Purpose: This manuscript proposes pharmacological strategies that might decrease persistent postsurgical pain (PPSP). These recommendations are based on a review of current publications available in the literature.
Principal findings: Persistent postsurgical pain has been defined by the International Association for the Study of Pain as clinical discomfort that lasts more than two months after surgery. Recent reviews reported that 10-50% of patients develop chronic pain after surgery, 2-10% with disabling chronic pain at six months. Preventive interventions should target all types of surgery, but specific attention should be placed on surgical insults that carry a high risk of pain chronicization. Regional anesthesia (RA) should be used whenever feasible, and a continuous perineural/epidural local anesthetic infusion is preferred over a single-shot technique. The RA should be initiated prior to the surgical incision and then continued for at least 24-72 hr after the surgery. Perioperative opioids should be used for nociceptive stimuli not managed by the RA. An intravenous infusion of ketamine, an N-methyl-D-aspartate receptor (NMDA) antagonist, might be added for a further decrease in neuronal sensitization, especially when the procedure is extensive or when RA is not feasible or contraindicated. A multimodal approach is always suggested. The literature still does not strongly support the use of gabapentinoids for PPSP prevention; however, they might be maintained in patients who use them preoperatively.
Conclusions: A winning strategy to reduce the incidence of PPSP may well involve performing minimally invasive surgery, providing adequate perioperative analgesia based on RA, and using a multimodal approach with NMDA antagonists.