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5 Articles in this Series
A Worldwide Take on Opioid Prescribing and Access
Evolution of the Neuropathic State and Evidence-Based Treatment
Incidence and Causes of Persistent Chronic Pain After Major Surgeries
Notable Industry Surveys
Putting a Stop to Guideline Warfare: Lower Back Pain

Incidence and Causes of Persistent Chronic Pain After Major Surgeries

With presentation by Kumar Buvanendran, MD

In his presentation, “Transition of Acute to Chronic Pain: Clinical Challenges to Prevention and Treatment,” Kumar Buvanendran, MD, professor of anesthesiology at the Rush University Medical Center in Chicago, IL, set out to discuss the perioperative factors that may prevent or decrease the incidence of chronic pain after surgery, or chronic post-surgical pain (CPSP). He spoke at the 2018 World Congress for Regional Anesthesia and Pain Medicine.1

“As perioperative clinicians and physicians, what can we do to mitigate or decrease the incidence of this persistent chronic pain after surgery?” Dr. Buvanendran asked in his introduction. Chronic post-surgical pain syndrome has been defined as pain that has developed after a surgical procedure for at least three months, in which other causes for the pain have been excluded, such as infection, loose prosthesis, or recurrence of surgical pathology.

Incidence of CPSP

Dr. Buvanendran outlined various incidences of CPSP after conditions such as thoracic surgery, breast cancer surgery, hernia surgery, and total knee replacement. Some key findings from each:

  • The incidence of CPSP after thoracic surgery is about 50 to 55% depending on the study design, with a large percentage of them being neuropathic in nature.2
  • A higher incidence of CPSP occurred after an axillary node dissection during breast cancer surgery.3
  • Despite finding the nerves associated with chronic pain after hernia surgery (ilioinguinal, lateral femoral cutaneous nerve, iliohypogastric, genitofemoral, and femoral), the identification of nerves during open inguinal herniorrhaphy does not reduce the risk of CPSP.4
  • The incidence of CPSP after total knee replacement rose significantly in studies published from 2007 to 2012, with as much as 53% reported in one study.5 Another study found that 6% of patients who have total knee arthroplasty (TKA) develop chronic neuropathic pain.6

How Does This Happen?

“What are the preoperative factors, what are the inter-operative factors that we can take care of?” Dr. Buvanendran rhetorically posed to the audience. Psychological factors are important to consider, he responded. For example, pain catastrophizing, an exaggerated negative mental state, places excessive focus on the negative aspects of the pain experience, magnifies pain sensations, and evokes feelings of hopelessness and inability to cope.7 Dr. Buvanendran pointed to several studies that have shown one’s psychophysical and psychosocial profile come into play in the preoperative space, and that instances of anxiety and depressive symptoms were prevalent among CPSP sufferers in a study of those who received TKA.8-10

Beyond the psychological side, Dr. Buvanendran shifted his attention to opioid use, examining a study11 that looked to identify rates of preoperative opioid use, evaluate postoperative trends, and identify risk factors for prolonged use of opioids after TKA. “If you came with a preoperative morphine equal utilization for TKA, your morphine consumption at 12 months was significantly higher than people who came in opioid naïve to the operating room,” he said. Opioid usage trends in this fashion are important for doctors to see how they can wean patients off opioids preoperatively.

Increased acute postoperative pain is another risk factor for CPSP. In one study,12 82% of patients who had higher than five episodes of severe pain during the first three days after surgery suffered from persistent pain at 6 months. The incidence of CPSP in this cohort was high at 82%, and moderately severe at 37%.


As to the consequences for those patients who develop CPSP, “not only do these patients increase their health care cost, but they go from doctor to physician to physician looking for treatment options,” Dr. Buvanendran said. Physicians who prescribe opioids for the treatment of chronic pain after surgery now cause the patients to become tolerant to opioids, according to one study.13 Dr. Buvanendran suggested that a referral to an interventional pain physician should be made early after conservative management of treatment has failed, in order to curb CPSP.


1. Buvanendran K. Transition of Acute to Chronic Pain: Clinical Challenges to Prevention and Treatment. Presented at the World Congress on Regional Anesthesia & Pain Medicine. April 19-21, 2018, New York, NY.

2. Mongardon N, Pinton-Gonnet C, Szekely B, et al. Assessment of chronic pain after thoracotomy: a 1-year prevalence study. Clin J Pain. 2011;27(8):677-681.

3. Gärtner R, Jensen M, Nielsen J, et al. Prevalence of and Factors Associated With Persistent Pain Following Breast Cancer Surgery. JAMA. 2009;302(18):1985–1992.

4. Bischoff JM, Koscielniak-Nielsen ZJ, Kehlet H, et al. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for persistent inguinal postherniorrhaphy pain: a randomized, double-blind, placebo-controlled, crossover trial. Anesth Analg. 2012;114(6):1323-1329.

5. Liu SS, Buvanendran A, Rathmell JP, et al. A cross-sectional survey on prevalence and risk factors for persistent postsurgical pain 1 year after total hip and knee replacement. Reg Anesth Pain Med. 2012;37(4):415-422.

6. Wylde V, Hewlett S, Learmonth ID, et al. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011;152(3):566-572.

7. Roth, ML, Tripp, DA, Harrison, MH, et al. Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty. Pain Res Manag. 2007;12(3):185–194.

8. Masselin-Dubois A, Attal N, Fletcher D, et al. Are psychological predictors of chronic postsurgical pain dependent on the surgical model? A comparison of total knee arthroplasty and breast surgery for cancer. J Pain. 2013;14(8):854-864.

9. Burns LC, Ritvo SE, Ferguson MK, et al. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015;8:21-32.

10. Lewis GN, Rice DA, McNair PJ, et al. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 2015;114(4):551-561.

11. Bedard NA, Pugely AJ, Westermann RW, et al. Opioid Use After Total Knee Arthroplasty: Trends and Risk Factors for Prolonged Use. J Arthroplasty. 2017;32(8):2390-2394.

12. Niraj G, Kelkar A, Kaushik V, et al. Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center. J Clin Anesth. 2017;36:174-177.

13. Gan TJ, Habib AS, Miller TE, et al. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014;30(1):149-160.

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