Invasive Surgery to Relieve Chronic Pain?

Invasive Surgery: Effective in Relieving Chronic Pain? By Sunali Wadehra, MD – Feb 2019

Invasive surgery may not be any more effective than sham procedures in reducing chronic pain, according to a meta analysis published by Wayne B. Jonas, MD, in Pain Medicine last September.

Dr. Jonas and his team performed a systematic review of 25 randomized controlled trials published between 1959 and 2013, involving 2,000 patients undergoing surgery for chronic pain.

This article explains a concept I haven’t seen elsewhere: chronic pain versus protracted pain. Especially in the case of EDS, this means we can hurt every day, but still not have true “chronic pain”.

Procedures performed included either endoscopic or percutaneous insertion of instruments to manipulate tissues. In these studies, sham groups received identical interventions, excepting any steps with therapeutic effects.

Chronic pain was defined as pain lasting at least 3 months, and the review included trials on:

  • low back pain (n = 7),
  • arthritis (n = 4),
  • angina (n = 4),
  • abdominal pain (n = 3),
  • endometriosis (n = 3),
  • biliary colic (n = 2), and
  • migraine (n = 2).

Data on back and knee pain were pooled together for a random-effects meta-analysis.

Lack of Evidence for Invasive Procedures

For all conditions studied, 87% of within-group improvement was attributable to the sham procedures.

Surgical intervention did not result in significant pain reduction in patients with either low back or knee pain (n = 445 patients, P = 0.26; and n = 496, P = 0.26 respectively), according to their findings

Additionally, the use of invasive procedures significantly increased the risk of adverse events, compared to sham (12% vs 4%; P = 0.01).

“There is currently insufficient evidence to support the specific efficacy of invasive procedures for the treatment of chronic pain,” the authors wrote.

“Given their high costs and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain.”

Additional Perspective

Dr. Arbuck is a clinical assistant professor of medicine and psychiatry at Indiana University School of Medicine,

“This meta-analysis shows that mixing protracted pain and chronic pain can create skewed and invalid results as it does not separate fundamentally different conditions,” he said. “There is still confusion in the pain community in regard to understanding chronic pain.”

He described how protracted pain, for instance, which also may last longer than 3 to 6 months, is often mistakenly defined as chronic pain.

  1. “Protracted pain is actually acute pain that is based on persisting tissue damage,” he said, and
  2. “regardless of the length of such an acute pain model, it responds to interventional treatments.

Chronic pain, on the other hand, is a disease based on central sensitization and is detached from tissue damage. “This disease poorly responds to local interventional treatment. The more centralization develops, the less interventional treatments help,”

…elaborating with this example:

“Imagine if someone pokes you with a needle for 6 months every day. You have acute pain for 6 months because of the needle prick.This is protracted pain.

This is very important for EDS patients: though we’ve been hurting for years and decades, our pain is NOT technically “chronic pain” which comes from the nervous system itself.

Instead, we experience a constant series of micro-tears in our connective tissue. This makes pain appear in different places at different times, though some parts of the body are micro-injured almost continuously.

These are places in our bodies that must withstand the greatest physical forces, like all along the spine and especially the sacroiliac joint where the top and bottom of our bodies are connected. Unfortunately, the pain from  EDS here falls under the common and much-derided “low back pain”.

The longer you are hurt, the more your central nervous system gets involved. If the pain is fully centralized, when you stop the trigger, the pain continues.

Even if longer lasting pain is more likely to be centralized, there are plenty of cases when it does not happen and pain does not progress from protracted to chronic. Thus, interventional treatments may work very well in such patients even after months and years of suffering.”

I have called this “Chronic Acute Pain”, and I believe that describes our situation perfectly, differentiating it from “chronic pain” that has metastasized into the nervous system.

Overall, Dr. Jonas said his team believes the “findings further support the call for patients to seek out non-pharmacologic approaches to manage chronic pain, which have been proven and are recommended by [multiple] organizations.”

Really?

I would like to know exactly what “non-pharmacologic approaches to managing chronic pain” have been proven significantly effective because my own research has found none. (For research purposes the standard is that “significant” pain relief means a reduction of 3 points or more on the “pain scale”.)

So many of us have already tried all the non-pharmacologic approaches we can afford and have found them of little use except as add-ons to the effective relief from opioids.

And, Dr. Jonas agrees:

He noted, however, that these are not meant to be standalone therapies. “Rather, they should be integrated with conventional treatments for optimal pain and opioid management.”

