Patients Who Fear Surgery, Report Pain, or Anticipate Postoperative Pain at Increased Risk of Postoperative Pain

Preoperative and expected postoperative pain predict postoperative pain, with a strong link between catastrophizing and preoperative anxiety, and a moderate link between depression and preoperative anxiety, according to a recent study published in the Journal der Deutschen Dermatologischen Gesellschaft.¹

Additionally, researchers recommended that clinicians pay special attention to patients who report a fear of surgery, report pain, or anticipate postoperative pain during preoperative assessments.

Image Credit: © blackday - stock.adobe.com

Background and Methods

Postoperative pain affects a substantial proportion of surgical patients, with estimates suggesting that 20% to 40% endure severe pain following procedures.² Particularly intense pain is often associated with thoracic and female breast surgeries. Unmanaged pain can impede recovery, limit functionality in the operated area, and, in severe cases, become chronic.²

Given the absence of standardized recommendations and the wide variability in pain management practices, researchers conducted a study to explore procedure- and patient-specific factors influencing perioperative pain during dermatologic surgery under local anesthesia.

This prospective, observational study took place from April to December 2021. The study included patients aged 18 and older undergoing dermatologic surgery under local anesthesia, hospitalized for more than 1 day postoperatively. Patients who underwent outpatient procedures or had surgeries under general or regional anesthesia, experienced chronic pain, and who were regular users of analgesics or psychotropic drugs were excluded from participation.

Findings

In this study, 125 patients who underwent skin tumor resection under local anesthesia were initially enrolled. After excluding 5 datasets due to patient non-attendance or withdrawal, a total of 120 datasets were analyzed.

The average age of participants was 69 years, with a range from 23 to 98 years. The study included 71 males (59.2%) and 49 females (40.8%).

In total, 23.3% of patients had received a diagnosis of malignant melanoma, 18.3% of patients were diagnosed with squamous cell carcinoma, and 49.2% with basal cell carcinoma. Other diagnoses included skin sarcomas, carcinoma in situ, cheilitis actinica, and benign skin tumors.

Surgical localization included the heck and neck region (65%), trunk (24.2%), and extremities (10.8%).

Fifty-five point eight percent of patients (n=67) reported no preoperative pain. Measured by a score of less than 4 on the Numerical Rating Scale (NRS), 25.8% of patients (n=31) had mild pain. NRS scores between 4 and 6, indicative of moderate pain, were attributed to 13.3% of patients (n=16). Scores greater than or equal to an NRS of 7 affected 5% of patients (n=6), who reported severe pain.

For anesthesia, patients received an average of 10.6 mL of prilocaine 0.5% with added adrenaline. Intraoperatively, only 1 patient required additional medication (500 mg metamizole). Postoperative analgesia was administered to 34 patients (28.3%), with metamizole being the most common (70.6%), followed by ibuprofen (29.4%) and acetaminophen (5.9%). Morphine was required by only 1 patient. The average time to first analgesic use was 490 minutes post-surgery.

Additionally, patients reported significantly lower pain levels if primary closure was used compared to flap surgery. The 24-hour postoperative pain scores indicated minimal pain overall, with men reporting less pain than women.

The study also found a significant correlation between preoperative pain and postoperative pain, and between pain expectation and postoperative pain. Other variables, such as gender, anxiety, diagnosis, localization, number of surgical sites, and staged procedures, did not show significant correlations.

Regarding psychological assessments, elevated Pain Catastrophizing Scale (PCS) scores (≥ 30) were observed in 5% of participants, with females scoring higher than males. Overall low Surgical Fear Questionnaires (SFQ) scores were observed, with measures slightly higher in women (15.92) compared to men (10.21). Approximately 22.5% of patients exhibited mild depression via PHQ-9 depression screening, with 3.3% exhibiting moderate depression, and 2.5% demonstrating severe depression.

Furthermore, researchers observed strong correlation between high PCS and SFQ scores, indicating a relationship between catastrophizing and fear of surgery. Moderate correlation was observed between higher PHQ-9 and SFQ scores, suggesting a link between depressive tendencies and surgical anxiety. No significant correlation was detected between fear of surgery and postoperative pain.

Conclusions

Potential limitations of the study included its limited sample size and high heterogeneity with respect to surgical areas. Additionally, there may have been some bias present due to the subjective nature of pain.

"Dermatologic surgery performed under local anesthesia is generally associated with low levels of pain. Postoperative pain management was required in only one-third of patients and could be managed with non-opioid analgesics," according to study authors Volberg et al. "In the cohort studied, only one patient required an escalation of pain therapy to a strong opioid. Nevertheless, patients should be regularly questioned about their pain postoperatively to ensure adequate analgesia."

Moving forward, researchers suggested that future, larger studies should investigate the association between preoperative pain, pain expectancy, and preoperative pain medication.

References

1. Volberg C, Gschnell M, Eubel V, Föhr J, Schubert AK, Pfützner W. Perioperative pain perception in patients undergoing dermatologic surgery with local anesthesia - A prospective observational study. J Dtsch Dermatol Ges. Published online July 3, 2024. doi:10.1111/ddg.15435.
2. Likar R, Jaksch W, Aigmüller T, et al. Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement“. Schmerz. 2017; 31(5): 463-482.