pain medication and cannot adequately perform activities that are helpful for recovery.
Other pain medications include:
Local anesthetics cause a short-term loss of sensation at a particular area of the body. Lidocaine and bupivacaine are typical local anesthetics.
Non-steroidal anti-inflammatory drugs (NSAIDs) lessen the inflammatory activity that exacerbates pain. These include ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, Anaprox, others), celecoxib (Celebrex), and ketorolac (Acuvail, others).
Non-opioid pain relievers include acetaminophen (Tylenol, others) and ketamine (Ketalar).
Other psychoactive drugs that can treat post-surgical pain include the anti-anxiety medication midazolam, the anticonvulsants gabapentin (Gralise, Horizant, Neurontin), and pregabalin (Lyrica).
A combination of treatments can help to control pain, lessen side effects, enable a resumption of activity appropriate for recovery, and lower the risks associated with using opioid medications.
Pain medications can be administered in several ways:
Oral Pain Medications. At some point during recovery from surgery, the doctor typically orders pain medications to be taken by mouth (orally). Most oral pain medications can be taken every 4 hours.
Injected Pain Medication. Narcotic pain medicine can be administered as an injection. Like oral medication, most injections provide relief for 4 to 6 hours.
Intravenous Patient-Controlled Analgesia (PCA). A computerized pump allows the patient to safely self-administer small amounts of pain medicine with a push of a button. The medication is automatically added to an intravenous (IV) line while in the hospital. PCA provides stable pain relief in most situations and gives the patient a sense of control over their pain management. The PCA pump is programmed to provide only a certain amount of medication when the button is pressed and a maximum amount of medication, no matter how often the button is pressed, to avoid over-dosing.
Patient-Controlled Epidural Analgesia. Often more effective in relieving pain than intravenous medications, this type of pain control is often used during childbirth. A PCA pump delivers pain-control medicine through an epidural catheter (a very thin plastic tube) to nerves near the spine. Additional pain medication can be administered by pressing the PCA button. Patients who receive epidural analgesia typically have less pain and may recover more quickly.
Nerve Blocks. Unlike an epidural, which controls pain over a broad area, a nerve block controls pain isolated to a specific area such as an arm or leg. An advantage of using a nerve block is that it may allow the amount of medication to be significantly reduced.
Wound infiltration anesthesia. This treatment involves the injection of an anesthetic drug at the wound site from a catheter (and may also be administered during the procedure), which can help reduce the use of opioids during recovery.
Alternative Methods to Control Post-Surgical Pain
Non-medication alternatives for controlling post-surgical pain include heating pads, ice packs, and relaxation techniques that help with pain either alone or along with medications.
After orthopedic surgery, patients are increasingly turning to alternative methods to supplement conventional pain medicine. A combined approach to pain management, using medication and alternative pain management techniques, may be best for some patients. Some alternative pain control options include:
Transcutaneous Electrical Nerve Stimulation (TENS). A special device transmits low-level electrical charges into the area of the body experiencing pain. Two electrodes are connected to the skin near the source of pain or at a pressure point. A mild electrical current travels through the skin and along nerve fibers which cause a warm, tingling sensation. There is also an acupuncture version of TENS in which the electrical impulses are sent through acupuncture needles instead of electrode pads, which is called “electro-acupuncture” or percutaneous electrical nerve stimulation (PENS). TENS is generally considered safe; however, routine use is not recommended.
Acupuncture. A form of traditional Chinese medicine, an acupuncturist inserts thin metal needles into the skin to stimulate energy points and relieve musculoskeletal pain. Some scientists believe that these “acupoints” possess special electrical characteristics that can be manipulated using the hair-thin needles.
Therapeutic Massage. An ancient means of treating musculoskeletal pain that remains popular today. Massage therapists help relieve pain by pressing and rubbing the muscles and soft tissues to help relax the muscles, as well as applying pressure to force knotted muscles to release.
Relaxation and Biofeedback. Meditation and other relaxation techniques can reduce stress hormone levels in the body to help reduce the perception of pain. Biofeedback can help perfect relaxation techniques using devices that display internal body processes like heart rate, blood pressure, and muscle tension.
Controlling Post-Surgical Pain is Important
It is important to remember that pain is different for everyone. What works for one patient may not be effective for another. However, treating pain early usually brings quicker and better control.
The use of pain medication prior to surgery was effective at reducing the need for post-surgery medication.
Patients who use pain medicine following surgery for pain control often use less medicine than those who try to avoid pain medicine.
Healing can occur faster when pain is under control. Pain affects blood pressure, heart rate, appetite, and general mood.
It is essential the patient talk honestly about any pain they feel following surgery. Doctors need to know how much it hurts, where it hurts, and what activities or positions make the pain better or worse.
Novus Spine & Pain Center
Novus Spine & Pain Center is in Lakeland, Florida, and specializes in treating post-surgical pain. By using a comprehensive approach and cutting-edge therapies, we work together with patients to restore function and regain an active lifestyle, while minimizing the need for opiates.