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Prädiktoren für chronische Schmerzen nach Operationen

Was wissen wir wirklich?

Predictors of chronic pain following surgery

What do we know?

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Zusammenfassung

Die Art des operativen Eingriffs scheint wesentlich zur Schmerzchronifizierung beizutragen. Besonders gefährdet sind in der Regel Patienten, die sich einer Thorakotomie, Brust- oder Leistenhernienoperation unterziehen müssen. Bekannt ist ebenfalls die hohe Rate von Phantomschmerzen nach Amputationen. In prospektiven und retrospektiven Untersuchungen konnte neben der Art der Operation eine Reihe weiterer, insbesondere patientenbezogener prä-, intra- und postoperativer Risikofaktoren für das Auftreten chronischer postoperativer Schmerzen nach einer Operation entschlüsselt werden. Hierzu zählen z. B. chronische Schmerzen schon vor der Operation, Alter und Geschlecht, genetische Faktoren, psychosoziale Eigenschaften und Schmerzen in den ersten Tagen nach der Operation. Da eine Vielzahl dieser Faktoren schon vor der Operation identifiziert werden kann, ist ein wichtiges Ziel zukünftiger Untersuchungen deshalb die präoperative Identifizierung von Patienten mit Risikofaktoren für die Entwicklung chronischer postoperativer Schmerzen. Das individuelle Risiko (bzw. ein Spektrum bestimmter Prädiktoren) muss ermittelt werden, um schon vor der Operation die Notwendigkeit und den Therapieerfolg eines präventiven Verfahrens voraussagen zu können. Da ein derartiges Vorgehen bislang noch nicht möglich ist, spielen aktuell eine nervenschonende Operationstechnik und eine effektive postoperative Akutschmerztherapie die bedeutsamste Rolle in der Prävention chronischer Schmerzen nach Operationen.

Abstract

Chronic postoperative pain is known to be a significant clinical and economic problem. The estimated mean incidence is high and varies between 10 and 50%, with variations mostly related to procedure-specific conditions. High-risk types of surgeries are e.g. thoracotomy, breast or inguinal hernia surgery and amputations. Although there is increasing knowledge about the incidence of chronic postoperative pain after certain types of surgical procedures, there are only limited data related to the mechanisms and pathophysiology leading to chronic pain after surgery. Neuropathic pain components have been discussed, especially following operations with a high incidence of nerve damage (for example axillary lymphadenectomy). Besides surgical factors it seems that there are a number of other factors which likely increase the risk of chronic postoperative pain. These predictors for the development of chronic postoperative pain are multiple and include individual genetic factors, age and sex of the individual patient, preoperative chronic pain, psychosocial factors, neurophysiological factors, intraoperative nerve and muscle damage, postoperative complications and acute pain in the early postoperative period. Quantitative sensory testing including tests of inhibitory circuits like DNIC might help to predict the risk of individual patients even before surgery has started. The perioperative identification of patients who are at high risk for developing chronic pain after surgery is therefore a major goal for the future. This may help to develop preventive treatment strategies and avoid treatments with side effects for patients who are not at risk for developing chronic pain after surgery. Due to a lack of appropriate data for sufficient preventive approaches an effective postoperative acute pain management and a nerve-conserving surgical technique are the major keys in the prophylaxis of chronic postoperative pain.

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  1. Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129, Münster, Deutschland

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Schnabel, A., Pogatzki-Zahn, E. Prädiktoren für chronische Schmerzen nach Operationen. Schmerz 24, 517–533 (2010). https://doi.org/10.1007/s00482-010-0932-0

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