Skip to main content

Predictors of one year chronic post-surgical pain trajectories following thoracic surgery

Abstract

Purpose

Chronic post-surgical pain (CPSP) is a highly prevalent complication following thoracic surgery. This is a prospective cohort study that aims to describe the pain trajectories of patients undergoing thoracic surgery beginning preoperatively and up to 1 year after surgery

Methods

Two hundred and seventy nine patients undergoing elective thoracic surgery were enrolled. Participants filled out a preoperative questionnaire containing questions about their sociodemographic information, comorbidities as well as several psychological and pain-related statuses. They were then followed-up during their immediate postoperative period and at the three, six and 12 month time-points to track their postoperative pain, complications and pain-related outcomes. Growth mixture modeling was used to construct pain trajectories.

Results

The first trajectory is characterized by 185 patients (78.1%) with mild pain intensity across the 12 month period. The second is characterized by 32 patients (7.5%) with moderate pain intensity immediately after surgery which decreases markedly by 3 months and remains low at the 12 month follow-up. The final trajectory is characterized by 20 patients (8.4%) with moderate pain intensity immediately after surgery which persists at 12 months. Patients with moderate to severe postoperative pain intensity were much more likely to develop CPSP compared to patients with mild pain intensity. Initial pain intensity levels immediately following surgery as well as levels of pain catastrophizing at baseline were predicting pain trajectory membership. None of the surgical or anesthetic-related variables were significantly associated with pain trajectory membership.

Conclusion

Patients who undergo thoracic surgery can have postoperative pain that follows one of the three different types of trajectories. Higher levels of immediate postoperative pain and preoperative pain catastrophizing were associated with moderately severe CPSP.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. 1.

    Yoon S, Hong WP, Joo H, Kim H, Park S, Bahk JH, et al. Long-term incidence of chronic postsurgical pain after thoracic surgery for lung cancer: a 10 year single-center retrospective study. Reg Anesth Pain Med. 2020;45(5):331–6.

    PubMed  Article  Google Scholar 

  2. 2.

    Steegers MA, Snik DM, Verhagen AF, van der Drift MA, Wilder-Smith OH. Only half of the chronic pain after thoracic surgery shows a neuropathic component. J Pain. 2008;9(10):955–61.

    PubMed  Article  Google Scholar 

  3. 3.

    Li WW, Lee TW, Lam SS, Ng CS, Sihoe AD, Wan IY, et al. Quality of life following lung cancer resection: video-assisted thoracic surgery vs thoracotomy. Chest. 2002;122(2):584–9.

    PubMed  Article  Google Scholar 

  4. 4.

    Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris HB. Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg. 1997;12(1):82–7.

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Bendixen M, Jorgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17(6):836–44.

    PubMed  Article  Google Scholar 

  6. 6.

    Rizk NP, Ghanie A, Hsu M, Bains MS, Downey RJ, Sarkaria IS, et al. A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy. Ann Thorac Surg. 2014;98(4):1160–6.

    PubMed  PubMed Central  Article  Google Scholar 

  7. 7.

    Bayman EO, Lennertz R, Brennan TJ. Pain-related limitations in daily activities following thoracic surgery in a United States population. Pain Physician. 2017;20(3):E367–78.

    PubMed  Article  Google Scholar 

  8. 8.

    Bayman EO, Parekh KR, Keech J, Selte A, Brennan TJ. A prospective study of chronic pain after thoracic surgery. Anesthesiology. 2017;126(5):938–51.

    PubMed  Article  Google Scholar 

  9. 9.

    Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):50–5.

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Yarnitsky D, Crispel Y, Eisenberg E, Granovsky Y, Ben-Nun A, Sprecher E, et al. Prediction of chronic post-operative pain: pre-operative DNIC testing identifies patients at risk. Pain. 2008;138(1):22–8.

    PubMed  Article  Google Scholar 

  11. 11.

