PROMs (Patient Reported Outcome Measures) after surgery for patients with chronic pain

In line with the new definition of chronic pain [1] outcome measures of pain treatment have shifted from unidimensional scales (NRS, VRS) to multidimensional patient reported outcome measures. The Patient Reported Outcome Measurement Information System (PROMIS) rates across seven domains (pain interference, physical functioning, anxiety, depression, fatigue, sleep disturbance, and the ability to participate in social roles and activities) with four questions in each domain. PROMIS have been shown to be adequate and cross-walks may replace disease specific legacy PROMS [2, 3]. In Europe, data for the general population are available online [4].

Opioids are an integral part of many chronic pain patients but are not associated with improvement of PROMIS PI (pain interference) and PF (physical function) scores [5]. A consensus group advocated against Buprenorphin tapering before surgery [6] but opioid weaning improves PROMIS profiles for patients undergoing spine surgery [7] and liver transplants [8]. Methadone may be more effective than conventional perioperative short acting opioids [9, 10] and may also prevent against chronic pain after surgery [11].

Perioperative low dose Ketamine treatment has been advocated for chronic pain patients [12, 13]. A combination of Methadone and Ketamine showed impressive results in spinal surgery patients [14]. Gabapentinoid treatment should be continued but not initiated for surgery [15, 16]. i.v Lidocaine currently has no clear beneficial impact [17]. Regional anesthesia is generally advocated as its opioid sparing effects are well documented. Whether it provides protection against chronic pain after surgery is less clear [18, 19].

[1] Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain, 2019; 160: 19–27.

[2] Horn ME, Reinke EK, Couce LJ, et al. Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review. J Orthop Surg Res, 2020; 15: 553.

[3] Fidai MS, Saltzman BM, Meta F, et al. Patient-Reported Outcomes Measurement Information System and Legacy Patient-Reported Outcome Measures in the Field of Orthopaedics: A Systematic Review. Arthroscopy. 2018; 34: 605–614.

[4] http://www.common-metrics.org /PROMIS_Profile_29_General_ Population.php (Accessed: 10 July 2021).

[5] Sawires AN, Divi SN, Schroeder GD, et al. Clin Spine Surg, 2021; 34: E154–E159.

[6] Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth, 2019; 123: 333–342.

[7] Hassamal S, Haglund M, Wittnebel K, Danovitch I. A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series. Scand J Pain, 2016; 13: 27–31.

[8] Fukazawa K, Rodriguez PJ, Fong CT, Gologorsky E. Perioperative Opioid Use and Chronic Post-Surgical Pain after Liver Transplantation: A Single Center Observational Study. J Cardiothorac Vasc Anesth, 2020; 34: 1815–1821.

[9] Kendall MC, Alves LJ, Pence K, et al. The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials. Anesth Res Pract, 2020, Article ID 6974321.

[10] D'Souza RS, Gurrieri C, Johnson RL, et al. Intraoperative methadone administration and postoperative pain control: a systematic review and meta-analysis. Pain, 2020; 161:237–243.

[11] Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery. Anesthesiology, 2020; 132: 330–342.

[12] Boenigk K, Echevarria GC, Nisimov E, et al. Low-dose ketamine infusion reduces postoperative hydromorphone requirements in opioid-tolerant patients following spinal fusion: A randomised controlled trial. Eur J Anaesthesiol, 2019; 36: 8–15.

[13] Riddell JM, Trummel JM, Onakpoy IJ. Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis. Br J Anaesth, 2019; 123: 325–334.

[14] Murphy GS, Avram MJ, Greenberg SB, et al. Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology, 2021; 134: 697–708.

[15] Verret M, Lauzier F, Zarychanski R, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology, 2020; 133: 265–279.

[16] Carley ME, Chaparro LE, Choinière M, et al. Pharmacotherapy for the Prevention of Chronic Pain after Surgery in Adults: An Updated Systematic Review and Meta-analysis. Anesthesiology 2021; doi:10.1097/ALN.0000000000003837 online

[17] Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev, 2018; 6(6): CD009642.

[18] Weinstein EJ, Levene JL, Cohen MS, et al. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev, 2018; 4(4): CD7105D.

[19] Harkouk H, Fletcher D, Martinez V. Paravertebral block for the prevention of chronic postsurgical pain after breast cancer surgery. Reg Anesth Pain Med, 2021; 46: 251–257.