Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study

This study was

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J Shoulder Elbow Surg (2012) 21, 441-450

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doi:10.1016/j.jse

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Postoperative pain associated with orthopedic shoulderand elbow surgery: a prospective study

Vimal N. Desai, MD, Emilie V. Cheung, MD*

Department of Orthopedic Surgery, Stanford University Medical Center, Redwood City, CA, USA

Background: In the last 2 decades, extensive research in postoperative pain management has been under-taken to decrease morbidity. Orthopedic procedures tend to have increased pain compared with otherprocedures, but further research must be done to manage pain more efficiently. Postoperative pain morbid-ities and analgesic dependence continue to adversely affect health care.Materials and methods: The study assessed the pain of 78 elbow and shoulder surgery patients preoper-atively and postoperatively using the Short-Form McGill Pain Questionnaire (SF-MPQ). Preoperatively,each patient scored their preoperative pain (PP) and anticipated postoperative pain (APP). Postoperatively,they scored their 3-day (3dpp) and 6-week postoperative pain (6wpp). The pain intensities at these 4 inter-vals were then compared and analyzed using Pearson coefficients.Results: APP and PP were strong predictors of postoperative pain. The average APP was higher than theaverage postoperative pain. The 6wpp was significantly lower than the 3dpp. Sex, chronicity, and type ofsurgery were not significant factors; however, the group aged 18 to 39 years had a significant correlationwith postoperative pain.Conclusion: PP and APP were both independent predictors of increased postoperative pain. PP was alsopredictive of APP. Although, overall postoperative pain was lower than APP or PP due to pain managementtechniques, postoperative pain was still significantly higher in patients with increased APP or PP than theircounterparts. Therefore, surgeons should factor patient’s APP and PP to better manage their patient’s post-operative pain to decrease comorbidities.Level of evidence: Level I, Prospective Study Design, Prognostic Study.� 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Perioperative pain; postoperative pain; pain predictors; elbow and shoulder surgery; SF-MPQ;
Short-Form McGill Pain Questionnaire; anticipated pain
Postoperative pain assessment and its propermanagementhas become a health care prerogative as more patients areopting for surgical treatment and surgical time lengths are

approved by the Stanford University Panel on Human

dical Research, Investigational Review Board No. 6-

l ID: 97712.

uests: Emilie V. Cheung, MD, Department of Orthopedic

d University Medical Center, 450 Broadway St, MC 6342,

A 94063, USA.

ss: [email protected] (E.V. Cheung).

ee front matter � 2012 Journal of Shoulder and Elbow Surgery

.2011.09.021

decreasing.40,42,45,46,51,56 Throughout health care institutes,providers and administrators are pushing for a decrease inpostoperative hospital stays, for which pain is one of the topreasons of prolonged inpatient care.66 Nonetheless, painmanagement has improved significantly, but assessment toprevent and care for pain postoperatively requires furtherresearch.64 Surveys demonstrated undermanaged post-operative pain in patients undergoing varioussurgeries.5,19,21,23,24 Patients are at an increased risk forinadequate pain control, especially after orthopedic

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442 V.N. Desai, E.V. Cheung

surgeries, which Chung et al13,17,64 showed had the highestincidence of pain compared with other types of procedures.This study aimed to determine if a preoperative pain survey,the Short-FormMcGill Pain Questionnaire (SF-MPQ), couldbe significantly predictive of postoperative pain in patientsundergoing shoulder and elbow operations.

Shoulder and elbow surgeries, ranging from debride-ment to arthroplasties, have a significant effect on func-tional ability postoperatively, and pain experiencedpostoperatively further effects patient functionality, reha-bilitation, and long-term functional outcomes.4,8,9,16,66 Tobetter control pain, predictive factors need to be used,among which are weight, surgical site,12 sex, depression,15

smoking, alcohol,18 preoperative catastrophizing tendency,anxiety,22,54,62 preoperative expectations,25 preoperativepressure pain,28 loss of passive range of motion, radio-graphic evidence, glenoid bone erosion,30 preoperativepain, age, type of surgery,31 prediction rules,33 Spielberg-er’s State Trait Anxiety Inventory, health-related quality oflife (Medical Outomes Study Short-Form 35-item HealthSurvey),35 chronic sleeping difficulties,44 fear,61 and theMPQ.63

