Demographic, ethnic, and perioperative practices associated with persistent incisional pain following surgery have been identified, according to research results published in Pain Medicine.

Using data from the VISION Study (ClinicalTrials.gov identifier NCT00512109) — an international, prospective cohort study — researchers sought to identified the incidence, characteristics, impact, and risk factors associated with persistent incisional pain after noncardiac surgery.

VISION participants underwent surgery between 2008 and 2014 in 28 centers across 6 continents. In the current substudy, investigators evaluated persistent incisional paint at 1 year after surgery, with data collection beginning in June 2012.


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The primary VISION study enrolled 40,037 patients with a total of 14,831 who were alive and able to provide 1-year data on incision pain for the substudy. Mean participant age was 68.7±10.9 years; 51% were women. Twenty percent had a history of diabetes, 14% had active cancer, and 41% had a history of tobacco use. Roughly 10% of patients reported chronic pain prior to surgery. The most common procedures were general, orthopedic, and urologic-gynecologic surgery (19.1%, 18.8%, and 14.5%).

At 1 year, 3.3% of patients (n=495) reported persistent incisional pain. Results of a univariate analysis compared with the entire sample showed those with persistent pain were significantly younger, more likely to be women, and had a higher rate of tobacco use, coronary artery disease, and a history of chronic pain. These patients had also undergone more orthopedic and neurosurgeries.

Incisional pain varied by surgical subgroup, with 7.1% of pain associated with pneumonectomies, followed by major spine surgery (6.2%), complex visceral resections (6.1%), thoracic aortic reconstructions (5.7%), and other thoracic surgery (5.5%). Persistent incision pain incidence was 7.3% in those with a history of chronic pain, vs 2.9% in those without.

At 1 year, the worst pain was 5.1±2.7, while least pain was 2.0±2.3 and pain on average was 3.6±2.5; pain at the time of the interview as 2.7±2.7 on a 0 to 10 pain scale. In terms of 24-hour pain intensity, 51.5% of participants reported mild pain (scores 0-3), 34.9% reported moderate pain (scores 4-6), and 13.5% reported severe pain (scores 7-10). Eighty-one percent of participants reported 1 or more features of neuropathic pain, including tingling, numbness, or allodynia associated with touch around the surgical scar.

Most participants — 85.1% — reported the interference of pain with some aspect of their daily living. The highest interference was associated with walking (3.5±3.7), normal work (3.5±3.4), and general activity (3.4+3.3). A total of 33.5% reported no interference, while 22.2%, 22.5%, and 21.7% reported mild, moderate, and severe interference.

Roughly 52.7% of patients with persistent incisional pain reported taking pain medication specifically for incisional pain relief. Those who took pain medication experienced significantly greater interference with all aspects of daily living.

Results of a multivariable logistic regression model of preoperative risk factors associated with the development of persistent incisional pain found 9 independent predictors: Asian ethnicity, history of chronic pain, surgery for fracture, history of coronary artery disease, female sex, history of tobacco use, age, South Asian ethnicity, Native American/Australian ethnicity, and Latin/Hispanic ethnicity.

In a multivariable logistic regression model of perioperative interventions to predict the development of persistent incisional pain, 6 variables were significantly associated. Only 1 — endoscopic surgery — was associated with a lower risk of persistent pain. The variables associated with an increased risk of pain were NSAIDs taking 1 to 7 days, but stopped 24 hours prior to, the surgery, postoperative patient-controlled analgesia use, postoperative continuous nerve block use, cyclooxygenase-2 inhibitors taken 1 to 7 days before, but stopped 24 hours prior to, the surgery, and insulin not taken within 1 to 7 days of surgery but given within 24 hours of surgery.

Study limitations include limited access to other baseline and perioperative variables of interest, lack of pain-specific data, and the time period being limited to that of the main study follow-up periods.

“Our findings across a large international cohort of patients suggest that persistent pain is unfortunately a common and problematic complication after surgery,” the researchers concluded. “Several demographic and perioperative factors have been identified to be associated with increased risk of persistent pain, and these data can help inform future studies in identifying high risk patients and randomized trials on whether modification of these risk factors can lead to reduced rates of persistent pain.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Khan JS, Sessler DI, Chan MTV, et al. Persistent incisional pain after noncardiac surgery: An international prospective cohort study. Anesthesiology. 2021;135(4):711-723. doi:10.1097/ALN.0000000000003951