    Behera BK, Puri GD, Ghai B. Patient-controlled epidural analgesia with fentanyl and bupivacaine provides better analgesia than intravenous morphine patient-controlled analgesia for early thoracotomy pain. J Postgrad Med. 2008;54(2):86–90.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Mukherjee M, Goswami A, Gupta SD, Sarbapalli D, Pal R, Kar S. Analgesia in post-thoracotomy patients: comparison between thoracic epidural and thoracic paravertebral blocks. Anesth Essays Res. 2010;4(2):75–80.

    PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Khan RS, Skapinakis P, Ahmed K, Stefanou DC, Ashrafian H, Darzi A, et al. The association between preoperative pain catastrophizing and postoperative pain intensity in cardiac surgery patients. Pain Med. 2012;13(6):820–7.

    PubMed  Article  Google Scholar 

  14. 14.

    Wildgaard K, Ringsted TK, Hansen HJ, Petersen RH, Kehlet H. Persistent postsurgical pain after video-assisted thoracic surgery–an observational study. Acta Anaesthesiol Scand. 2016;60(5):650–8.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Katz J, Asmundson G, McRae K, Halket E. Emotional numbing and pain intensity predict the development of pain disability up to one year after lateral thoracotomy. Eur J Pain. 2008;13:870–8.

    PubMed  Article  Google Scholar 

  16. 16.

    Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009;36(1):170–80.

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    Amaya F. A good beginning makes a good ending: association between acute pain trajectory and chronic postsurgical pain. J Anesth. 2018;32(6):789–91.

    PubMed  Article  PubMed Central  Google Scholar 

  18. 18.

    Chapman CR, Donaldson GW, Davis JJ, Bradshaw DH. Improving individual measurement of postoperative pain: the pain trajectory. J Pain. 2011;12(2):257–62.

    PubMed  PubMed Central  Article  Google Scholar 

  19. 19.

    Page MG, Katz J, Curtis K, Lutzky-Cohen N, Escobar EM, Clarke HA. Acute pain trajectories and the persistence of post-surgical pain: a longitudinal study after total hip arthroplasty. J Anesth. 2016;30(4):568–77.

    PubMed  Article  Google Scholar 

  20. 20.

    Page MG, Katz J, Romero Escobar EM, Lutzky-Cohen N, Curtis K, Fuss S, et al. Distinguishing problematic from nonproblematic postsurgical pain: a pain trajectory analysis after total knee arthroplasty. Pain. 2015;156(3):460–8.

    PubMed  Article  Google Scholar 

  21. 21.

    Chapman CR, Davis J, Donaldson GW, Naylor J, Winchester D. Postoperative pain trajectories in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on acute pain. J Pain. 2011;12(12):1240–6.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–9.

    Article  Google Scholar 

  23. 23.

    Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. an updated literature review. J Psychosom Res. 2002;52(2):69–77.

    PubMed  Article  Google Scholar 

  24. 24.

    Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.

    CAS  Article  Google Scholar 

  25. 25.

    Taylor S, Zvolensky MJ, Cox BJ, Deacon B, Heimberg RG, Ledley DR, et al. Robust dimensions of anxiety sensitivity: development and initial validation of the anxiety sensitivity index-3. Psychol Assess. 2007;19(2):176–88.

    PubMed  Article  Google Scholar 

  26. 26.

    McCracken LM, Dhingra L. A short version of the pain anxiety symptoms scale (PASS-20): preliminary development and validity. Pain Res Manag. 2002;7(1):45–50.

    PubMed  Article  Google Scholar 

  27. 27.

    Sullivan M, Bishop S, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.

    Article  Google Scholar 

  28. 28.

    Pollard CA. Preliminary validity study of the pain disability index. Percept Mot Skills. 1984;59(3):974.

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Derogatis L. SCL-90-R Administration, scoring and procedures manual-II. Clinical psychometric research. Towson; 1983. p. 14–5.

    Google Scholar 

  30. 30.

    Woo A, Lechner B, Fu T, Wong CS, Chiu N, Lam H, et al. Cut points for mild, moderate, and severe pain among cancer and non-cancer patients: a literature review. Ann Palliat Med. 2015;4(4):176–83.

