Rethinking the definition of chronic postsurgical pain: composites of patient-reported pain-related outcomes vs pain intensities alone

Debora M Hofer, Thomas Lehmann, Ruth Zaslansky, Michael Harnik, Winfried Meissner, Frank Stüber, Ulrike M Stamer, Debora M Hofer, Thomas Lehmann, Ruth Zaslansky, Michael Harnik, Winfried Meissner, Frank Stüber, Ulrike M Stamer

Abstract

Chronic postsurgical pain (CPSP) is defined by pain intensity and pain-related functional interference. This study included measures of function in a composite score of patient-reported outcomes (PROs) to investigate the incidence of CPSP. Registry data were analyzed for PROs 1 day and 12 months postoperatively. Based on pain intensity and pain-related interference with function, patients were allocated to the groups " CPSPF " (at least moderate pain with interference), " mixed " (milder symptoms), and " no CPSPF ". The incidence of CPSPF was compared with CPSP rates referring to published data. Variables associated with the PRO-12 score (composite PROs at 12 months; numeric rating scale 0-10) were analyzed by linear regression analysis. Of 2319 patients, 8.6%, 32.5%, and 58.9% were allocated to the groups CPSPF , mixed , and no CPSPF , respectively. Exclusion of patients whose pain scores did not increase compared with the preoperative status, resulted in a 3.3% incidence. Of the patients without pre-existing pain, 4.1% had CPSPF. Previously published pain cutoffs of numeric rating scale >0, ≥3, or ≥4, used to define CPSP, produced rates of 37.5%, 9.7%, and 5.7%. Pre-existing chronic pain, preoperative opioid medication, and type of surgery were associated with the PRO-12 score (all P < 0.05). Opioid doses and PROs 24 hours postoperatively improved the fit of the regression model. A more comprehensive assessment of pain and interference resulted in lower CPSP rates than previously reported. Although inclusion of CPSP in the ICD-11 is a welcome step, evaluation of pain characteristics would be helpful in differentiation between CPSPF and continuation of pre-existing chronic pain.

Conflict of interest statement

U. Stamer received fees and reimbursement for travel costs from Sanofi Aventis outside the submitted work, paid to her institution. W. Meissner received fees outside the submitted work from Ethypharm, Grünenthal, Kyowa Kirin, Mundipharma, Northern Swan Holdings, Septodont, Spectrum Therapeutics, and TAD Pharma. The remaining authors have no conflicts of interest to declare.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.

Figures

Figure 1.
Figure 1.
Flowchart with number (%) of patients. Definition of CPSPF considers not only pain but also pain-related functional interference assessed with a questionnaire 12 months (M12) after surgery. CPSPF: CPSP defined by chronic postsurgical pain and pain-related interference of function.
Figure 2.
Figure 2.
Percent of patients with CPSPF and CPSP in the present cohort applying different definitions of CPSP. For comparison, some results of previous studies are displayed. CPSPF ICD-11: Patients meeting the ICD-11 requirement that pain intensity at the site of surgery had increased compared with the preoperative situation. CPSP-0, CPSP-3, and CPSP-4 (orange bars): application of the cutoff NRS >0, NRS ≥3, or NRS ≥4 to this cohort. Time after surgery is indicated after the author's name (i.g. 3M: 3 months). a: mixed surgical group; b: trauma/orthopedic surgery; c: breast cancer surgery; d: gynecological surgery; e: thoracic or cardiac surgery; f: outpatient surgery. NRS, numeric rating scale.
Figure 3.
Figure 3.
Patient-reported outcomes of the 3 CPSPF groups 24 hours after surgery. PCS-1: pain composite score at the first day after surgery; PRO-1: composite score for patient-reported outcomes at the first day after surgery; side effects: composite score corresponding to the mean of the variables dizziness, drowsiness, nausea, and itching. Box and whisker plots with median, IQR, 10% to 90% percentiles; +: mean; ** P < 0.001.
Figure 4.
Figure 4.
Multivariable linear regression analysis with PRO-12 score as dependent variable. Reference for analysis of the surgical groups is general surgery. Boxes represent regression coefficients, and whiskers are 95% CI. Exact measures are shown in the right column. * P < 0.05; **P < 0.001; *** P < 0.001.

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