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      Risk Factors Associated with Development of Acute and Sub-Acute Post-Cesarean Pain: A Prospective Cohort Study

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          Although cesarean delivery is one of the most commonly performed surgical procedures, robust data regarding post-cesarean pain is still lacking. Recent studies showed an association between pain upon local anesthetic (LA) injection for spinal anesthesia, or the use of a “three simple questions”, and acute post-cesarean pain. Nevertheless, these assessments have yet to be validated further, despite their relative ease of use. We aimed to assess the association between pain score upon LA injection with acute post-cesarean pain after 24 hours at rest (primary outcome) and sub-acute post-cesarean pain lasting for 4 weeks or more (secondary outcome).


          Women undergoing cesarean delivery under spinal anesthesia were given pre-operative questionnaires on pain and psychological vulnerability. We also assessed the pain score upon LA injection and mechanical temporal summation. Univariate and multivariable logistic regressions were performed.


          The incidence of moderate-to-severe acute post-cesarean pain at 24 hours was 21.0% (95% CI=16.6–27.6%) (48 of 217 patients). Pain score upon LA injection was not significantly associated with acute post-cesarean pain after 24 hours at rest (unadjusted OR=1.10, 95% CI=0.95–1.27, P=0.21). However, pain score upon LA injection was significantly associated with sub-acute post-cesarean pain (adjusted OR=1.29, 95% CI=1.07–1.55, P=0.0089) with significant covariate of increased pre-operative central sensitization inventory (CSI) scores (adjusted OR=1.05, 95% CI=1.01–1.09, P=0.0111; area under the curve (AUC)=0.691).


          There was no association between increased pain score upon LA injection and acute post-cesarean pain, but it was associated with sub-acute post-cesarean pain. Further work is needed to define pain score upon LA injection as a convenient pragmatic measure of risk stratifying patients predisposed to sub-acute post-cesarean pain.

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          Most cited references 26

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          Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.

          Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.
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              The development and psychometric validation of the central sensitization inventory.

              Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term "central sensitivity syndrome (CSS)" has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients who presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test-retest reliability = 0.817; Cronbach's alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to 4 groups: fibromyalgia (FM); chronic widespread pain without FM; work-related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the patients with FM reported the highest CSI scores and the normative population the lowest (P < 0.05). Analyses also demonstrated that the prevalence of previously diagnosed CSSs and related disorders was highest in the FM group and lowest in the normative group (P < 0.001). Taken together, these 2 studies demonstrate the psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating CS-related clinical symptoms in chronic pain populations.  Published 2011. No claim to original US government works. Pain Practice © 2011 World Institute of Pain.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                18 September 2020
                : 13
                : 2317-2328
                [1 ]Department of Women’s Anesthesia, KK Women’s and Children’s Hospital , Singapore
                [2 ]Anesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School , Singapore
                [3 ]Centre for Quantitative Medicine, Duke-NUS Medical School , Singapore
                [4 ]Department of Anesthesiology, Duke University , Durham, NC, USA
                Author notes
                Correspondence: Ban Leong Sng Department of Women’s Anesthesia, KK Women’s and Children’s Hospital , 100 Bukit Timah Road, 229899, SingaporeTel +65 6394 1081Fax +65 62912661 Email sng.ban.leong@singhealth.com.sg
                © 2020 Chan et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 3, Tables: 12, References: 30, Pages: 12
                Funded by: SingHealth Duke-NUS Academic Medical Centre;
                This work was supported by the funding from the SingHealth Duke-NUS Academic Medical Centre, Anesthesiology and Perioperative Science Academic Clinical Program Pilot Research Grant (Grant no. ANAESPRG18/02). The aforementioned sponsor was not involved in the study activities.
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