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Nearly 1 in 5 patients who have undergone ambulatory surgery experience chronic postsurgical pain (CPSP) at 3 months, with the majority suffering from moderate to severe pain, according to a new prospective cohort study.¹

A changing landscape

Chronic postsurgical pain is a recognized complication of various surgical procedures, with reported incidences ranging from 5% to 50%.^2,3 However, the incidence and factors associated with CPSP specifically after ambulatory surgeries have not been well studied. As the number and complexity of ambulatory surgeries continue to increase, understanding the risk and burden of CPSP in this population becomes crucial. Previous studies have suggested that a significant number of day surgery patients experience inadequate pain management in the immediate postoperative period, but most of these studies had short follow-up periods and did not assess long-term pain outcomes.

The primary objective of this study, conducted by Harsha Shanthanna, MD, PHD, MBBS, MSc, of the Department of Anesthesia of St. Joseph鈥檚 Healthcare in Ontario, Canada, and colleagues, was to determine the incidence of CPSP at 3 months after ambulatory surgery with potential to cause moderate to severe pain.¹

Methods

This prospective cohort study included 208 patients who had previously participated in a randomized controlled trial comparing morphine and hydromorphone for postoperative analgesia in ambulatory surgeries. Patients underwent procedures such as cholecystectomy, inguinal hernia repair, and surgeries on uterine adnexal structures. CPSP was defined according to the International Classification of Diseases-11 criteria. At 3 months post-surgery, patients were assessed for the presence of CPSP, its intensity, pain interference, and analgesic use. The researchers also explored factors associated with CPSP development.¹

Key findings

The investigators found that the incidence of CPSP at 3 months was 18.8% (39/208 patients; 95% CI, 13.7%鈥�24.7%). Among patients with CPSP, the average pain intensity was 5.5 on a 0-10 numerical rating scale (95% CI, 4.7鈥�6.4). Notably, 71.8% (28/39) of patients with CPSP reported moderate-to-severe pain (鈮�4/10 on NRS). Additionally, 25.6% (10/39) of CPSP patients were using pain medications that had been initiated soon after surgery for a period of 鈮�1 months.¹

In exploring factors associated with CPSP, the researchers found that patients reporting CPSP at 3 months had higher baseline levels of anxiety, depression, and pain catastrophizing. They also observed higher rates of chronic pain in other parts of the body among these patients. Importantly, the study revealed that the highest pain score over the first 24 hours after surgery was significantly higher in the CPSP group compared to the no-CPSP group.¹

In adjusted analyses, the average pain score over the first 24 hours after surgery was significantly associated with increased odds of moderate-to-severe CPSP at 3 months (OR, 1.28; 95% CI, 1.04鈥�1.58, P=.02).¹ This finding suggests that effective pain management in the immediate postoperative period, even after discharge, may be crucial in reducing the risk of developing chronic pain.

Limitations

The study has several limitations that should be considered when interpreting the results. First, there was a significant loss to follow-up, with only 208 of the 402 patients from the original trial completing the 3-month assessment. This low response rate could have introduced selection bias. Additionally, being a secondary analysis of a published RCT, the study was limited by the available data and lacked a formal sample size estimation. The study also did not capture information about the type of pain (neuropathic vs. non-neuropathic) or include longer-term follow-up, which would have provided more insight into the eventual burden and trajectory of CPSP.¹

Clinical implications

The high incidence of CPSP after ambulatory surgeries, particularly moderate-to-severe CPSP, highlights a significant clinical problem that requires attention. These findings suggest that current post-discharge care frameworks for ambulatory surgery patients may be inadequate in addressing long-term pain outcomes. Clinicians should be aware of the substantial risk of CPSP in this population and consider implementing follow-up protocols to identify and manage chronic pain in these patients.

The association between pain scores in the first 24 hours post-surgery and the development of moderate-to-severe CPSP underscores the importance of effective pain management strategies that extend beyond the immediate postoperative period. This finding suggests that interventions targeting this critical window could potentially reduce the risk of long-term pain issues. Healthcare providers should consider more aggressive pain management strategies for the first 24 hours post-discharge, which may include more detailed patient education, scheduled analgesic regimens, or even telemedicine follow-ups to assess and manage pain.

The identified risk factors, including higher baseline levels of anxiety, depression, and pain catastrophizing, suggest that a more comprehensive pre-operative assessment may be beneficial. Patients with these risk factors might benefit from targeted interventions, such as pre-operative counseling, anxiety management techniques, or more tailored pain management strategies. Additionally, the high rate of moderate to severe CPSP indicates that current pain management approaches may be insufficient for a significant portion of patients, highlighting the need for more effective long-term pain management strategies in this population.

Future studies

The authors call for further research into effective post-discharge pain management strategies for ambulatory surgery patients, with a focus on testing interventions that could reduce the incidence of CPSP in this growing patient population.¹

Published: July 30, 2024