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Managing postoperative pain

Baltimore Sun
Thanks for joining us for a live chat on post-operative pain with Dr. Paul Christo of Johns Hopkins. In a study published last week in the Journal Lancet, Hopkins Drs. Christopher Wu and Srinivasa Raja wrote that pain management for patients after surgery remains inadequate. (Read more from ABC News.)

Christo is director of the Multidisciplinary Pain Fellowship Training Program at Johns Hopkins University School of Medicine. He also has a radio talk show Saturday nights on WBAL.

Comments made here are for informational purposes only and do not represent or substitute as medical advice. Patients are advised to consult their own physician or pharmacist for advice, diagnosis and treatment.

 Health chat: Post-operative pain(06/29/2011) 
11:45
Baltimore Sun Health: 
Hi, Dr. Christo will be joining us at noon, but feel free to add your questions to the queue now.
Wednesday June 29, 2011 11:45 Baltimore Sun Health
12:00
Baltimore Sun Health: 
Welcome to our live chat on postoperative pain with Dr. Paul Christo of Johns Hopkins. Add your questions and we'll get to them one at a time. It's always helpful for Dr. Christo to be as specific as your can about your issue as well as yourself (age, town, etc.).
Wednesday June 29, 2011 12:00 Baltimore Sun Health
12:01
dr. christo: 
Hello, I look forward to your questions.
Wednesday June 29, 2011 12:01 dr. christo
12:02
Baltimore Sun Health: 
Ok let's get started.
Wednesday June 29, 2011 12:02 Baltimore Sun Health
12:03
Baltimore Sun Health: 
How common is postoperative pain? And why should doctors be concerned with this issue?

