Immediate Postsurgical Pain Outcomes Mediate Transition to Persistent Pain

Asian senior or elderly old lady woman patient show her scars surgical total knee joint replacement Suture wound surgery arthroplasty on bed in nursing hospital ward : healthy strong medical concept.
Outcomes of acute postsurgical pain management appear to mediate the process of transitioning to persistent, chronic pain.

A systematic review and meta-analysis found that risk for persistent postsurgical pain (PPP) is reduced using multimodal interventions and that pain during the immediate postoperative period was an important mediator of transition to chronic pain. These findings were published in the European Journal of Pain.

Investigators from the University of Calgary in Canada searched publication databases through January 2021 for studies of PPP. Persistent pain was defined as pain lasting >3 months after surgery. This study defined a clinically important difference as >10% reduction in the risk for persistent pain.

A total of 107 trials comprising 13,553 patients were included in this analysis. Patients were randomized to receive placebo or 1 of 13 treatments involving 10 active components.

PPP was reported by 22% of patients. Among patients with PPP, the most common categories of persistent pain were thoracic (24%), arthroplasty (20%), and breast (19.1%), among others.

Compared with placebo, the favored treatments were serotonin-norepinephrine reuptake inhibitors (SNRI; relative risk [RR], 0.34; 95% CI, 0.19-0.60), neural block with N-methyl-D-aspartate (NMDA) blocker (RR, 0.61; 95% CI, 0.46-0.81), neural block with gabapentinoid (RR, 0.61; 95% CI, 0.48-0.78), systematic local anesthetic (RR, 0.69; 95% CI, 0.50-0.96), and neural block (RR, 0.73; 95% CI, 0.61-0.87).

The most important predictor for treatment effect was immediate postoperative benefit (coefficient, -0.23; 95% CI, -0.49 to 0.03; P =.08).

Stratified by whether there was a postoperative benefit, anti-inflammatory (RR, 0.30; 95% CI, 0.12-0.78), SNRI (RR, 0.31; 95% CI, 0.17-0.56), neural block with gabapentinoid (RR, 0.38; 95% CI, 0.17-0.85), systemic local anesthetic (RR, 0.63; 95% CI, 0.42-0.93), gabapentinoid (RR, 0.65; 95% CI, 0.49-0.86), and neural block (RR, 0.69; 95% CI, 0.55-0.85) treatments were favored over placebo.

Limitations of this analysis included small sample sizes, the limited number of trials for specific interventions, and lack of patient diversity.

The study authors concluded, “The results from this exploratory network meta-analysis suggest that, irrespective of the interventions used, outcomes of acute postoperative pain management were a mediator for the transition to persistent pain.”


Allen C, Walker AM, Premji ZA, et al. Preventing persistent postsurgical pain: a systematic review and component network meta-analysis.Eur J Pain. Published online January 28, 2022. doi:10.1002/ejp.1915