Inadequate management of postoperative pain is common, and postoperative pain is a risk factor for prolonged pain. In addition to medical and technical factors, psychological factors may also influence the experience of postoperative pain.
Pain was measured postoperatively at 24, 48, and 72 hr in hospital and after 3 months at home in 140 patients undergoing radical prostatectomy (RP). Patients answered questionnaires about anxiety and depression (HAD scale) and health-related quality of life (SF-36) at baseline and 3 months after surgery.
In the first 3 postoperative days, mild pain was reported by 45 patients (32%), moderate pain by 64 (45%), and severe pain by 31 (22%) on one or more days. High postoperative pain scores were correlated with length of hospital stay and with high pain scores at home. Forty patients (29%) reported moderate (n = 35) or severe (n = 5) pain after discharge from hospital. Patients who experienced anxiety and depression preoperatively had higher postoperative pain scores and remained anxious and depressed 3 months after surgery. The scores for the physical domains in the SF-36 were decreased, while the mental health scores were increased at 3 months. Anxiety and depression were negatively correlated with all domains of the SF-36.
There is a need for nurses to be aware of the psychological status of RP patients and its impact upon patients' experience of postoperative pain and recovery. The ability to identify patients with psychological distress and to target interventions is an important goal for future research.
The objective of this observational prospective study was to investigate the effect of depression on short-term outcome after lumbar spinal stenosis (LSS) surgery. Surgery was performed on 99 patients with clinically and radiologically defined LSS, representing ordinary LSS patients treated at the secondary care level. They completed questionnaires before surgery and 3 months postoperatively. Depression was assessed with the 21-item Beck Depression Inventory (BDI). Physical functioning and pain were assessed with Oswestry disability index, Stucki Questionnaire, self-reported walking ability, visual analogue scale (VAS) and pain drawing. Preoperatively, 20% of the patients had depression. In logistic regression analyses, significant associations were seen between preoperative depression and postoperative high Oswestry disability and Stucki severity scores and high intensity of pain (VAS score). In subsequent analyses, the patients with continuous depression, measured with BDI (60% of the patients who had preoperative depression), showed fewer improvements in symptom severity, disability score, pain intensity and walking capacity than the patients who did not experience depression at any phase. In those patients who recovered from depression, according to BDI-scores (35% of the patients with preoperative depression), the postoperative improvement was rather similar to the improvement seen in the normal mood group. In the surgical treatment of LSS, we recommend that the clinical practice should include an assessment of depression.
Lumbar spinal stenosis; Depression; Surgery; Short-term outcome
The primary purpose of this study was to investigate the influence of an individual’s Gender Role Expectations of Pain (GREP) on experimental pain report. One hundred and forty-eight subjects (87 females and 61 males) subjects underwent thermal testing and were asked to report pain threshold, pain tolerance, VAS ratings of pain intensity and unpleasantness, and a computerized visual analogue scales (VAS) rating of pain intensity during the procedure. Subjects completed the GREP questionnaire to assess sex-related stereotypic attributions of pain sensitivity, pain endurance, and willingness to report pain. Consistent with previous research, significant sex differences emerged for measures of pain threshold, pain tolerance, and pain unpleasantness. After statistically controlling for age, GREP scores were significant predictors of threshold, tolerance, and pain unpleasantness, accounting for an additional 7, 11, and 21% of the variance, respectively. Sex remained a significant predictor of pain tolerance in hierarchical regression analyses after controlling for GREP scores. Results provide support for two competing but not mutually exclusive hypotheses related to the sex differences in experimental pain. Both psychosocial factors and first-order, biological sex differences remain as viable explanations for differences in experimental pain report between the sexes. It appears that GREP do play a part in determining an individual’s pain report and may be contributing to the sex differences in the laboratory setting.
