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.”