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462 L. Shamalov et al.
1 Introduction
Background and Significance of Chronic Pain in Anticipation
of Surgery
The prevalence of chronic pain prior to surgery is an ever-growing problem with
widespread implications. It can complicate the surgical process, which could result
in poorer outcomes such as protracted hospital stays and slower recoveries. The
increased fear and psychological discomfort that individuals with preoperative pain
face only serve to exacerbate these problems. Therefore, it is crucial to control
preoperative discomfort in order to optimize surgical outcomes and patient satis-
faction. It is imperative to use a multidisciplinary approach combining surgeons,
anesthesiologists, pain specialists, and other healthcare professionals to design
specialized preoperative pain management regimens. Healthcare practitioners can
enhance surgical outcomes and guarantee greater patient satisfaction by managing
preoperative discomfort through the use of interventional pain procedures.
2 Understanding Chronic Pain in Anticipation of Surgery
Definition/Classification of Chronic Pain
The general consensus is that chronic pain is persistent or recurrent pain that lasts
longer than three months or persists after the anticipated time for tissue healing
despite adequate treatment [1]. It is a multifactorial condition that comprises intri-
cate relationships between economic, psychological, and physical elements. The
classification of chronic pain can be broken down into neuropathic pain, nociceptive
pain, or mixed pain depending on the underlying pathology. Neuropathic pain is a
condition that develops as a result of damage or dysfunction to the nervous system.
Neuropathic pain is frequently described as an electric, shock-like pain that comes
with shooting, burning, or tingling sensations [1]. Since nerve injury is a major cause
of neuropathic pain, it can result from disorders such as post-herpetic neuralgia and
diabetic neuropathy. In contrast to neuropathic pain, nociceptive pain is induced
through the stimulation of nociceptors, specialized nerve endings that detect tissue
injury.Nociceptive pain is frequently localized to the area of inflammation or damage
and is typically described as dull, achy, or throbbing. It may be triggered by disorders
such as osteoarthritis, musculoskeletal trauma, and inflammatory conditions.
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3 Preoperative Assessment and Evaluation
In the preoperative phase, a comprehensive assessment that includes the patient’s
pain history, pain assessment tools, physical examination, and diagnostic tests is
crucial for effective management of chronic pain.
Patient History and Pain Assessment Tools
Obtaining a comprehensive patient history helps develop a relationship with the
patient and foster an understanding of the nature and impact of chronic pain. Health-
care professionals should inquire about pain duration, location, intensity, and quality,
as well as factors that worsen or alleviate pain. Assessing pain’s impact on daily
activities, sleep, mood, and quality of life aids in developing an individualized pain
management plan.
Pain assessment tools, such as visual analog scales (VAS) or numeric rating scales
(NRS), provide standardized methods to measure pain intensity and track changes
over time [2]. These tools facilitate effective communication between patients
and healthcare professionals, enabling accurate pain assessment and monitoring
treatment response.
Physical Examination and Diagnostic Tests
A comprehensive physical examination serves as a fundamental component in
identifying physical aberrations and manifestations of underlying pathologies that
contribute to chronic pain. Thorough evaluation of parameters such as posture, r ange
of motion, muscle strength, and sensory function facilitates the detection of localized
tenderness or inflammatory indications.
Diagnostic tests involving imaging modalities (e.g., X-rays, MRI, CT scans),
nerve conduction studies, and laboratory assessments are often imperative for further
assessment of the root cause of chronic pain. These diagnostic measures provide
invaluable insights into structural irregularities, nerve functionality, inflammatory
markers, and metabolic factors that exert influence over treatment decisions.
Integrating patient history, pain assessment tools, physical examination findings,
and diagnostic test results provides a comprehensive understanding of the patient’s
pain profile, optimizing preoperative pain control, improving surgical outcomes, and
enhancing the patient experience.
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4 Multidisciplinary Approach to Pain Management
Collaboration of the Healthcare Team
Managing chronic preoperative pain requires a collaborative, multidisciplinary
approach involving surgeons, anesthesiologists, pain specialists, and other health-
care professionals. By integrating patient assessments, developing individualized
treatment plans, and fostering communication among team members, this approach
ensures comprehensive care and optimal pain control. Patient education and empow-
erment are vital in promoting active participation and enhancing treatment outcomes.
The multidisciplinary approach improves surgical results, minimizes preoperative
pain, and increases patient satisfaction.