Pain; Gender; Sex differences; Experimental pain; Thermal pain
Recent studies have documented the importance of psychological factors in the experience of chronic pain in persons with spinal cord injury (SCI). The current study sought to replicate and extend previous work demonstrating associations among specific pain-related beliefs, coping, mental health, and pain outcomes in persons with SCI. A return-by-mail survey assessing psychological functioning and pain was completed by 130 individuals with SCI. Measures included short forms of the Survey of Pain Attitudes and the Chronic Pain Coping Inventory. After factor analysis, multiple regression was used to predict pain outcomes (psychological functioning and pain interference) after controlling for pain intensity. Results indicated that psychological factors, particularly beliefs about pain (including catastrophizing) and pain-related coping strategies (including passive coping), were significant predictors of pain outcomes and accounted for 21% to 25% of unique variance. Zero-order correlations suggested that the specific variables most closely associated with negative pain outcomes were perception of oneself as disabled, perceptions of low control over pain, and tendency to catastrophize. In general, negative attributions and coping were stronger predictors of pain adjustment than were positive ones. Results highlight the importance of psychological factors in understanding chronic pain in persons with SCI and provide further support for the biopsychosocial model.
adjustment; attributions; biopsychosocial model; catastrophizing; chronic pain; coping; CPCI; pain interference; rehabilitation; SOPA; spinal cord injury
Depression, somatisation and pain beliefs influence outcome of several painful musculoskeletal disorders. Their influence on the postoperative outcome of total hip replacement was investigated. A total of 79 patients who underwent primary total hip replacement completed questionnaires preoperatively and six weeks postoperatively addressing depression (Hospital Anxiety and Depression Scale–German version), pain beliefs (Pain Beliefs Questionnaire) and somatisation (Screening of Somatoform Disorders-2) as well as outcome [Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), Medical Outcomes Study 36-Item Short Form (SF-36)]. Depressive patients showed a median preoperative WOMAC sum score of 30 compared to 45 in other patients and a postoperative score of 72 compared to 85, and patients with somatoform disorder of 32 compared to 46 preoperatively and 73 versus 86 postoperatively. Patients with high somatisation and depression scores feel worse in their hips and in general well-being before and after surgery, but they experienced the same benefit from total hip replacement as those with low scores.
Total hip arthroplasty; Depression; Somatisation; Pain beliefs; WOMAC; SF-36
Two separate studies were carried out to determine if three visual analogue scales for various feelings including pain could be marked consistently by patients, without reference to previously completed scales. Sixty patients undergoing extraction of their lower third molars had measurements of acute preoperative anxiety, expected postoperative pain and postoperative perceived pain three times in quick succession. There was no significant difference between the three measurements for any of the feelings. Although a correlation was detected between expected pain and preoperative anxiety, there was no meaningful relationship between perceived postoperative pain and expected pain or preoperative anxiety. Eighty patients suffering from a wide range of chronic painful states completed three identical scales for pain, anxiety, depression and mood during their first visit. These measurements were repeated at a later time following a treatment, with the addition of a visual analogue scale for pain relief. Mean scores for anxiety, mood and pain relief were consistent, but mean pain scores were more variable. There was a very close correlation between any two feelings expressed on these visual analogue scales during both the initial and second visits. Litigation or social problems were not associated with increased pain scores.
Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. The objective of this study was to investigate whether preoperative electrical and pressure pain assessment can predict post-caesarean section pain and analgesic requirement.
Materials and Methods:
A total of 65 subjects scheduled for elective caesarean section, who gave written informed consent, were studied. Preoperatively, PainMatcher® was used to evaluate electrical pain threshold, while manual PainTest™ FPN 100 Algometer and digital PainTest™ FPX 25 Algometer determined pressure pain threshold and tolerance. Postoperatively, numerical rating scales were used to assess pain at regular time intervals. Patients received intramuscular pethidine (100mg, 6 hourly), rectal diclofenac (100mg, 12 hourly), and oral paracetamol (1g, p.r.n.) for pain relief. Statistical analysis was conducted using PASW Statistics 18 software.
Preoperative electrical pain threshold correlated significantly with post-caesarean pain scores at 6 and 24 hours (r = –0.26, P < 0.02; r = –0.23, P < 0.04, respectively), and with the quantity of paracetamol consumed by the patient within 48 hours of surgery (r = –0.33, P < 0.005). Preoperative pressure pain tolerance measured by PainTest™ FPX 25 Algometer was significantly correlated with pain scores 6 hours postsurgery (r = –0.21, P < 0.05). Pain scores 6 hours post-caesarean section correlated significantly with anesthesia—general or spinal (F = 4.22, v1 = 1, v2 = 63, P < 0.05).