    PubMed  Google Scholar 

  31. 31.

    Centre NP. 2019 Canadian guideline for safe and effective use of opioids: McMaster University http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b08.html. Accessed 15 Mar 2021

  32. 32.

    McCracken LM, Zayfert C, Gross RT. The pain anxiety symptoms scale: development and validation of a scale to measure fear of pain. Pain. 1992;50(1):67–73.

    PubMed  Article  Google Scholar 

  33. 33.

    Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The pain disability index: psychometric and validity data. Arch Phys Med Rehabil. 1987;68(7):438–41.

    CAS  PubMed  Google Scholar 

  34. 34.

    Asparouhov T, Muthen B. Multilevel mixture models. In: Hancock GR, Samuelsen KM, editors. Advances in latent variable mixture models. Charlotte, NC: Information Age Publishing Inc; 2008. p. 27–51.

    Google Scholar 

  35. 35.

    Muthen B, Asparouhov T. Growth mixture modeling Analysis with non-Gaussian random effects. In: Fitzmaurice G, Davidian M, Verbeke G, Molenberghs G, editors. Longitudinal Data Analysis. Boca Raton: CRC Print ; 2009. p. 143–65.

    Google Scholar 

  36. 36.

    Muthen B, Shedden K. Finite mixture modeling with mixture outcomes using the EM algorithm. Biometrics. 1999;55:463–9.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    Proust-Lima C, Philipps V, Diakite A, Liquet B. Estimation of latent class mixed models joint latent class mixed models and mixed models for curvilinear outcomes: the R package version 1632013. J Stat Softw. 2013. https://doi.org/10.18637/jss.v078.io2.

    Article  Google Scholar 

  38. 38.

    Proust-Lima C, Philipps V, Diakite A, Liquet B. lcmm: extended mixed models using latent classes and latent proceses. R package version 1722015. J Stat Softw. 2015. https://doi.org/10.18637/jss.v078.io2.

    Article  Google Scholar 

  39. 39.

    Akaike A. Information measures and model selection. Int Stat Instit. 1983;44:277–91.

    Google Scholar 

  40. 40.

    deLeeuw J. Introduction to Akaike (1973) information theory and an extension of the maximum likelihood principle. In: Kotz S, Johnson NL, editors. Breakthrough in statistics. 1st ed. London: Springer; 1992. p. 599–609.

    Chapter  Google Scholar 

  41. 41.

    Katz J, Asmundson GJ, McRae K, Halket E. Emotional numbing and pain intensity predict the development of pain disability up to one year after lateral thoracotomy. Eur J Pain. 2009;13(8):870–8.

    PubMed  Article  Google Scholar 

  42. 42.

    Turner JA, Anderson ML, Balderson BH, Cook AJ, Sherman KJ, Cherkin DC. Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial. Pain. 2016;157(11):2434–44.

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Gibson E, Sabo MT. Can pain catastrophizing be changed in surgical patients? Sc Rev Can J Surg. 2018;61(5):311–8.

    Article  Google Scholar 

  44. 44.

    Nelson EA, Dowsey MM, Knowles SR, Castle DJ, Salzberg MR, Monshat K, et al. Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures. Complement Ther Med. 2013;21(6):697–711.

    PubMed  Article  Google Scholar 

  45. 45.

    Darnall BD. Pain psychology and pain catastrophizing in the perioperative setting: a review of impacts, interventions, and unmet needs. Hand Clin. 2016;32(1):33–9.

    PubMed  PubMed Central  Article  Google Scholar 

  46. 46.

    Abid Azam M, Weinrib AZ, Montbriand J, Burns LC, McMillan K, Clarke H, et al. Acceptance and commitment therapy to manage pain and opioid use after major surgery: preliminary outcomes from the toronto general hospital transitional pain service. Can J Pain. 2017;1(1):37–49.

    Article  Google Scholar 

  47. 47.