5 Non-pharmacological Interventions
Physical Therapy and Rehabilitation
Physical therapy and rehabilitation interventions are essential non-pharmacological
approaches for managing chronic pain. They aim to reduce pain intensity, improve
physical function, and enhance overall well-being. Through the use of techniques,
such as manual therapy and therapeutic exercises, physical therapists are able to target
specific areas of pain and promote muscle strength, joint flexibility, and mobility.
Rehabilitation programs, including occupational therapy, focus on restoring function-
ality and independence. Physicians widely employ them due to their effectiveness in
reducing pain, improving functional outcomes, and enhancing quality of life. Inte-
grating physical therapy and rehabilitation into comprehensive management plans
can optimize pain control and improve overall well-being.
6 Pharmacological Interventions
Medications for Chronic Pain Management
Pharmacological interventions play a vital role in managing chronic pain in the
preoperative phase. Several medications can be utilized, and careful consideration is
needed when selecting and dosing them. Medications commonly used for preoper-
ative chronic pain management include analgesics, nonsteroidal anti-inflammatory
drugs (NSAIDs), opioids, and additional medications such as antidepressants or
anticonvulsants. The choice of medication depends on the type and severity of pain,
individual patient factors, and potential risks and benefits.
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Considerations for Medication Selection and Doses
Considerations for medication selection involve assessing the patient’s medical
history, concurrent medications, allergies, and potential drug interactions. Dosing of
medications should be individualized based on the patient’s pain intensity, response
to treatment, and potential side effects. Starting with the lowest effective dose and
titrating as needed is important to achieve optimal pain control while minimizing
adverse effects.
7 Interventional Pain Procedures
Overview of Interventional Pain Procedures
Interventional pain procedures aim to specifically target and alleviate the underlying
sources of pain, offering an alternative or complementary approach to pharmacolog-
ical and non-invasive treatments. Interventional pain procedures encompass diverse
techniques, including nerve blocks, injections, implantable devices, and minimally
invasive surgeries. They serve both diagnostic and therapeutic purposes, allowing
for accurate identification of pain origin and tailored treatment interventions.
Peripheral nerve stimulation (PNS) is a common interventional procedure used
in the treatment of chronic pain. The procedure begins by implanting a small wire-
like electrode next to one of the peripheral nerves [3]. It is then able to modulate
the activity of the peripheral nerves by delivering electrical impulses to the nerve,
thus providing pain relief and blocking abnormal nerve activity. Although used for
chronic pain, recent studies [4, 5] demonstrate the benefits of using percutaneous PNS
preoperatively. The peripheral nerve stimulation was shown to decrease pain scores
and opioid requirements for at least a week after ambulatory orthopedic surgery,
with some studies showing improvement from baseline for 3 months [6]. Interest-
ingly, using percutaneous PNS postoperatively for chronic post amputation pain
has demonstrated remarkable improvements of pain, demonstrating its effective-
ness in amputees [4, 6]. Percutaneous PNS following amputation reduces chronic
pain, permitting for better mobility and quality of life postoperatively. Similarly, the
benefits of using PNS postoperatively may change the management of pain in the
ambulatory setting.
Epidural steroid injections (ESIs) are a common medical procedure used in the
management of chronic pain due to irritation and/or inflammation around the spinal
nerves [7]. ESIs involve the injection of an anti-inflammatory corticosteroid medi-
cation into the epidural space which surrounds the spinal cord. This provides pain
relief to the patient by reducing the inflammation and swelling around the spinal
nerves. ESIs are usually given with the assistance of fluoroscopy in order to ensure
proper placement of the needle [8]. The real time X-ray allows for the visualiza-
tion of spinal structures, ensuring accurate needle placement, avoidance of critical
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466 L. Shamalov et al.
structures, and verification of accurate contrast spread [9]. Because needle placement
alters the spread of the contrast, and hence the effectiveness of the mit is important
to use fluoroscopy to guide ESIs.
ESIs are given to patients with a multitude of conditions, some including herniated
discs, degenerative disc disease, spondylosis, and spinal stenosis. ESIs conducted
preoperatively in those with radiculopathy have demonstrated immediate improve-
ments in short term radicular pain with no long-term effects [10], thus not having
any effect on long term surgery risk. The effectiveness of ESIs in patients with
spinal stenosis is considerable, with short-term improvement of radicular pain and
no worsening of pain or function [11].
An important consideration is the use of an epidurogram postoperativelyfollowing
epidural catheter placement. While this technique is generally considered in the
setting of chronic pain procedures, the use of an epidurogram postoperatively
following epidural catheter placement reliably predicts the clinical functionality of
the catheter [12, 13]. The ability of the epidurogram to verify bilateral and appropriate
dermatomal coverage supports its use in clinical practice.
