First Posted June 19, 2000 Last updated October 24, 2012
Post Operative Pain
This is an actual patient in the recovery room, minutes after surgery on her hand. She is smiling because she doesn't hurt, and she doesn't hurt because of my post-operative pain program.
I am "allergic" to pain, and I presume that you are, too! Your post-operative pain is important to me. Please read on!
If you ask patients what they want from their surgery, I think that you will find that the answers almost always are these, and in this order:
- I want the surgery to be successful
- I don't want any complications
- I don't want it to hurt
Is this about what you would say? I think it is exactly what I would want from my own surgery. Doctors spend a lot of time making sure the surgery is successful, and they spend a lot of time trying to avoid complications. But they tend to ignore the patient's pain.
I don't think that is what patients really want. It is certainly not what I want from my own physicians. So I have been studying post-operative pain since 1989. I joined the International Association for the Study of Pain (a professional organization of doctors, principally anesthesiologists, and PhD's), bought and studied books on pain, subscribed to a pain journals, attended pain lectures, and talked to pain specialists.
Based on this work, I designed a post-operative pain program for my hand surgery patients, and when I had surgery on my own hands (carpal tunnel releases, both hands, same day), this is what I used for my own pain. I have performed a three-year, prospective study of the success of my post-operative pain program on my own patients and presented this study at the International Association for the Study of Pain, and at regional surgery meetings. The response from specialists in pain management has been very positive.
Dr. Nelson's Pain Study
The goal of the study was to evaluate the effectiveness of our current post-operative pain protocol by measuring patients' post-operative pain. It is very difficult to measure pain, since it is essentially a subjective perception, a private experience that you can try to explain to someone else but you never fully can. It is your private perception. Real, but subjective. I spent some time trying to figure out how to measure post-operative pain: visual analog scales, numbering scales, etc.
The method of the study that I finally decided upon was to allow the patients unlimited access to narcotic pain medication and just count the number of pills taken in the post-operative period (10 days) before they saw me in the office. This method (measuring the amount of narcotic pain medication) has been used in many studies of other parts of the body and is widely supported as an effective way of measuring pain. The study was approved by the Institutional Review Board of Marin General Hospital. I used the pain management protocol listed below, with slight changes over the course of the study (eg, substitute a COX-2 inhibitor for Motrin, call the patient the day after surgery rather than the evening of surgery).
The results of the study: We collected data for over three years (the study started December 10, 1998). At the three year mark, the average number of Vicodin or Tylenol #3 taken, for all patients, was only a total of 2.26 pills within the first 10 days after surgery, and 46% of the patients did not take any narcotic medication, only antiinflammatory medication such as Celebrex plus Tylenol (acetamenophen). That's all! I think, and my surgery colleagues agree, that this is a rather dramatically low number. (We do not have a control group, but many surgeons are giving their patients 30 or 40 narcotic pills for the same kinds of surgeries.) For surgeries involving only soft tissue (like carpal tunnels, trigger fingers, Dupuytren's releases), the average was only 1.1 Vicodin pills in the first 10 days after surgery; the average for bone procedures (like fixing fractures, correcting malunions, etc) is 6.1 Vocodin pills. I have slightly modified my techniques since the 1998-2000 study (improved post-operative injection of long-acting pain medicine, substitute long-acting Tylenol Arthritis for short-acting regular or extra strength Tylenol), and currently 72% of the patients find that they have so little pain that they do not want to take any Vicodin, only the Tylenol and Celebrex. We estimate that the average total number of Vicodin taken is now less than 1 pill in ten days.
How can I make my surgeries hurt so little?
Here's the secret: listen to your patients, and then act on what you hear. That's all there is to it.
By listening to my patients, I have developed a 8 stage approach to pain:
Preventative Regimen Against Pain
Celebrex is a non-steroid, non-narcotic, non-addicting antiinflammatory medication that significantly reduces swelling, inflammation, and pain. It is a member of a special class of medications called COX-2 inhibitors, that center in on your pain but have much less effect on the function of your stomach lining, kidneys, and other normal body processes. It does not interfere with blood clotting or wound healing, and can be taken with or without food, before and after surgery. It has been shown to be effective in controlling post-operative pain in studies of dental surgery and knee surgery. Taking this medication greatly decreases the need for addictive, narcotic pain medication after surgery; in fact, in the study I did that I mentioned above, 46% of the patients did not need any narcotic pain medication after surgery.
It has been shown that caffeine can interfere with the action of acetaminophen function, so you should try to avoid any caffeine for a day or so.
I have found that this program is very effective, keeps the patient informed and in control, and provides feedback to me so that I can continue to improve. If you are considering surgery, please discuss this program with me. I have asked several patients to write about their pain and their post-operative experiences.
Click here if you would like to read what some patients have written about their experience having surgery.