    Krebs ED, Mehaffey JH, Sarosiek BM, Blank RS, Lau CL, Martin LW. Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol. J Thorac Cardiovasc Surg. 2019;159(1):284–94.

    Article  Google Scholar 

  48. 48.

    Flores RM. Commentary: minimally invasive thoracic surgery lobectomy: truth versus hype. J Thorac Cardiovasc Surg. 2019. https://doi.org/10.1016/j.jtcvs.2019.09.017.

    Article  PubMed  Google Scholar 

  49. 49.

    Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. Rev Predict Factors Anesthesiol. 2000;93(4):1123–33.

    CAS  Google Scholar 

  50. 50.

    Katz J. One man’s risk factor is another man’s outcome: difference in risk factor profiles for chronic postsurgical pain maintenance vs transition. Pain. 2012;153(3):505–6.

    PubMed  Article  Google Scholar 

  51. 51.

    Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother. 2009;9(5):723–44.

    PubMed  Article  Google Scholar 

  52. 52.

    McNicol ED, Schumann R, Haroutounian S. A systematic review and meta-analysis of ketamine for the prevention of persistent post-surgical pain. Acta Anaesthesiol Scand. 2014;58(10):1199–213.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013;111(5):711–20.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  54. 54.

    von Knorring L, Perris C, Eisemann M, Eriksson U, Perris H. Pain as a symptom in depressive disorders. II. Relationship to personality traits as assessed by means of KSP. Pain. 1983;17(4):377–84.

    Article  Google Scholar 

  55. 55.

    Lee P, Zhang M, Hong JP, Chua HC, Chen KP, Tang SW, et al. Frequency of painful physical symptoms with major depressive disorder in asia: relationship with disease severity and quality of life. J Clin Psychiatr. 2009;70(1):83–91.

    Article  Google Scholar 

  56. 56.

    Aguera-Ortiz L, Failde I, Mico JA, Cervilla J, Lopez-Ibor JJ. Pain as a symptom of depression: prevalence and clinical correlates in patients attending psychiatric clinics. J Affect Disord. 2011;130(1–2):106–12.

    CAS  PubMed  Article  Google Scholar 

  57. 57.

    Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163(20):2433–45.

    PubMed  Article  Google Scholar 

  58. 58.

    Williams LS, Jones WJ, Shen J, Robinson RL, Weinberger M, Kroenke K. Prevalence and impact of depression and pain in neurology outpatients. J Neurol Neurosurg Psychiatry. 2003;74(11):1587–9.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    Birket-Smith M. Somatization and chronic pain. Acta Anaesthesiol Scand. 2001;45(9):1114–20.

    CAS  PubMed  Article  Google Scholar 

  60. 60.

    Bayman EO, Brennan TJ. Incidence and severity of chronic pain at 3 and 6 months after thoracotomy: meta-analysis. J Pain. 2014;15(9):887–97.

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

Hance Clarke is supported by a Merit Award from the Department of Anaesthesia at the University of Toronto. M Gabrielle Pagé is a Junior 1 research scholar from the Fonds de recherche du Québec en santé. Joel Katz is supported by a Canadian Institutes of Health Research, Canada Research Chair in Health Psychology at York University. This study is funded by a peer-reviewed grant from Physician Services Incorporated.

Funding

KL is a co-principal investigator for an observational study of medical cannabis funded by Shopper’s Drug mart.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Hance Clarke.

Ethics declarations

Conflict of interest

KL is a co-principal investigator for an observational study of medical cannabis funded by Shopper’s Drug mart. The other authors have no conflicts of interest to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

About this article

Verify currency and authenticity via CrossMark

Cite this article

Liu, C.W., Page, M.G., Weinrib, A. et al. Predictors of one year chronic post-surgical pain trajectories following thoracic surgery. J Anesth 35, 505–514 (2021). https://doi.org/10.1007/s00540-021-02943-7

Download citation

Keywords

  • Post-thoracotomy pain syndrome
  • Chronic post-surgical pain
  • Thoracotomy
  • Thoracic surgery
  • Pain trajectory