The predictive methods proposed may aid in identifying patients at greater risk for postoperative pain. Electrical pain threshold could be useful in personalizing the postoperative analgesic protocol.
Analgesia; caesarean section; general anesthesia; postoperative pain; pain threshold; spinal anesthesia
Several recent reports suggest that pain-related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long-term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.
Arthroplasty; Catastrophizing; Depression; Knee replacement; Pain
This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddell’s nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery
Biomechanics; Low back pain; Lumbar stenosis; Outcome scales; Predictive models
Barriers to cancer pain management can contribute to the undertreatment of cancer pain. No studies have documented barriers to cancer pain management in Chinese American patients. The purposes of this study in a community sample of Chinese Americans were to: describe their perceived barriers to cancer pain management; examine the relationships between these barriers and patients’ ratings of pain intensity, pain interference with function, mood disturbances, education, and acculturation level; and determine which factors predicted barriers to cancer pain management. Fifty Chinese Americans with cancer pain completed the following instruments: Brief Pain Inventory (BPI), Karnofsky Performance Status (KPS) scale, Barriers Questionnaire (BQ), Hospital Anxiety and Depression Scale (HADS), Suinn-Lew Asia Self-Identity Acculturation (SL-ASIA), and a demographic questionnaire. The mean total BQ score was in the moderate range. The individual barriers with the highest scores were tolerance to pain medicine, time intervals used for dosage of pain medicine, disease progression, and addiction. Significant correlations were found between the tolerance subscale and least pain (r= 0.380) and the religious fatalism subscale and average pain (r=0.282). These two subscales were positively correlated with anxiety and depression levels: (tolerance: r=0.282, r=0.284, respectively; religious fatalism: r=0.358, r=0.353, respectively). The tolerance subscale was positively correlated with pain interference (r=0.374). Approximately 21% of the variance in the total BQ score was explained by patients’ education level, acculturation score, level of depression, and adequacy of pain treatment. Chinese American cancer patients need to be assessed for pain and perceived barriers to cancer pain management to optimize pain management.
Barriers; cancer pain; Chinese; acculturation; ethnicity
The aim of this study was to explore the intensity of post-arthroscopy knee pain during the first 24 hours, and to study the influence of pre-operative pain, tourniquet time and amount of surgical trauma on post-arthroscopy pain. In 78 male patients that underwent elective arthroscopic menisectomy or diagnostic arthroscopy of the knee, preoperative and post-operative pain were registered using the Visual Analogue Scale. Variance for repeated measures and for independent observations was analysed. Supplementary analgesia was required for 23% of the patients, more often in the recovery room and between 2 and 8 hours postoperatively. Of all factors analyzed, only time was statistically significant in determining the level of post-operative pain. Supplementary analgesia was required only in patients that underwent operative arthroscopy, and more often in patients with tourniquet time of more than 40 minutes. In conclusions, post-operative time is the most significant factor related to the post-arthroscopy knee pain.
The middle cingulate cortex (MCC) has been implicated in pain processing by studies of cingulotomy for chronic pain and imaging studies documenting increased MCC blood flow in response to acute pain. The only previous report of quantitative sensory testing following cingulotomy described increased intensity and unpleasantness ratings of painful hot and cold stimuli in a single patient with psychiatric disease. We now report a case in which perception of pain and temperature was assessed before and after cingulotomy for obsessive-compulsive disorder (OCD). Positron emission tomographic (PET) studies of the bloodflow response to acute pain were carried out using a single subject design which allowed for statistical evaluation of postoperative blood flow changes in this case.
