Clinical Update: Helping Patients With Chronic Postoperative Pain

Making a referral to an expert is an intimidating but necessary first step.

No surgeon wants to face a postoperative complication. But the reality is that complications, such as chronic postoperative pain, happen to patients even when they’re under the care of the best physicians. The worst thing we could do as surgeons would be to bury our heads in the sand and let our patients live in pain month after month while we hope for their suffering to disappear. If their pain is stemming from a nerve that was unknowingly damaged during surgery, it won’t go away on its own.

As a plastic reconstructive and peripheral nerve surgeon specializing in the treatment of nerve injuries, I have unfortunately seen dozens of patients who have lived this experience. The good news is that, with a timely referral, nerves can be surgically repaired to potentially resolve pain.

Proactive and pragmatic

It’s understandable that providing a referral to another surgeon to look at your work can feel intimidating. But with so much at stake, a proactive approach is the most pragmatic. Despite there being a complication, most patients appreciate the act of a referral to help address their pain and perceive it as an initiative-taking collaboration.

If your patient is experiencing ongoing pain weeks or months after surgery and the cause can’t be identified through typical means like an X-ray, CT scan, or MRI, consider that they could potentially have a nerve injury that was sustained during surgery. Don’t be afraid to refer them to an experienced microsurgeon specializing in nerve surgery. If nerve damage is the issue, a surgeon with this expertise can help.

Patients with this post-op complication often see more than 20 providers before finally being evaluated by a surgeon who specializes in nerve function and repair. You can help patients avoid this by making a referral as early as possible. If nerve repair is indicated, surgery should ideally take place within the first three to six months from when the injury occurred to best repair the nerve damage and to reduce pain levels. That said, a referral should still be made even if the six-month window has passed.

How can surgery result in nerve damage and cause pain?

Nerves are like the electrical wiring of the body that carry signals to and from the brain. They allow people to feel, move and touch, but when a nerve is cut or damaged during surgery, the signals are disrupted and cause ongoing pain. Sometimes the pain is caused by a neuroma — a tangled mass of nerve and scar tissue that forms in the nerve. Pain can also be caused by secondary scarring leading to tethering and/or compression. Symptoms of nerve injuries can present as pain, numbness, burning sensations or loss of function in the affected area. If these symptoms last longer than three months after surgery, it may be a sign of nerve damage.

Chronic postoperative pain is common. Ten to 40% of patients experience chronic neuropathic pain after surgery, known as induced neuropathic pain or SNPP. Common signs of nerve damage include pain that ranges from tingling to sharp shooting spasms, numbness, pressure or squeezing sensations, hypersensitivity, weakness or decreased motor function or physical changes such as changes to skin color or muscle mass. Nerve size, anatomy and location vary from patient to patient, so nerves can be difficult to see during surgery. As a result, they can be unintentionally and unknowingly cut, compressed or stretched. This happens most frequently during the following procedures: Joint replacements, laparoscopic or arthroscopic procedures, amputation, mastectomy, nerve biopsy, thoracotomy, hernia repair, caesarean section, abdominoplasty and hysterectomy.

How can a surgeon discuss the possibility of nerve damage with a patient?

If a patient is experiencing ongoing pain for longer than three months post-surgery, it may be prudent to start talking about the possibility of nerve damage and nerve repair options. You can explain to them that nerves run throughout the body and that everyone’s anatomy differs, so inadvertent nerve injuries are common and a risk during any surgery. Share with your patient that there are surgeons who specialize in diagnosing and treating nerve injuries and that you can offer a referral for a consultation. You can explain that an initial consult would involve discussing their recent medical history, as well as a noninvasive physical examination to determine where the pain is stemming from and where a potential nerve issue may exist.

I know from many experiences that patients appreciate this upfront, proactive approach. After all, they’re in pain, they want relief, and their patience and tolerance can understandably fade fast. We all know that patients who are in chronic pain can quickly become labeled as difficult, but if we’re transparent about the possibilities of what could be causing their pain and promptly help them find answers, I believe our reputations as surgeons improve and patients end up being more understanding.

Education is power, so ASC administrators and HOPD directors can help by having surgeons who specialize in the treatment of nerve injuries come into their facilities for presentations to provide education about the causes of and solutions for nerve injuries, and the importance of swift intervention can be informative and impactful.

Many patients find immediate relief after nerve repair surgery, such as a patient of mine who experienced unrelenting pain in his lower leg and a foot drop due to his surgeon unknowingly putting a suture through his peroneal nerve during meniscus repair surgery. This patient is now living 100% pain-free and has been able to get back to the activities he enjoys, such as hiking.

Not enough healthcare providers, including surgeons, know about nerve pain, how it can affect people’s lives, or that there are potentially permanent ways to resolve it. Complications will happen. What we can control is what we do in the proceeding weeks and months. When we know more, we can do better — for our patients and ourselves. If you ever find yourself in a situation where you think nerve damage could be causing your patient pain, know that help is just a referral away. OSM