Surgery

Surgery for pain can follow two different approaches. The surgeon can try to correct or stabilize the underlying condition. Surgery can also serve to try to alter the pain pathway

Structural surgery is aimed towards changing the pathological state that produces the pain. This can be accomplished by removal of the lesion, such as a disc herniation or by stabilization of the injured structure, such as a degenerative disc. In the former case a discectomy may be adequate, while in the latter a fusion would be required. All types of surgery for correction of underlying structural damage can be effective in relieving pain. Removal of tumors, stabilization of badly broken bones, repair of ligaments and tendons, removal of obstructions, prosthetic organ replacements, organ transplants, and entire removal of organs may help reduce or remove pain in these type of repairs.

Surgery may be performed to interrupt pain pathways. There are procedures that can be performed on the peripheral nerves, spinal cord and brain. The idea is to create lesions that interrupt transmission of pain along the pain pathway. Sometimes amputations are performed to control pain, although good preoperative analgesic care should be taken to avoid phantom pain or stump pain.

Surgeries may also cause pain syndromes and almost all surgery at least causes acute pain. Unfortunately there is still an attitude about post operative pain that eschews the use of pain medication after the immediate post operative period. Although IV pain control is utilized more effectively than it used to be, it remains all too common for surgeons to tell their patients that they should not need pain medication after discharge, even if the patient is experiencing considerable pain. The myth that opioids mask post operative pain and will lead to injuries is a slow one to die. Fear of addiction, concerns about medical board scrutiny, and inexperience with post operative opioids may also inhibit prescription of adequate post operative pain medications. Although many patients may be comfortable enough to avoid the use of post operative pain medications, many do require improved pain control and numerous studies show that high percentages of patients do not feel that they are helped with adequate postoperative pain control. Aside from the obvious and often unnecessary discomfort to post operative patients, there is significant risk of untreated acute pain evolving into chronic intractable pain. This is not a psychological process, but is instead caused by a potent combination of neurophysiological, neurochemical, psychological and social factors. Prevention of this process with good postoperative pain control is a critical, but often missed step.

At times despite the best pain control technique, post operative chronic pain syndromes develop. These are caused by neuroma formation, nerve resections, sympathetic coupling, nerve entrapment, translation of physical forces to contingent anatomical areas, scar induced obstructions, wound infections, and intraoperative positioning problems. The pain needs to be treated symptomatically and may require further surgical revision.

Surgical intervention is responsible for good pain control in most patients. It also causes acute and chronic pain problems. It is important for residual pain problems to be treated as aggressively as the underlying lesion.