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      Chronic post-sternotomy pain.

      Acta Anaesthesiologica Scandinavica

      Adolescent, Adult, Aged, Aged, 80 and over, Chronic Disease, Coronary Artery Bypass, adverse effects, Female, Humans, Male, Middle Aged, Pain, Postoperative, epidemiology, etiology, Risk Factors, Sternum, surgery, Thymectomy

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          Abstract

          Chronic postoperative pain is a well-recognised problem. The incidence of severe incapacitating pain is about 3-5% after various types of surgery such as thoracotomy, repair of inguinal hernias and mastectomy. Sternotomy causes considerable postoperative pain and patients with chronic post-sternotomy pain are often referred to pain clinics. Epidemiological studies on chronic post-sternotomy pain are scarce, however. The aim of this paper was to study the incidence and possible risk factors of chronic pain following sternotomy operations performed for coronary bypass grafting or thymectomy. Two groups of patients were studied for persistent pain following sternotomy operations. A questionnaire was sent in January 1997 to 71 patients with myasthenia gravis (MG) who had undergone a thymectomy during 1985-1996 and 720 patients who had had coronary bypass grafting (CABG) in 1994 were interviewed by letter. The patients were asked about the presence of pain and other symptoms in the chest, shoulders, arms or legs that they thought were connected to surgery. They were also asked about the quality of the pain and its evolvement with time. The patients' records were checked for details about surgery, anaesthesia and the state of the coronary disease. The response rate was 87%. The interval between the interview and surgery varied from 6 months to 12 years in the MG group and it was 2-3 years in the CABG group. In the MG group, 27% of the patients reported chronic post-sternotomy pain, which was moderate to severe in 48% of the patients. In the CABG group, 28% of the patients still had post-sternotomy pain, which was moderate to severe in 38% of patients. Of the patients who had post-sternotomy pain, one-third reported sleep disturbances due to the pain. Chronic post-sternotomy pain is an important complication that may have a significant impact on the patient's everyday life. Future studies will show whether minimising complications, improving postoperative care and starting early adequate pain management will reduce the incidence of this problem.

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          Most cited references 19

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          Acute pain after thoracic surgery predicts long-term post-thoracotomy pain.

          Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors responsible for the transition of acute to chronic pain. The aim of the present study is to identify predictors of long-term post-thoracotomy pain. Follow-up was for 1.5 years for patients who had participated in a prospective, randomized, controlled trial of preemptive, multimodal analgesia. Subjects were recruited from a tertiary care center. Thirty patients who had undergone lateral thoracotomy were followed up by telephone, administered a structured interview, and classified according to long-term pain status. Present pain status was measured by a verbal rating scale (VAS). Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later. These include VAS pain scores at rest and after movement, McGill Pain Questionnaire data, patient-controlled morphine consumption (mg), and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision. Fifty-two percent of patients reported long-term pain. Early postoperative pain was the only factor that significantly predicted long-term pain. Pain intensity 24 h after surgery, at rest, and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients. A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Questionnaire. Cumulative morphine was comparable for the two groups. Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups. Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain.
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            Prospective study of chronic pain after groin hernia repair.

             H Kehlet,  K Bech,  T Callesen (1999)
            The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia. This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation. Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0.001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0.05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0.001). Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.
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              Pain location, distribution, and intensity after cardiac surgery.

              To study the location, distribution, and intensity of pain in a sample of adult cardiac surgery patients during their postoperative hospital stay. In a prospective study, pain location, distribution (number of pain areas per patient), and intensity (0 to 10 numerical rating scale) were documented on the first, second, third, and seventh postoperative day (POD). Patient characteristics (age, sex, size, and body mass index) were analyzed for their impact on pain intensity. A university hospital. Two hundred consecutive adult patients who underwent median sternotomy for open heart surgery. There were 121 male and 79 female patients, with a mean (+/- SD) age of 60.9 +/- 19.2 years. The maximal pain intensity was significantly higher on POD 1 and 2 (3.7 +/- 2 and 3.9 +/- 1.9, respectively) and lower on POD 3 and 7 (3.2 +/- 1.5 and 2.6 +/- 1.8, respectively). The pain distribution did not vary significantly throughout the hospital stay, but the location did, with more shoulder pain on POD 7. Only age was found to have an impact on pain intensity, with patients < 60 years having a higher pain intensity than older patients on POD 2 (4.3 +/- 2.2 vs 3.6 +/- 2.4; p = 0.02). In this patient population, the pain intensity diminished from POD 3 onward, although its distribution did not vary significantly during the first postoperative week. Moreover, pain location changed with time, with more osteoarticular type pain at the end of the first postoperative week. Among the patients' characteristics, only younger age had an impact on pain intensity, with a higher value on POD 2.
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