Postoperatively, the patient demonstrated increased intensity and unpleasantness ratings of painful thermal waterbath stimuli. The PET studies demonstrated preoperative contact heat pain-evoked activation of the bilateral MCC/SMA (supplementary motor area) and the left (contralateral) fronto-parietal operculum. Postoperative pain-evoked activation was demonstrated in the right (ipsilateral) parasylvian cortex but not of the MCC/SMA. Prior studies of forebrain lesions, and of cortical synchrony during the application of painful stimuli suggest the presence of functional connectivity between components of the MCC/SMA and the fronto-parietal opercula. Therefore present results suggest that cingulate lesions disinhibit ipsilateral parasylvian cortex and so are independent evidence of functional connectivity between these cortical areas, the defining characteristic of components in a pain network.
Cingulotomy; Pain Intensity; Pain Unpleasantness; Human Anterior Cingulate Cortex; Insula; S2
The effect of lidocaine and bupivacaine on postoperative pain were compared in a double blind crossover study. Diflunisal (500 mg) was used as an analgesic and given before commencement of the surgical procedure.
Bilateral impactions of lower third molars were removed on two occasions, four weeks apart, in a sample of 26 Chinese patients. One local anesthetic was used on one occasion and the alternate on the second. Pain intensity was indicated on a visual analogue scale hourly for eight hours, beginning one hour after the start of surgery.
Pain at each postoperative hour was lower after bupivacaine and more patients indicated little or no pain after bupivacaine than after lidocaine. This was not reflected in patients' preference: 12 preferring lidocaine, 11 bupivacaine, and 3 indicating no preference, an important reason being a shorter period of numbness with lidocaine.
Although diflunisal was given preoperatively, the postoperative course was not complicated by alveolitis in any case.
While bupivacaine plus diflunisal resulted in less postoperative pain than lidocaine plus diflunisal, some patients were willing to sustain some pain after oral surgery if sensation was regained sooner.
To determine prevalence and intensity of pain after stroke, focusing on patients' perspectives.
During a one year period, 416 first‐ever stroke patients were included in the population based Lund Stroke Register. After 4 and 16 months (median), 297 patients (98% of survivors) were followed up. Worst pain intensity during the previous 48 hours was assessed on a visual analogue scale (VAS), range 0 to 100: a score of 0 to 30 was defined as no or mild pain; 40 to 100 as moderate to severe pain. NIH stroke scale (NIHSS) score and HbA1c were assessed at baseline. At 16 months, screening for depression was done using the geriatric depression scale (GDS‐20), and cognition with the mini‐mental state examination (MMSE). Predictors of pain were determined by multivariate analyses.
Moderate to severe pain was reported by 96 patients (32%) after four months (VAS median = 60). Predictors of pain were younger age (p = 0.01), female sex (p = 0.006), higher NIHSS score (p<0.001), and raised HbA1c (p = 0.001) at stroke onset. At 16 months, only 62 patients (21%) had moderate to severe pain, but pain intensity was more severe (median VAS score = 70; p<0.016). Higher pain intensity correlated with female sex, worse GDS‐20 score, better MMSE score, and raised HbA1c. Pain was persistent in 47%, disturbed sleep in 58%, and required rest for relief in 40% of patients.
Although prevalence of pain after stroke decreased with time, after 16 months 21% had moderate to severe pain. Late pain after stroke was on average more severe, and profoundly affected the patients' wellbeing.
pain; patient perspective; stroke; stroke management
Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support; and does not account for chronic pain’s multidimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n = 971), headache (n = 1078), or orofacial pain (n = 455). At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with “possible” or “probable” chronic pain. The 0–28 Risk Score was based on pain intensity, pain-related activity limitations, depressive symptoms, number of pain sites, and Pain Days. Pain and behavioral outcomes were assessed at six-month follow-up, and long-term opioid use was assessed two to five years after baseline. Risk Score consistently predicted clinically significant pain at six months better than did Pain Days alone (Area under the Curve of 0.74–0.78 for Risk Score vs. 0.63–0.73 for Pain Days). Risk Score was a stronger predictor of future SF-36 Physical Function, pain-related worry, unemployment, and long-term opioid use than Pain Days alone. Thus, for these three common pain conditions, a prognostic Risk Score had better predictive validity for pain outcomes than did pain duration alone. However, chronic pain appears to be a continuum rather than a distinct class, because long-term pain outcomes are highly variable and inherently uncertain.
