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Surgical Recovery Among Patients With Chronic Pain Undergoing Pelvic Reconstructive Surgery
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DOI：10.1097/01.ogx.0001113784.26523.b1.png)
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Abstract
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Chronic pain affects an estimated 11% to 40% of people in the United States and has been shown to affect quality of life and relationships as well as to be associated with loss of employment and disability. In addition, it represents a large financial burden related to healthcare costs, at an estimated $635 billion annually. Previous literature has shown that pain during the preoperative period in surgeries such as mastectomy, hysterectomy, and inguinal hernia repair, among others, is a significant predictor of postoperative pain, including chronic pain. Although these studies have shown a predictive association, not many studies have focused on patients with previously occurring chronic pain, especially chronic pain occurring outside the pelvis. This study was designed to address this gap by assessing if patients with versus without self-reported preoperative chronic pain have different surgical outcomes and recovery after pelvic reconstructive surgery; the hypothesis was that women with preoperative chronic pain would have significantly worse postoperative recovery. This was a prospective cohort study of patients with pelvic organ prolapse who had pelvic reconstructive surgery between September 2022 and May 2023. Preoperative assessment of chronic pain was done using the 9-question Brief Pain Inventory and the Pepper Assessment Tool for Disability (PAT-D) over the past 3 months. Postoperative recovery was assessed with the Postdischarge Surgical Recovery (PSR) scale, the 1-item Global Surgical Recovery (GSR) index, and a repeat of the PAT-D questionnaire. The primary outcome for the study was the PSR scores at 4 weeks postsurgery in patients with versus without chronic pain. Secondary outcomes included inpatient pain scores, opioid use, time to return to work, and PSR and GSR scores at other timepoints. Final analysis included 90 patients, with 43 reporting preoperative chronic pain (47.8%) and 47 reporting none (52.2%). Average pain levels on the Brief Pain Inventory questionnaire were 3.0 in the chronic pain group and 0 in the control group on a scale from 1 to 10 (P < 0.001). Baseline PAT-D scores were also higher in the chronic pain group, showing greater disability (24.9 + 8.4 vs 20.0 + 3.6, P = 0.004). Other characteristics were not significantly different at baseline, with the exception of rheumatologic disease, which was more prevalent in the chronic pain group (P = 0.03). PSR scores at 4 weeks postoperatively were not significantly different between groups, although the observed difference exceeded the clinical relevance threshold in the prolapse surgery population of 5 points. There were also no significant differences in PSR or GSR scores at other timepoints, including 2, 4, and 12 weeks. PAT-D scores also showed no significant differences at 2 or 4 weeks postsurgery, but at 12 weeks, the chronic pain group had significantly higher scores consistent with greater disability (21.0 + 4.7 vs 18.4 + 2.6, P = 0.003). Both groups received similar pain medications intraoperatively in morphine milligram equivalents (MMEs), but patients in the chronic pain group needed significantly more medication postoperatively, both at the hospital (27.0 + 27.8 MME vs 24.3 + 60.3 MME, P = 0.03) and at home (40.1 + 54.7 MME vs 19.9 + 39.0 MME, P = 0.03). Analysis by surgical approach showed that patients who underwent a laparoscopic approach were more recovered and had higher PSR scores at 2 and 4 weeks, but 12-week scores were comparable to those undergoing vaginal surgery. Assessing employment outcomes, a significantly higher percentage of those in the chronic pain group who were employed preoperatively had not returned to work at 12 weeks when compared with the control group (31.3% vs 0%, P = 0.02). Of those who returned to work, there was no significant difference in the time of return to work between groups. These results indicate that recovery after pelvic reconstructive surgery is similar for patients who report chronic pain before surgery and those who do not. Although baseline pain is significantly higher and those with chronic pain had a higher rate of disability, recovery outcomes were not significantly different. This is in direct contrast to previous results showing that there was higher pain reported immediately postoperatively in those who reported chronic pain preoperatively. This difference may have several sources, one being respective definitions of preoperative pain. Future research in this area should focus on barriers for patients returning to work with chronic pain and reasons for requesting more time off work as well as evaluating policies surrounding time off for pelvic reconstructive surgery.
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