Surprises found in postoperative pain rankings

By Eleanor McDermid, Senior medwireNews Reporter

Patients report "unexpectedly high" levels of pain after some relatively minor surgical procedures, including some laparoscopic procedures, say researchers.

Hans Gerbershagen (University Medical Center Utrecht, the Netherlands) and team ranked the pain responses of 50,199 patients who underwent 179 types of surgery. Supposedly minor procedures, such as appendectomy and tonsillectomy, appeared high in the ranking, they report in Anesthesiology.

In an accompanying editorial, Girish Joshi (University of Texas Southwestern Medical School, Dallas, USA) and Henrik Kehlet (Copenhagen University, Denmark) stress that "it is imperative that this ranking is not taken 'literally' to suggest the degree of pain intensity generated by a certain surgical procedure."

They say: "The most likely reason for the observations of this study is that patients undergoing the surgical procedures that have the reputation of being less painful received inadequate pain relief. In contrast, patients undergoing highly painful surgical procedures received more aggressive analgesic therapy."

Indeed, some major procedures, such as above-knee amputation, total gastrectomy, mastectomy, open lung resection, and radical prostatectomy, were ranked below position 115 out of 179, with a median worst-pain score of about 4 out of a possible 10.

Tonsillectomy, open appendectomy, hemorrhoidectomy with plastic reconstruction, and open cholecystectomy were all ranked within the top 25 positions. Two "minor" orthopedic procedures - arthrodesis of foot joint and arthrodesis of metacarpophalangeal joints - were ranked within the top 10 positions, with median pain scores of 6.2 and 6.1, respectively.

The patients' records indicated they had not received opioids, or were given only low doses, after these minor surgical procedures despite reporting significant pain. "It is thus conceivable that high pain intensities were often ignored or not taken seriously," says the team.

Patients undergoing major abdominal surgery were generally given adequate pain relief, resulting in median pain scores of about 4. But those undergoing major orthopedic surgery frequently reported high pain scores; three types of spinal surgery occupied positions 2, 3, and 6 in the ranking.

The top-ranked procedure was open reduction of the calcaneus. Although patients undergoing this operation or the spinal surgeries were given opioids, the average amount given was well below what patients reportedly use in trials of patient-controlled analgesia.

Joshi and Kehlet comment: "The failure of the currently available guidelines [for pain management] may be because they are generalized for all surgical procedures and may confuse a practitioner who intends to use them for a specific procedure." They emphasize the need for "updated, evidence-based, procedure-specific pain management guidelines."

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