Prediction of Pain and Opioid Utilization in the Perioperative Period in Patients Undergoing Primary Knee Arthroplasty: Psychophysical and Psychosocial Factors

Christopher R Abrecht, Marise Cornelius, Albert Wu, Robert N Jamison, David Janfaza, Richard D Urman, Claudia Campbell, Michael Smith, Jennifer Haythornthwaite, Robert R Edwards, Kristin L Schreiber, Christopher R Abrecht, Marise Cornelius, Albert Wu, Robert N Jamison, David Janfaza, Richard D Urman, Claudia Campbell, Michael Smith, Jennifer Haythornthwaite, Robert R Edwards, Kristin L Schreiber

Abstract

Objective: To identify factors associated with pain severity and opioid consumption in the early perioperative period.

Design: Prospective observational cohort study.

Setting: Tertiary academic medical center.

Subjects: Patients with osteoarthritis older than age 45 years undergoing primary total knee replacement at Brigham and Women's Hospital. A total of 126 patients enrolled.

Methods: Preoperatively, pain questionnaires and quantitative sensory testing were performed on patients to develop a psychosocial and psychophysical profile. Postoperatively, pain scores and opioid consumption were measured as primary end points. Univariate and multiple linear regression analyses were performed to determine the predictive value of these characteristics on perioperative pain scores and opioid consumption.

Results: Regression analysis revealed several predictors of acute postoperative pain scores including temporal summation of pain (TSP; P = 0.001), body mass index (BMI; P = 0.044), number of previous knee surgeries (P = 0.006), and female gender (P = 0.023). Similarly, predictors of opioid utilization included TSP (P = 0.011), BMI (P = 0.02), age (P = <0.001), and tourniquet time (P = 0.003).

Conclusions: The only significant, unique predictors of both pain and opioid consumption were TSP, an index of central pain facilitatory processes, and BMI. Interestingly, psychosocial factors, such as catastrophizing and somatization, although correlated with postoperative pain scores and opioid consumption, generally did not independently explain substantial variance in these measures. This study suggests that BMI and quantitative sensory testing, specifically the temporal summation of pain, may provide value in the preoperative assessment of patients undergoing total knee arthroplasty and other surgeries via predicting their level of risk for adverse pain outcomes.

Figures

Figure 1
Figure 1
All recorded pain numerical rating scores (NRS) across the entire postoperative course. Standard deviation is depicted by the vertical line within each epoch, with mean NRS depicted by the circle along each standard deviation line. PACU = post-anesthesia care unit; POD = postoperative day.
Figure 2
Figure 2
Distribution of average numerical rating scale (NRS) pain score by patient. For each patient, the summation of all recorded NRS pain scores was divided by the number of observations. Frequency denotes the number of patients in each category.
Figure 3
Figure 3
Distribution of average oral morphine milligram equivalent (MME) per day over a two-day postoperative period. For each patient, the summation of all MME doses was divided by the total number of hospital days. Frequency denotes the number of patients in each category.
Figure 4
Figure 4
Values are overlaid with lines of best fit. MME = morphine milligram equivalent; PACU = post-anesthesia care unit; POD = postoperative day.

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