Many of these predictive factors have been significant indetermining postoperative pain intensity; however, to focuson anticipated and preoperative pain as predictive factorswe used the SF-MPQ.6,14,49,74 We had hypothesized thatanticipated postoperative pain (APP) and preoperative pain(PP) would be predictors of postoperative pain and therebyeffect pain management and control. This preoperative painassessment can improve postoperative pain managementthereby decrease morbidity rates that may be associated tothe postoperative pain and discomfort.3,68

Many patients are at risk of inadequate postoperativecare, and since January 2001, the Joint Commission onAccreditation of Healthcare Organizations set the standardfor pain assessment and management: patients havea right to have their pain assessed and treated properly.55

Proper pain management will have a positive effect onpatients’ overall experience and potentially decreasemorbidity.10,11,29,69,70,72 Because there are inadequate datafor pain assessment in orthopedic surgeries, more data mustbe collected to better predict postoperative pain in order toimprove pain management.2,13,14,46,56,57

Materials and methods

The study enrolled 80 consecutive patients undergoing shoulder orelbow surgery from May 2008 to October 2008. Two patients werelost to follow-up; therefore, 78 patients (39 men, 39 women) wereincluded. Our main analyses consisted of 11 separate Pearsoncorrelations. Using a Bonferroni adjustment, the adjusted a for thestudy was [0.05/11 ¼ 0.0045]. To detect Pearson correlations ofa magnitude of 0.40 at this a level and b ¼ 0.20, power analysesdetermined that 80 patients were required.

Patients were asked to complete a pain survey before and aftertheir operation. Each patient was operated on and treated by

a single orthopedic shoulder and elbow specialist (E.V.C.) at oneinstitute. The analysis excluded patients who were unable tounderstand the consent or survey or who were known to havea history of opioid or substance abuse.34,41,47 The average age was51 years (range, 18-89 years).

The procedures included all shoulder and elbow surgeries in anacademic practice. There were 39 patients undergoing elbowsurgery and 39 patients undergoing shoulder surgery.26,28,65,67 The39 elbow surgeries comprised 17 open reduction internal fixationof fractures, 10 open capsular releases, 1 ulnar nerve decom-pression, 3 olecranon bursectomies, 3 lateral epicondylitis repairs,1 open debridement of osteochondral lesion and synovectomy, 1synovial biopsy, 1 open removal of loose bodies, 1 open removalof nonunited capitellar fragment, and 1 irrigation and debridementof a nonhealing wound with anconeus muscle flap transfer.

Of the 39 shoulder surgeries, 6 included open reduction withinternal fixation of fractures, and 17 were arthroscopic shouldersurgeries of the following type: 5 rotator cuff repairs, 3 rotator cuffrepairs with subacromial decompression, 3 subacromial decom-pressions, 2 subacromial decompressions with debridement, 2rotator cuff repairs with superior labrum anteroposterior (SLAP)repairs, 3 SLAP repairs. Three were open surgeries, whichincluded 1 rotator cuff repair with biceps tenodesis, 2 distalclavicle excisions. Four were combined arthroscopic and openprocedures, which included arthroscopic rotator cuff repairs con-verted to open repairs, 8 were total shoulder arthroplasties, and 1was a hardware removal.

Conditions were chronic in 51 patients and acute in 27.General anesthesia was used in 47 patients and regional anesthesiain 31. There were no biases or exclusion criteria, except for theones stated.78

The SF-MPQ was used to assess pain. The patients completedthe present pain intensity (PPI) score part of the SF-MPQpreoperatively. They were then asked to complete the entire SF-MPQ for their APP and again were asked to do the same post-operatively at 3 days (3dpp) and 6 weeks (6wpp).38,43,49,50,76,77

