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A paper in the current issue<\/a> of the Postgraduate Medical Journal tackles a relatively modern concern: chronic postsurgical pain.<\/p>\n With the advent of modern anaesthetics, and advances in surgical technique, the potential for surgical intervention to tackle disease exploded.\u00a0 Indeed, there is now a whole industry based on surgically changing the way people look, which in the early days of surgery would have been almost unthinkable. For example, Samuel Pepys put off an operation for his bladder stone (which caused great pain and many infections) for many years before submitting to be cut by Thomas Hollier. [The lithotomy is now a rare beast, having been superseded by less invasive means of removing stones from the urinary tract.]<\/p>\n So surgery is now a much more accessible, and much safer option for the management of disease than it once was.\u00a0 However, it is not without its problems, and one which may have been under-represented for many years is that of ongoing pain.\u00a0 The incidence of chronic pain is quite remarkable, with up to 35% of patients undergoing hernia repair reporting pain more than 3 months after their surgery, and higher percentages in patients\u00a0 undergoing cardiac or thoracic surgery, and even in cholecystectomy rates of CPSP of up to 50% have been reported.<\/p>\n The paper discusses the pathophysiology of pain, and strategies to reduce the likelihood of developing chronic pain. The concepts of central sensitisation, secondary hyperalgesia, wind-up potentiation and pre-emptive and preventative analgesia are of great interest.<\/p>\n However, as one progresses through the article, a change takes place.\u00a0 One is guided into the realm of the pain clinic.\u00a0 Here, it is recognised that pain is not simple, it cannot be neatly captured in a line diagram of the spinothalamic tracts, but that pain is a multi-faceted experience for each patient, that can be influenced by a whole range of factors.\u00a0 The physical risk factors identified for the development of chronic postsurgical pain are important to note, including surgical technique, repeat surgery, and radiation to the surgical site, but what struck me more was the number of risk factors which could be described as relating to mental wellbeing.\u00a0 Six of the listed risk factors relate to mental state.<\/p>\n This key component of chronic postsurgical pain is borne out by the authors as they discuss the importance of the fear-avoidance model, and how anticipation, and fear have measurable influences on pain perception – confirmed through neuro-imaging studies.\u00a0 These insights into the development of a chronic condition, and how patients respond to their pain is hugely important, and their application extends beyond chronic postsurgical pain.<\/p>\n One of the key interventions the authors highlight is the provision of information to patients who are undergoing surgery to enable them to understand what they were experiencing post-operatively.\u00a0 The paper refernced was the report of an experiment conducted about 50 years ago <\/a>\u00a0 that examined the effect of an enthusiastic anaesthetist discussing the expected levels of post-operative pain, non-pharmacological methods of alleviating that pain, and a daily reinforcement of this message.\u00a0 The results are quite impressive, with a reduction in narcotics required, improved comfort, and a 2.7 day reduction in length of stay.<\/p>\n