I don’t know about you but I hate pain. I hate it for my patients and I hate it when it affects me. Truthfully, I hate it more when my patients have pain as it causes me pain internally as well. We both end up in a painful state. Patients do not realize how much we really suffer as surgeons when our patients are having a complication or more pain than is expected. At least when I have pain, I know for the most part that I can modulate it in some way or understand it to a greater extent than my patient can.
As surgeons, our greatest fear is having that scant percentage of patients who sadly develop a chronic pain syndrome. The statistics are staggering for the prevalence of chronic pain in the general population and more specifically when we look at pain that goes from acute postoperative surgical pain to chronic postoperative pain.
According to a recent article by Carroll and colleagues in the 2012 Journal of Reconstructive Microsurgery, approximately 10 percent of patients can develop chronic pain after a variety of different procedures.1 That statistic is truly astounding if you just sit back and chew on that number for a minute or two.
When you are working up that patient for surgery, are you contemplating what that patient may experience from a pain perspective? All of you know, provided that you have done this for an adequate amount of time, that patients who have more postoperative pain consume more time postoperatively, and negatively drain your internal mojo, than the patient who experiences no pain or very little pain. Those patients who rock through that immediate postoperative period and do well with no pain build your surgical mojo. I call it the surgeon mojo tide. The ebb and flow. The mo and the jo. Time is precious but if we can prevent pain or at the very least keep it to the very minimum, this is even more impactful for the patient and you get some “hero worship.” We all love heroes and want to be heroes.
Pain is complex, multifaceted and difficult to predict. How is it that you can do the same procedure with the same technique on two patients the same day and one has intense postoperative pain and the other has none? For that matter, why is it that you do the same procedure on both extremities, either simultaneously or at separate times, and one side is not painful and the other is intensely painful?
Why is that? What is contributing to it? Were your biorhythms better one day or did you pray harder to the surgical gods on the first surgery? Did patients not have pain on the first surgery but when round two came about, oh baby, that sucker really hurt? You didn’t do anything different in the two procedures. Perhaps you used the same technique but had a totally different result. I know this is hard to swallow.
Doesn’t it frustrate the hell out of you when you don’t know why something happens? It frustrates me. I can deal with complications conceptually and hopefully change whatever variable led to it if I can identify what has gone wrong in the first place.
Here is an example of something I recently encountered. Two days ago, I took a patient back to the OR to do a delayed primary closure of a wound that had dehisced due to a hematoma. I had performed two other nerve decompressions on the patient. Two of the three incisions healed uneventfully but the one at the foraminal level of the superficial peroneal nerve decompression did not. It was the same protoplasm at all three sites but a bleeder was in the third. I can understand that and knowing why this happened makes me feel better. There is a clear reason and this happens occasionally, although it is very rare.
So we take her back to the OR and I open it up and begin my exploration into the abyss. It was deep, I can assure you. I expected to see Sigourney Weaver at any moment. The tissue quality was really poor but thankfully not infected. What was the surgical plan? Go in, find the bleeder, treat the bleeder, clean the cavern, place a drain, close it up, let it heal and ride off into the beautiful Arizona sunset knowing that the problem has been solved.
As Lee Corso would say, not so fast, my surgical friends. (If you don’t get that, watch ESPN more. You won’t see it on DSPN, the other network I talked about before.) Anyway, I get a call. The patient started having intense pain for eight hours post-op (I did not get the call until the next afternoon) but for some reason could not come to the office until 42.6 hours post-surgery. You figure it out? Intense pain. We told the patient to come to the office ASAP and that was at post-op time 21.3 hours.
Anyway, at 35.6 hours post-op, I examined the patient. The wound looked great and there was minimal drainage in the vacutainer but she had intense pain. The patient is a nurse and admitted to hitting mom’s morphine to ameliorate her pain. She also requested a peripheral nerve block. Then she said: “When I clamped the hose to the vacutainer off, the pain dropped almost to zero. “Then I opened it up and boom!” (This was her word, not mine, but I love “boom.”)
“Interesting,” I said. While talking with her, I opened the suction up again and she almost immediately levitated out of the examination chair while expelling a guttural, tympanic membrane shattering F-bomb. The levitation truly scared me and the F-bomb repelled my exam stool, with me perched on top of it, away from her due to the acoustic wave. (If my shockwave machine goes on the fritz, I can just employ her to render repeated F-bombs to the affected plantar fasciopathy.)
At first, I felt like David Copperfield. I now had the secret to levitation. Put a drain in and have it suck directly on the nerve. I bet it will work every time. Quickly, I shut off the suction and she abruptly descended back down to earth with a sigh of relief and a significant thud. (I wanted to confirm my hypothesis with another trial but I could not bring myself to do it. As I told you, I hate pain but this was interesting no doubt.)
I gently pulled out the drain and the patient immediately felt better. I gave her some of her own morphine because Mom now had “lessphine” and I assumed that Mom had probably really needed it for some reason.
So what does this all mean? First, I think it reflects the fact that pain is complex and many factors can induce it or ameliorate it. It also means that we need to be looking for some better ways to psychologically screen these pre-surgical patients for pain and there are some options. Additionally, there are better ways to treat patients perioperatively and this will decrease their pain.
I have a secret recipe (it’s not really secret but it makes this blog much more intriguing if I say “secret”), and you deserve it if you have made it through this blog this far. I have been using it and I have been getting some serious hero worship.
Okay, here it is. Give patients 600 mg of gabapentin (Neurontin, Pfizer) two hours pre-op with just a sip of water and them take another 600 mg after they get home from their surgery. Then patients take 1,200 mg to 1,800 mg of gabapentin in three or four divided doses for seven to 14 days post-op. Start them on 50 mg to 1,000 mg of vitamin C for eight weeks. Vitamin C reduces the risk of developing chronic pain postoperatively. I don’t know why but that is what Carroll found out with thoracotomy patients.2
Have your anesthesiologist start a bolus of ketamine of 0.5 mg/kg. Then have the anesthesiologist provide an infusion of 0.25 mg/kg/hr during the case and give patients a preemptive local anesthetic nerve block to the area prior to your incision. Also have patients take a nonsteroidal anti-inflammatory drug (preferably a COX-2 inhibitor), if they can tolerate it, for a couple of weeks after surgery and start it a few days before surgery. Then give them their opiate of choice. Remember, if they tell you codeine doesn’t work, tend to believe them and DNA test them for cytochrome P450 enzymes. Trust me, they will tell you what they like but surprisingly, they won’t have to take much.
Go get your superhero costume out of that trunk in your attic and dust it off. If it needs cleaning and it is not mid-October, I recommend that you have your wife or other family member take it to the cleaners. It is easier and much less embarrassing that way.
1. Carroll I, Hah J, Mackey S, Ottestad E, Kong JT, Lahidji S, Tawfik V, Younger J, Curtin C. Perioperative interventions to reduce chronic postsurgical pain. J Reconstr Microsurg 2013, 29(4):213-222.
2. Carroll I. Presented at AENS Wine and Nerve Meeting, Napa, CA, 2013.