CPSP is the MC and serious complication post surgery No universally agreed definition >4 million people undergo Sx in UK
↑ analgesic use Restriction of activities of daily living Sig effects on QOL ↑ health care utilization
What do you understand by the term CPSP ? (10 %)
CPSP is a type of neuropathic pain
What types of Surgical procedures does it most commonly follows? (10%)
Type of surgery Incidence of chronic pain (%) › Amputation 30–85 › Thoracotomy 5–67 › Mastectomy 11–57 › Inguinal hernia repair 0–63 › Sternotomy 28–56 › Cholecystectomy 3–56 › Knee arthroplasty 19–43 › Breast augmentation 13–38
It may be related to the nerve injury, but not all patients with nerve injury get CPSP and not all patients with CPSP have nerve injuries
Central sensitization Peripheral nerve injury ↑ Na+ channel expression ↑ Spont activity and discharge, ↑ Glutamate release from nerve endings Acts on Glutamate receptors, Intracellular changes Sustained Central sensitization
What are the risk factors for the development of CPSP? (30%)
Preop › Severe, long-term preop pain › ↓ with increase in age › Genetic susseptibility › Psychosocial factors e.g. fear of surgery
Intra op › Longer, more complicated operation › Open (rather than laparoscopic) › Repeat surgery e.g. Hernia
Post op › Adjuvant interventions e.g.Radiotherapy › Severe post-op pain
What can be done to prevent it? (20%)
Good post-op pain relief itself eg. Epidural/ Paravertebral Gabapentin and IV Ketamine are being used Targinact ®(newer agents) Oxycodone +Naloxone in fastrack colorectal surgery No evidence for pre-emptive RA
What is the management of CPSP ? (30%)
Multimodal Multidisciplinary approach with rational use of polypharmacy Pharmacological- WHO, Antidepressants, anticonvulsants, NMDA Non-pharmacological Psychotherapy (CBT, PMP) Complementary therapies (Acu, TENS) Functional rehabilitation Others
WHO analgesic ladder › Simple analgesics to Strong opiods › Anti depressants eg Amitryptilline › Anti convulsants eg. Carbamazapine › Calcium channel blockers eg. gabapentin › Directly acting eg clonidine › Nerve blocks › Acupuncture › Heat/cold, TENS