chronic pain; back pain; headache; orofacial pain; classification; epidemiology
Objective. To compare Visual Analogue Scale (VAS) scores with overall postoperative pain medication requirements including cumulative dose and patterns of medication utilization and to determine whether VAS scores predict pain medication utilization. Methods. VAS scores and pain medication data were collected from participants in a randomized trial of the utility of phenazopyridine for improved pain control following gynecologic surgery. Results. The mean age of the 219 participants was 54 (range19 to 94). We did not detect any association between VAS and pain medication utilization for patient-controlled anesthesia (PCA) or RN administered (intravenous or oral) medications. We also did not detect any association between the number of VAS scores recorded and mean pain scores. Conclusion. Postoperative VAS scores do not predict pain medication use in catheterized women inpatients following gynecologic surgery. Increased pain severity, as reflected by higher VAS scores, is not associated with an increase in pain assessment. Our findings suggest that VAS scores are of limited utility for optimal pain control. Alternative or complimentary methods may improve pain management.
To test the hypothesis that psychological factors correlate with pain intensity in trigger finger (TF).
Patients with TF were selected from two previous cohort studies measuring pain intensity and psychological parameters, 82 from one study and 72 from another. Correlation testing and multiple linear regression was performed. Measures included the pain catastrophizing scale (PCS), pain self-efficacy questionnaire (PSEQ), patient health questionnaire depression (PHQ-D) scale, center for epidemiologic studies depression (CES-D) scale, pain anxiety symptoms score (PASS), and the eysenck personality questionnaire (EPQ-R) scales.
There was moderate correlation between pain intensity and PCS (ρ = 0.52; P < 0.001) and PSEQ (ρ = − 0.36; P < 0.001). There was weak correlation between pain and PHQ-D (ρ = 0.23; P = 0.019). No significant correlation existed with CES-D or EPQ-R. PCS accounted for 26% of the variance in pain for patients awaiting surgery (P < 0.001).
Self-reported pain in TF has moderate correlation with psychological factors, most predominantly pain catastrophizing.
Psychological factors within the Fear-Avoidance Model of Musculoskeletal Pain (FAM) predict clinical and experimental pain in both symptomatic and asymptomatic individuals. Clinicians routinely examine individuals with provocative testing procedures that evoke symptoms. The purpose of this study was to investigate which FAM factors were associated with evoked pain intensity, non-painful symptom intensity, and range of motion during an upper-limb neurodynamic test. Healthy participants (n = 62) completed psychological questionnaires for pain catastrophizing, fear of pain, kinesiophobia, and anxiety prior to neurodynamic testing. Pain intensity, non-painful sensation intensity, and elbow range of motion (ROM) were collected during testing and served as dependent variables in separate simultaneous regression models. All the psychological predictors in the model accounted for 18% of the variance in evoked pain intensity (p = .02), with only pain catastrophizing (β = .442, p < .01) contributing uniquely to the model. Psychological predictors did not explain significant amounts of variance for the non-painful sensation intensity and ROM models. These findings suggest that pain catastrophizing contributed specifically to evoked pain intensity ratings during neurodynamic testing for healthy subjects. Although these findings cannot be directly translated to clinical practice, the influence of pain catastrophizing on evoked pain responses should be considered during neurodynamic testing.
neurodynamic testing; Fear-Avoidance Model of Musculoskeletal Pain; pain catastrophizing
To assess the severity and evolution of sinonasal symptoms in patients following endoscopic anterior skull base surgery to define the typical postoperative course. Design: Cross sectional study. Participants include 69 patients who underwent endoscopic skull base surgery by a dual surgeon team (otolaryngologist and neurosurgeon) from January 2008 to August 2009. Main outcome measures: Sinonasal Outcomes Test (SNOT)-20 survey scores at preoperative and at three postoperative time points. An ordinal logistic regression model was used to analyze the data, summarizing the relationship between the outcome (SNOT score) and the predictor (time point) using an odds ratio. Scores for the symptoms of need to blow nose, sneezing, runny nose, postnasal discharge, thick nasal discharge, ear fullness, and facial pain showed significant worsening at the early postoperative time point. These symptoms showed significant improvement over time; however, scores for post nasal discharge remained high at the late time period compared with baseline. All patients will experience considerable sinonasal symptoms following transnasal endoscopic skull base surgery. Postnasal discharge and thick nasal discharge improve significantly over time. Symptoms approach baseline by 6 to 9 months following surgery.
