Practical Tips for Managing Post-Op Pain
Ann-Marie Yost, M.D., neurosurgeon, Providence Brain & Spine Institute
Surgery hurts. The "pain as 5th vital sign" movement has left many people feeling that there should be no pain after surgery. The VAS (visual analog scale) has lost meaning now that exaggerated scores are the rule and not the exception. As physicians and surgeons, we have to help educate patients and manage post-operative issues.
Managing post-operative pain begins in the pre-operative period. Patient selection and setting realistic expectations are key. The Scoliosis Research Society and others have recommended postponing surgery on patients who are taking more than 120 ME (morphine equivalents) of narcotic/day. Patients on large doses of pre-op narcotics have more surgeries and do less well. Having a plan to wean narcotics pre-operatively is critical to managing post-operative pain. Morbidly obese patients also have more overall complications which can lead to increased pain. Pre-operative optimization can include weight loss. Patients with uncontrolled depression and anxiety have worse recoveries. The anesthesia pre-op clinic can assist with all of these potential barriers to better outcomes.
Coordinated post-operative care planning also helps manage pain. Adjunctive pre-op meds such as around the clock acetaminophen, NSAIDs when possible, muscle relaxants, supplemental gabapentin in narcotic tolerant patients, ketamine drips, local anesthetic injections into the wound, and the use of steroids and local anesthetics on nerve roots can all be helpful. Less well publicized but validated methods include breathing exercises, the viewing of calming natural images, and meditation. Mobilizing can be painful but helps patients alleviate stiffness and aggravation of pressure areas, as well as diminishing the risk of DVT. Having a clear post-operative plan to wean narcotics is comforting to patients as well.
Patients typically want to know whether they have a “normal” recovery. We can and should reassure them that some post-operative pain is normal. For example, patients with lumbar surgery could have residual nerve irritation for up to 6 weeks afterwards. Steroids and gabapentin or Lyrica can be helpful at this stage as an adjunct to narcotics and muscle relaxants. Physical therapy helps combat deconditioning and relieves stiffness. With these elements, a consistent plan from pre-op surgical decision-making through post-op release will assist patients through their recovery.