Pain Control After Surgery

There are many choices for pain control after surgery and choosing the best one involves learning about all of the options, and choosing the best one based upon your personal medical history, and input from your surgeon and anesthesiologist.

There are a wide range of pain relief strategies and in many cases they can be combined to provide optimal pain relief.  Choosing the best protocol will require communicating with your surgical team, but here you can learn some of the options so that you are familiar with the choices when you talk to them.

Oral pain meds
These may be given before or after the surgery.  They are usually very effective, particularly for a surgery with a brief hospital stay. 

Pain Patch
Some patients are given a patch which gives a low level amount of medication through the skin.  This is a strategy which is used in many patients with chronic pain syndromes.

IV Pain meds
In this strategy medication can be given by a hospital worker on as needed basis every thirty minutes to two hours. This is a good choice as it allows the nurse or caregiver to evaluate you every time they give medication.  A wide variety of pain medication can be given ranging from anti inflammatory medication to narcotic pain relieving medication.

Patient Controlled Analgesia
This is a pump that is connected to a button that you as a patient can push.  The nice thing about this approach is that every 6 to 10 minutes you can give yourself a small dose of pain relieving medication.  Sometimes a PCA also gives a low dose infusion in addition to the patient controlled doses.  The specific medication will be determined by your doctor but the most common choices are fentanyl, dilaudid, and morphine.  Many patients enjoy the control that they feel they have over the pain with this technique.

Epidural anesthesia
Epidural anesthesia is an excellent choice for pain control after surgery. It involves placing a small catheter in the epidural space and then infusing local anesthetic medication.  When it is used after surgery a dilute form of local anesthetic medication and commonly a low dose of narcotic medication are infused for several days after a procedure through an epidural.  In this setting the area of the body that is affected may be somewhat but not totally numb.  

The location of the epidural depends on the location of the surgery.  For example, in a surgery on the legs or pelvis it is common to place a lumbar epidural.  This is located in the lower back.  However, for abdominal surgeries, it is common to place a thoracic epidural.  This is usually placed in the lower thoracic region of the back because this is where the nerves which innervate the abdomen and skin over the abdomen begin to exit the spinal cord.  In chest surgery of the heart and lungs, thoracic epidurals are placed at a point higher in the back typically between the shoulder blades.  
Epidurals can be combined with any or all of the pain relieving strategies mentioned above.

Spinal anesthesia:
Spinal anesthesia involves placing a small amount of medicine in the cerebrospinal fluid in the lumbar area.  This is an excellent choice for pain relief after surgery.  Sometimes a small amount morphine is added to the mixture to provide 12 to 24 hours of pain relief.  In other cases a dilute form of local anesthetic is added to this mixture to provide extra pain relief in the first few hours after surgery.  The advantage of this is that when you recover from surgery initially there in very little or no pain.  As the spinal anesthetic wears off, one of the oral/IV pain relief techniques mentioned above can be used to provide continued relief.
 
Peripheral Nerve Blocks:
One exciting advance in anesthesia is the improvement and increased use of peripheral nerve blocks.  In a regional block a local anesthetic is placed around a large peripheral nerve to control pain during and after a surgery.  In addition a catheter is sometimes placed.  When using this treatment, local anesthetic will be infused around the nerve for a day or a few days to help control pain.  In this sense it is similar to an epidural but the catheter is by a peripheral nerve instead of near the spinal cord.  Common locations for peripheral nerve blocks include the brachial plexus in and around the neck and shoulder, as well as the femoral nerve near the groin, and the popliteal nerve behind the knee. If you chose a peripheral nerve block with your anesthesiologist, usually this will be combined with either MAC or GA.

If the block is performed in the neck it is called a brachial plexus block.  In the groin it is called a femoral nerve block.  At the level of the knee it is called a popliteal nerve block.  The advantage of these blocks is that they provide very good pain relief that is localized to the site of surgery.  All of these regional techniques can be combined with any of the oral/IV pain relief strategies mentioned above.