Skull base; sinonasal; endoscopic; sinus surgery
Purpose This study aimed to identify self-perception variables which may predict return to work (RTW) in orthopedic trauma patients 2 years after rehabilitation. Methods A prospective cohort investigated 1,207 orthopedic trauma inpatients, hospitalised in rehabilitation, clinics at admission, discharge, and 2 years after discharge. Information on potential predictors was obtained from self administered questionnaires. Multiple logistic regression models were applied. Results In the final model, a higher likelihood of RTW was predicted by: better general health and lower pain at admission; health and pain improvements during hospitalisation; lower impact of event (IES-R) avoidance behaviour score; higher IES-R hyperarousal score, higher SF-36 mental score and low perceived severity of the injury. Conclusion RTW is not only predicted by perceived health, pain and severity of the accident at the beginning of a rehabilitation program, but also by the changes in pain and health perceptions observed during hospitalisation.
Return to work; Injury; Accident; Pain; PTSD; IES-R
Ureteroscopic removal of stones (URS) has been widely used to treat ureteral stones because it is comparatively safe, has a high success rate, and enables patients to rapidly return to their daily routines. However, some patients experience pain after URS, but the incidence of acute post-URS pain remains largely unknown. This study aimed to investigate the incidence of acute postoperative pain after URS and the associated risk factors.
Materials and Methods
Data for 143 consecutive patients who underwent URS from June 2008 to December 2010 were collected. After excluding 8 patients who developed intraoperative complications, the patients were divided into two groups according to postoperative pain on the first postoperative day. Acute postoperative pain was defined as a pain score greater than 4 on a visual analogue pain scale (normal range, 0 to 10). Various factors were analyzed to identify the risk factors that could predict acute postoperative pain after URS.
The stone-free rate without URS intraoperative complications was 95.5%. A total of 21 (14.6%) patients experienced postoperative pain on the first postoperative day. Young age, psychiatric illness, history of urinary tract infection, use of a stone basket, large stone size, and prolonged operation time were identified as risk factors for acute postoperative pain.
The incidence of acute postoperative pain is not that low and should not be overlooked, because it is associated with postoperative complications that could result in an unscheduled hospital admission or visit. Active pain control should be contemplated after URS in young patients and in those with a history of urinary tract infection, psychiatric illness, large stone size, and prolonged operation time.
Pain, postoperative; Ureterolithiasis; Ureteroscopy
The study is a prospective blinded randomised controlled trial to compare the efficacy of triamcinolone acetonide, bupivacaine or in combination in managing pain after lumbar discectomy. Patients undergoing primary single-level lumbar discectomy were randomised. Triamcinolone acetonide, bupivacaine or in combination was instilled at the nerve root as decompression. Preoperative, day 1 and 6 weeks pain score, 24-h postoperative opiate requirements and duration of inpatient stay were recorded. Data was analysed using Mann–Whitney test for statistical significance. 100 patients were recruited. A significant difference was noted in day one postoperative mean pain score, mean 24-h opiate requirement and mean inpatient stay in the triamcinolone acetonide and bupivacaine group. At 8 weeks postoperatively, no significant differences were seen in the pain score in all groups. Significant postoperative pain reduction and opiate requirements in the first 24 h, and significantly shortened duration of inpatient stay were achieved in the triamcinolone acetonide and bupivacaine group compared with other groups.
Pain management; Discectomy; Steroid; Local anaesthesia
Previous research has shown an association between preoperative depressive symptoms and a poorer surgery outcome in lumbar spinal stenosis (LSS). It is not known whether depressive symptoms throughout the recovery period are relevant to the outcome of surgery in LSS. In this prospective clinical study the predictive value of preoperative and postoperative depressive symptoms with respect to the surgery outcome is reported.