Facet joint injections are a widely used interventional pain management technique
for relieving pain and inflammation related to facet joint conditions. These injections
deliver a combination of local anesthetic and corticosteroid directly to the affected
joint, providing both diagnostic and therapeutic benefits. The procedure is guided by
imaging techniques to ensure accurate needle placement and maximize the success
rate of pain relief [14]. Facet joint injections are most effective for pain originating
from the facet joints themselves, but they may not address other underlying causes of
pain. The duration of pain relief varies, typically lasting from a few weeks to several
months, requiring potential repeat injections. While complications are rare, they can
include infection, bleeding, nerve damage, and allergic reactions. Swelling and pain
at the injection site are usually temporary, and adverse reactions to the medication
used are uncommon and resolve quickly. To achieve optimal long-term outcomes,
a comprehensive approach to pain management that considers the patient’s overall
condition and incorporates other treatment modalities is recommended.
Nerve Blocks and Regional Anesthesia Techniques
Injections involve the targeted delivery of medications, such as corticosteroids or
local anesthetics, to specific sites of pain. This can reduce inflammation, numb painful
areas, or provide therapeutic benefits. Common injection procedures include epidural
steroid injections, trigger point injections, and joint injections.
Implantable devices, such as spinal cord stimulators or intrathecal drug delivery
systems, are utilized in certain cases to deliver pain-relieving medications directly
to the affected area or to modulate effect of pain. Minimally invasive surgeries,
such as radiofrequency ablation or neurolysis, involve precise thermal or chemical
destruction of specific pain-causing nerves or tissues to achieve pain relief.
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Integrating interventional pain procedures into a comprehensive pain management
plan offers personalized and targeted treatment options for individuals with chronic
pain. These procedures can significantly alleviate pain, enhance functional outcomes,
and improve the overall quality of life. However, careful consideration of potential
risks, benefits, and patient-specific factors is essential to achieve optimal outcomes
and ensure patient safety.
Limitations of Interventional Pain Procedures
As physicians, considering the limitations to the interventional pain procedures
discussed earlier is instrumental in selecting the most appropriate intervention.
Peripheral nerve stimulation, despite providing patients with immediate relief and
improving function and mobility, can have its efficacy hindered due to inability to
place the lead directly near the nerve. This is often due to limitations such as inva-
siveness, intricacy of lead placement, and risk of nerve damage, infection, pain at the
site of pulse generator, lead migration, and hardware/battery failure [15]. In addition,
the lead can become dislodged and/or fractured during use or removal [4]. Lastly,
other important considerations include the lack of potency of PNS as an analgesic as
compared to a peripheral nerve block and the insertion time and technique required
for lead placement.
In addition, epidural steroid injections (ESI) are an example of another technique
whose limitations must be examined closer for physician consideration. Improper ESI
placement, also known as a false ESI, can result in the endangerment of nearby tissue
and lack of medication delivery. Staining of paravertebral muscles and ligaments,
intravascular injection, inadvertent facet joint injection, dural puncture, subdural
injection, nerve injury, and disk injury are examples of possible outcomes of improper
ESI placement [8]. Preoperative ESI has also been linked to postoperative infection
[10, 16, 17], which has prompted recommendation to wait 1 month after ESI to
perform surgery [18]. Other potential risks include hematoma, pain at the site of
injection, allergic reaction, and radiation exposure [19].
Facet joint injections have several limitations which physicians must take into
consideration. Firstly, accurately diagnosing the exact source of back or neck pain
can be challenging, and facet joint injections serve as a diagnostic tool in some
cases. Although they can provide temporary pain relief, the facet joint may not
always be the primary source of the pain. Additionally, the duration of pain relief
varies among individuals, ranging from a few weeks to several months, necessitating
potential repeat injections. Moreover, facet joint injections are most effective for pain
originating from the facet joints themselves, such as facet joint arthritis or facet joint
syndrome, and may not address other underlying causes of pain, such as herniated
discs or spinal stenosis. Furthermore, while complications are rare, they can include
infection, bleeding, nerve damage, and allergic reactions. It is essential to weigh
the benefits and limitations of facet joint injections and develop a comprehensive
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468 L. Shamalov et al.
treatment plan that considers the individual’s overall health and medical history for
optimal pain management outcomes [14].