5 thoughts on “Invasive Surgery to Relieve Chronic Pain?

  1. leejcaroll

    low back pain (n = 7),
    arthritis (n = 4),
    angina (n = 4),
    abdominal pain (n = 3),
    endometriosis (n = 3),
    biliary colic (n = 2), and
    migraine (n = 2).

    why would any doc operate for arthritis, absent physical findings indicating surgery is indicated. Migraine is not a surgical issue nor is angina. Some low back pain may have a possible cause that surgery can help but for the most part from my understanding it is not a surgical situation
    Endometriosis may require surgery for removal of tissue same too for colic, not a surgical cause and abdominal pain without a specific proven cause that is amenable to surgery is not a surgical issue.
    “Protracted pain is actually acute pain that is based on persisting tissue damage,” he said, and
    “regardless of the length of such an acute pain model, it responds to interventional treatments.” Most chronic pain disorders like CRPS, MS, Lupus Rheumatoid arthritis fibromyalgia seem to have a bad history re response to interventions (absent for some folks to opioids) (I am not familiar enough with EDS to know if it also responds to various interventions)
    Cranial neuropathies like trigeminal neuralgia do respond to some surgical interventions and the benefit of implants on many chronic pain disorders is ignored.
    All in all. this article leaves me annoyed. Too often when articles like these come out they indicate the studies are about chronic pain but then use as their basis back pain, etc and ignore the diseases and disorders that are the root of much chronic pain

    Liked by 1 person

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    1. Zyp Czyk Post author

      You’re absolutely right. “Chronic pain” is not a single entity and cannot be treated as such – at least not successfully for the patient.

      Perhaps some doctors can rake in the dough by assuming “it’s all the same thing” and “slicing and dicing” us for profit, but it certainly doesn’t solve the problem. However, when all you only have is a hammer, everything looks like a nail :-(

      Even when surgery is possibly indicated, the cutting and “fixing” itself can cause additional new chronic pain in us older folks – and most of us *are* older. Each patient has a different response to different surgeries, so it’s hard to know when it would really be helpful.

      When I was younger, I was looking for some cause for my pain that could be surgically fixed and was disappointed to learn my EDS couldn’t be helped, but by now, I’m very glad I didn’t end up suffering more iatrogenic pain from some enthusiastic surgeon.

      Liked by 1 person

      Reply
    2. Heather Hooper

      Agreed! A microdiscectomy to remove a herniated disc caused my chronic back pain. I felt much less pain when I woke up from the surgery than when I went under, and recovered pretty well.

      Until ~6 weeks post-op, that is. My Mum was visiting, and we were in a museum looking at some paintings. Suddenly, I felt a completely different kind of pain deep in my lower back, where I’d had the surgery. It got worse quite quickly, I began to feel sciatic pain in my L leg (it had been in my R leg before the op), and about 20 mins later My L lower back went into spasm. I had to taxi home. By the time my Mum got back a few hours later the sciatica was shooting from my buttock to my calf, I could barely move because the spasm had spread into my buttock,hip and thigh, and several muscles along my spine felt like they were on fire. Luckily I had some codeine left from the prescription I was given when I was discharged from the hospital after the op, so I wasn’t sobbing anymore (my Mum is easily upset). Over the next couple of weeks it got worse, most of my L foot went numb or developed pins-&-needles, and the spasms grew strong that sometimes they’d drag me up to a seated position when they happened. Most disturbing, I quickly lost the ability to twist and bend my back at the level of the scar, and my R leg contracted so that my knee was bent at about 30°, and I was unable to straighten it. Walking was impossible.

      An emergency MRI on the advice of my neurosurgeon revealed that my body had spent that relatively pain-free 6 weeks quietly growing massive amounts of scar tissue and some interesting adhesions. The scar tissue extended along the surgical wound from my skin to my spine, and it had wrapped itself around my spinal nerves and both sciatic nerves. It rubbed constantly.

      Not much to be done – surgery to remove it had a high chance of damaging some very important nerves, and I’d almost certainly grow more scar tissue as a result. You know those very small # of patients who have really poor surgical outcomes? Hi. *waves*

      And yes, I hate how “back pain” is the go-to example of chronic pain! So many different kinds of back pain, and so many other kinds of chronic/persistent pain! Harmful generalisation

      Liked by 1 person

      Reply
  2. GZB

    I wish someone had told me this thirty(some) years ago. Very serious subject, yet you still make me smile. “When all you have is a hammer everything looks like a nail”. You hit that nail on the head!

    Liked by 2 people

    Reply

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