Wednesday June 29, 2011 12:03 Baltimore Sun Health
12:04
Baltimore Sun Health: 
And for those new to our live chats, we have an archive on our discussions of many pain topics (neck, back, knee, shingles, etc.) here: http://www.baltimoresun.com/health/bal-hs-health-chat-postoperative-pain-20110627,0,1878837.htmlstory
Wednesday June 29, 2011 12:04 Baltimore Sun Health
12:06
Baltimore Sun Health: 
Sorry, here's the correct link to the archive: http://www.baltimoresun.com/health/bal-health-chats,0,3625121.storygallery
Wednesday June 29, 2011 12:06 Baltimore Sun Health
12:10
dr. christo: 
Post operative pain is common and not managed as intensely as it should, unfortunately. There are several methods of treating pain during and after surgery depending on the type of surgery: nerve blocks, spinals, epidurals, intravenous pumps that deliver opioids (morphine for example), and oral medications. Better pain control leads to benefits in terms of cardiovascular and respiratory complications as well as endocrine, immunologic, gastrointestinal, and hematological outcomes. Importantly, we've learned that pain that persists following surgery can lead to chronic pain conditions.
Wednesday June 29, 2011 12:10 dr. christo
12:11
[Comment From keithkeith: ] 
Good Morning (afternoon) I am a 59 yr old professional golfer from Ventura, CA. In February I had sections of my 8th, 9th and 10th ribs removed due to a malignant tumor. I still experience a fair amount of pain and some sweilling. Is there anything I can do to alleviate the pain without taking the dilaudid
Wednesday June 29, 2011 12:11 keith
12:17
dr. christo: 
HI Keith,
Rib surgery can cause nerve pain (neuropathic pain): burning, shooting, stabbing. The opioids can be helpful, but the long acting ones (oxycontin, MS Contin, Fentanyl patch, etc) typically offer better pain relief because they last longer in the bloodstream. The nerve pain may be better treated with medicines like neurontin, lyrica, nortriptyline. You could also try specific nerve blocks performed from your back along the 8th, 9th, 10th intercostal nerves with steroid and local anesthetic. If helpful, we do pulsed radiofrequency ablation (sometimes not covered by insurance) along the same nerves to provide longer lasting pain relief. Later, spinal cord stimulation may be a good option if you don't get enough relief from the medicines or other procedures.
Wednesday June 29, 2011 12:17 dr. christo
12:18
[Comment From IBIB: ] 
Dr. Christo, Why aren't nerve blocks used more frequently in the postoperative management of pain as opposed to frequent use of narcotic analgesics?
Wednesday June 29, 2011 12:18 IB
12:25
[Comment From keithkeith: ] 
Thanks Doc, I will say this, the post-surgical pain is alot different (and more tolerable) than the pain that was resulting from the cancer
Wednesday June 29, 2011 12:25 keith
12:26
dr. christo: 
IB,
Nerve blocks can be very useful for certain types of surgery. They take time to set up and you need experienced anesthesiologists who can place them. Also, the surgeon needs to feel comfortable performing the case with regional anesthesia (nerve blocks). If these elements aren't all aligned, then nerve blocks typically aren't offered. Today, ultrasound-guided nerve blocks are being performed more frequently and with more consistent results. I think you'll see more surgeons and anesthesiologists offering regional anesthesia. There are several patients who prefer to be completely asleep (general anesthesia) for surgery and really don't want any type of epidural, spinal, or nerve block as well. Narcotics (Opioids) are the common group of medicines that we use to treat surgical pain because they are very effective during the surgery and afterward.
Wednesday June 29, 2011 12:26 dr. christo
12:28
Baltimore Sun Health: 
Is there a certain amount of pain to be expected after surgery? And at what point should a patient be concerned and alert their doctor?
Wednesday June 29, 2011 12:28 Baltimore Sun Health
12:35
What type of pain topic do you want to discuss next?
Pelvic pain
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Pediatric pain
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Pain and depression
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Alternative treatments
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Wednesday June 29, 2011 12:35 
12:38
dr. christo: 
Smaller and less extensive procedures typically hurt less and require fewer pain relievers. For instance, removal of moles on the skin just need an injection of local anesthetic into the skin before the incision is made and often don't hurt later. On the other hand, surgery on the chest wall (thoracotomy) can lead to more severe pain so epidurals placed before the surgery can provide significant postoperative pain control. If your pain isn't controlled after surgery, then you should alert the nurse and doctor right away while your in the hospital or before you leave the hospital. This doesn't mean that you won't have some pain. Eliminating all pain following surgery isn't necessarily the goal; rather, reducing and controlling it should be the focus so that it doesn't become chronic.
Wednesday June 29, 2011 12:38 dr. christo
12:41
[Comment From LizLiz: ] 
after a rhizotomy for trigeminal neuralgia at JHH, what do you suggest for continuing extreme facial pain (lightening bolts).
Wednesday June 29, 2011 12:41 Liz
12:51
dr. christo: 
Hi Liz,
I would suggest trying tegretol because that drug is approved for the treatment of trigeminal neuralgia. You probably already tried that before the surgery, though. Other medicines that can be useful: lyrica, neurontin, nortriptyline, baclofen, trileptal. opioids. We sometimes try nerve blocks around one of the branches of the trigeminal nerve (maxillary or mandibular) with local anesthetic and steroid as well. Some patients have found relief from microvascular decompression (neurosurgical procedure) or radiation surgery. Rarely, electrical stimulation around that nerve with a small wire has been used.
Wednesday June 29, 2011 12:51 dr. christo
12:52
Baltimore Sun Health: 
What are some of the typical categories of post-surgical pain and what are the treatment options?
Wednesday June 29, 2011 12:52 Baltimore Sun Health
12:54
dr. christo: 
The first category is somatic pain. This results from fractures, burns, or infection for example. Usually constant, aching, sharp, and stabbing. Treatments include heat/cold, acetaminophen (tylenol), anti-inflammatories, opioids, and even topical local anesthetics.
Wednesday June 29, 2011 12:54 dr. christo
12:58
dr. christo: 
The next category is visceral pain which means that it's related to the organs of the body (liver, stomach, prostate, uterus, etc). Examples include muscle spasm, infection of the internal organs or inflammation, obstruction inside an organ, or following abdominal or pelvic surgery. Treatments focus on using anti-inflammatory medicines, opioids, and muscle relaxants.
Wednesday June 29, 2011 12:58 dr. christo
12:58
[Comment From LizLiz: ] 
Thank you Dr. Christo. I have tried all of the meds you mentioned and I am currently taking Neurontin, oxycontin and oxycodone. My PCP monitors me very closely (every 1-2 weeks). I still have break-through shocks of pain on my left cheek, jaw and forehead. I am currently re-trying relaxation methods (massage). However, I still get these extreme shocks of pain that come without warning. I will print out your previous response and discuss them with my PCP. Thanks!
Wednesday June 29, 2011 12:58 Liz
1:03
dr. christo: 
Finally, neuropathic pain can result from surgery. Examples would be the pain felt after a leg is amputated, or if the nerves under the ribs are damaged from chest surgery, or the nerves from the spinal cord are disrupted from spinal surgery. Patients describe this pain as radiating, burning, tingling, electric-like or shock-like. Treatments can include nerve blocks, antidepressants (pamelor, cymbalta), anticonvulsants (neurontin, for example), opioids, or electrical stimulation.
Wednesday June 29, 2011 1:03 dr. christo
1:04
Baltimore Sun Health: 
That's all the time we have for today. Thanks for your questions.
Wednesday June 29, 2011 1:04 Baltimore Sun Health
1:05
dr. christo: 
Thank you for your questions. Hope this was helpful.
Wednesday June 29, 2011 1:05 dr. christo
1:05
 

 
 
 

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