8 Preoperative Pain Optimization Strategies
Timing of Interventions and Pain Procedures
Several studies have shown that administering steroids into the knee before knee
arthroplasty increases the probability of experiencing postoperative infection [20,
21]. In one meta-analysis, patients who had received an intra-articular corticos-
teroid injection within 3 months before arthroplasty had a higher risk of postop-
erative periprosthetic joint infection [20]. Similarly, another meta-analysis revealed
that patients who received hyaluronic acid or corticosteroid injections within three
months prior to total knee arthroplasty had a significantly higher risk of postoper-
ative infection, whereas no notable difference in infection rates was observed for
injections administered between four to six months or seven to twelve months before
the procedure [21]. Furthermore, another investigation found that receiving corticos-
teroid injections within two weeks before total knee arthroplasty significantly raised
the risk of postoperative infection, while injections within two to four weeks showed
a potential trend towards increased infection risk. However, no significant differences
were observed for other injection time frames. The multivariate analysis identified
injections within two weeks before total knee arthroplasty as an independent risk
factor for postoperative infection. Therefore, several articles suggest that undergoing
total knee arthroplasty within four weeks to three months of a corticosteroid injection
may be linked to a higher risk of postoperative infection [20–22].
9 Conclusion
Future Directions/Areas for Research
Future research should focus on conducting prospective studies with well-defined
time frames to investigate the relationship between preoperative steroid injections
and postoperative infection risk in knee arthroplasty. Specifically, studies should
evaluate infection rates in patients receiving intra-articular corticosteroid injections
within different time intervals before the arthroplasty procedure, such as two weeks,
two to four weeks, four to six months, and seven to twelve months. Additionally,
exploring the impact of different types and dosages of steroids on infection risk can
provide valuable insights into optimizing pain management strategies while mini-
mizing complications. Such evidence-based guidelines can significantly improve
patient outcomes in knee arthroplasty procedures.
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Chronic Pain Procedures in Anticipation of Surgery/Pain Status … 469
Key Takeaways and Implications
In conclusion, this chapter has highlighted the significance of addressing chronic
pain in anticipation of surgery and the need for a comprehensive, multidisciplinary
approach to optimize pain status. Key takeaways from this chapter include the under-
standing of chronic pain classification, differentiating between neuropathic and noci-
ceptivepain, and the importance of preoperative assessment and evaluation to develop
personalized pain management plans.
The role of non-pharmacological interventions, such as physical therapy and reha-
bilitation, has been emphasized as essential components in reducing pain intensity
and improving patient well-being. Similarly, pharmacological interventions, when
carefully selected and dosed, play a vital role in managing chronic pain in the
preoperative phase.
The chapter delves into various interventional pain procedures, providing insights
into their benefits and limitations. Integrating these procedures into a comprehensive
pain management plan offers personalized and targeted treatment options for individ-
uals with chronic pain, significantly improving pain relief and overall quality of life.
Hence, this chapter serves as a guide to preoperative interventional pain procedures
to optimize patient outcomes.
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Perioperative Management of Pumps
and Stimulators
Dylan Lewis, Alexander Bautista, and Alaa Abd-Elsayed
Abstract The number of chronic pain patients with implantable devices presenting
for surgery has increased substantially as the indications for these devices has
continued to expand. This patient population may present a challenge to health-
care professionals and a comprehensive understanding of the devices is necessary to
optimize the analgesic and anesthetic care of these patients. Implantable neuromodu-
lation devices include intrathecal pain pumps, spinal cord stimulators, and peripheral
nerve stimulators. Specific implications for these devices may vary depending on the
type of device, location of the surgical procedure, and whether the implantable device
is intended to address analgesic concerns within the realm of the surgical insult.
Keywords Neuromodulation
· Intrathecal pain pump · Spinal cord stimulation ·
Perioperative management · Neuraxial block
1 Introduction
A variety of implantable devices have been utilized to help patients suffering from
a diverse scope of chronic pain indications. The use of intrathecal pain pumps has
been approved for targeted drug delivery of baclofen in the management of spasticity,
and opioids and ziconotide for the management of a wide range of nociceptive,
neuropathic, or mixed chronic pain syndromes [1]. Spinal cord and peripheral nerve
stimulation has been used in patients with chronic neuropathic pain resulting from
failed back surgery, chronic regional pain syndrome types 1 and 2, painful diabetic
D. Lewis · A. Bautista
Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville,
KY, USA
e-mail: dylan.lewis@louisville.edu
A. Bautista
e-mail: alexander.bautista@louisville.edu
A. Abd-Elsayed (
B
)
Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
e-mail: abdelsayed@wisc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_30
471
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