CPSP is the MC and serious complication post surgery

No universally agreed definition >4 million people undergo Sx in UK

↑ analgesic use Restriction of activities of daily living Sig effects on QOL ↑ health care utilization

What do you understand by the term CPSP ? (10 %)

• CPSP is a type of neuropathic pain

What types of Surgical procedures does it most commonly follows? (10%)

Type of surgery Incidence of chronic pain (%)› Amputation 30–85› Thoracotomy 5–67› Mastectomy 11–57› Inguinal hernia repair 0–63› Sternotomy 28–56› Cholecystectomy 3–56› Knee arthroplasty 19–43› Breast augmentation 13–38

It may be related to the nerve injury, but not all patients with nerve injury get CPSP and not all patients with CPSP have nerve injuries

Central sensitization

What are the risk factors for the development of CPSP? (30%)

Preop› Severe, long-term preop pain› ↓ with increase in age› Genetic susseptibility› Psychosocial factors e.g. fear of surgery

Intra op› Longer, more complicated operation› Open (rather than laparoscopic)› Repeat surgery e.g. Hernia

Post op› Adjuvant interventions e.g.Radiotherapy› Severe post-op pain

What can be done to prevent it? (20%)

Good post-op pain relief itself eg. Epidural/ Paravertebral

Gabapentin and IV Ketamine are being used

Targinact ®(newer agents) Oxycodone +Naloxone in fastrack colorectal surgery

No evidence for pre-emptive RA

What is the management of CPSP ? (30%)

Multimodal Multidisciplinary approach with rational use of polypharmacy

Pharmacological- WHO, Antidepressants, anticonvulsants, NMDA

Non-pharmacological Psychotherapy (CBT, PMP) Complementary therapies (Acu, TENS) Functional rehabilitation Others

WHO analgesic ladder› Simple analgesics to Strong opiods› Anti depressants eg Amitryptilline› Anti convulsants eg. Carbamazapine› Calcium channel blockers eg. gabapentin› Directly acting eg clonidine› Nerve blocks› Acupuncture› Heat/cold, TENS