96 patients (mean age 62 years) with symptomatic lumbar spinal stenosis underwent decompressive surgery. They completed the same set of questionnaires preoperatively and 3 months, 6 months, 1 year and 2 years postoperatively. Depressive symptoms were assessed with the 21-item Beck Depression Inventory. Physical functioning and pain were assessed with the Oswestry Disability Index, the Stucki Questionnaire, self-reported walking ability and VAS rating. Logistic regression analyses were used to examine the predictive value of preoperative and postoperative depressive symptoms regarding the surgery outcome. A "good" outcome was defined in two ways: first, by gaining a 30% improvement in relation to the preoperative disability and pain, and second, by having a score at or below the median value for disability and pain on 2-year follow-up.
Having elevated depressive symptoms particularly on 3-month follow-up was predictive of a poorer surgery outcome regarding pain and disability: when the outcome was defined as less than 30% improvement from the baseline, the OR's (with 95% confidence intervals) were 2.94 (1.06-8.12), <0.05 for Oswestry and 3.33 (1.13-9.79), <0.05 for VAS. In median split approach the OR was 4.11 (1.27-13.32), <0.05 for Oswestry. Predictive associations also emerged between having depressive symptoms on 6-month and 1-year follow-ups and a poorer outcome regarding disability. The predictive value of elevated depressive symptoms particularly with respect to 2-yeard disability was evident whether the outcome was defined as a 30% improvement compared to the preoperative status or as belonging to the better scoring half of the study population on 2-year follow-up.
Preoperative and postoperative depressive symptoms may indicate those patients at greater risk of a poorer postoperative functional ability. For these patients, further clinical evaluation should be carried out, especially during postoperative stages.
OBJECTIVES: To show whether intra-articular steroid injections are effective in osteoarthritis; to determine factors that predict response; and to determine whether injection has a beneficial effect on muscle strength. METHODS: Double blind, placebo controlled, crossover study in 59 patients with symptomatic osteoarthritis of the knee. Outcome measure-Primary outcome measure: change in visual analogue score for pain at three weeks. Predictors of response analysed using logistic regression with a 15% decrease in pain score at three weeks defining response. RESULTS: Intra-articular methyl prednisolone acetate produced a significant reduction in visual analogue pain score at three weeks compared to both baseline (median change -2.0 mm, interquartile range -16.25 to 4.0) and placebo (median 0.0 mm, interquartile range -9.0 to 6.25). No clinical predictors of response could be identified. Muscle strength was not significantly improved in the short term by intra-articular injection. CONCLUSIONS: Intra-articular corticosteroids are effective for short term relief of pain in osteoarthritis but predicting responders is not possible. There may be a place for their more widespread use.
Video-assisted thoracoscopic surgery (VATS) and median sternotomy (MS) are two approaches in lung-volume reduction surgery (LVRS). This study focused on the two surgical approaches with regard to postoperative pain.
In this prospective, non-randomized study, pain was measured preoperatively and postoperatively using the visual analog scale (VAS) and the brief pain inventory (BPI). Incentive spirometry (IS) assessed restriction of the thoracic cage due to pain. Factors associated with treatment complications, medication usage, hospital stay, operating times, and chest-tube duration differences were examined between groups.
Of 85 patients undergoing LVRS, 23 patients underwent reduction via MS and 62 patients via bilateral VATS. VAS scores revealed no difference in postoperative pain except for VAS scores on days 6 (PM) and 7 (PM). BPI scores yielded higher scores in the VATS group on postoperative day (POD) 1 in the reactive dimension, but no other overall differences. MS patients receiving tramadol consumed a higher mean amount than VATS patients on POD 5 and POD 6. IS change from baseline to postoperative were similar between groups, and increased pain correlated with decreased IS scores on POD 1. Chest-tube duration, complications, and pain medication were similar between groups.
Bilateral VATS and MS offer similar outcomes with regard to postoperative pain and complications. These results suggest that the choice of LVRS operative approach should be dependent on disease presentation, surgeon expertise, and patient preference, not based upon differences in perceived postoperative pain between MS and bilateral VATS.
Median sternotomy; Bilateral thoracoscopy; Pain; Lung-volume reduction surgery; Visual analog scale; Brief pain inventory