Included were a PPI scale, a visual analog scale (VAS),a sensory pain scale, and an affective pain scale. The PP, APP, and3dpp surveys were conducted with direct patient assessmentswithin the clinic after consent. Of the 6wpp surveys, 43 were donein the clinic, and 35 patients were surveyed over the phone by oneof the authors. Conducting the SF-MPQ survey over the phone hasnot been validated formally through comparative studies; however,results obtained by phone were used and applied in reports byBrennan et al7 and Ekdahl and Petersson.20

The surveys, whether conducted in person on the phone, hadfew variations because they were simple ‘‘yes’’ and ‘‘no’’ ques-tions or a number rating. However, the VAS over the phone mighthave introduced errors because it requires a physical mark of painon a line that is 10.5 cm long. To determine this value over thephone, the 43 patients were told to determine their pain during the6-week postoperative period on a scale of 0 to 10.5. The answerwas then used as the VAS value. The preoperative assessmentswere conducted between 1and 7 days before surgery.75

Patients who were treated in an outpatient setting were givenoral hydrocodone/acetaminophen or oxycodone/acetaminophen.36

Patients who were admitted to the hospital were treated withpatient-controlled analgesia using morphine or hydromorphone,with standard pain control regulations according to institutionalpolicy.39,58-60,73,79 Inpatients were discharged with similar anal-gesia regimens as outpatients.10,11,48

Postoperative pain 443

Statistical analysis was conducted using Excel data analysissoftware (Microsoft Corp, Redmond, WA, USA).

Histograms for PP using the PPI scale were made as well as forthe APP, 3dpp, and 6wpp for the SF-MPQ PPI, VAS, sensory painscore, and affective pain score. The PPI is scored on a scale of 0 to5 as no pain (0), mild (1), discomforting (2), distressing (3),horrible (4), and excruciating (5). The VAS is measured incentimeters with a minimum score of 1 cm and a maximum of10.5 cm. The maximum sensory pain score is 33 and is scored ona scale of 0 to 3 with 11 descriptions of throbbing, shooting,stabbing, sharp, cramping, gnawing, hot-burning, aching, heavy,tender, and splitting. The maximum affective pain score 12, alsousing a scale of 0 to 3, with a description of tiring-exhausting,sickening, fearful, and punishing-cruel. These were created tovisualize distribution variations of pain intensities experienced bypatients.

Means, standard deviations (SD), and 95% confidence intervals(CI) for each type of pain score at each respective interval werecalculated. A Pearson correlation was calculated to determine thepredictive value of the PP and APP with the 3dpp and 6wpp. Itwas used to also calculate the P values to better determine theirsignificance.

Two-sample t statistics were stratified to determine the rela-tionship between sex, age, chronicity (chronic vs acute), type ofanesthesia and type of surgery with 3dpp on the 4 pain scales. Todetermine the power of the population-specific factors and theirrelationship to the outcomes, a Bonferroni adjustment was used.These comparisons were not powered appropriately. There were20 comparisons made, thereby giving a Bonferroni corrected valueof 0.0025. The surgical types for shoulders were categorized into 6types: (1) fixation with or without ligament repair, (2) capsularrelease, (3) ulnar nerve surgery, (4) bursectomy, (5) epicondylitis,and (6) other. The surgical types for elbows were categorized into6 types: (1) open reduction and internal fixation, (2) arthroscopic,(3) open surgeries for rotator cuff repair, biceps tenodesis, distalclay excision, or others, (4) combined arthroscopic and open, (5)arthroplasty and joint replacements, and (6) other.

Results

PPI scale

On the PPI scale, PP was compared with APP, 3dpp, and6wpp. APP was also compared with 3dpp and 6wpp. ThePP demonstrated a bimodal distribution, with most painexperienced peaking between 2 and 3 of 5 points andanother peak between 0 and 1 of 5 points (Fig. 1). Its meanwas 2.8 (SD, 1.4; 95% CI, 2.5-3.1; Table I). However, theAPP showed a monomodal peak between 2 and 3 points,with a shift to the left end and a mean of 2.4 points (SD,1.2; 95% CI, 2.1-2.7; Fig. 1, Table I). The 3dpp showeda peak distribution between 0 and �1, which thenprogressively decreased and had a mean of 1.7 (SD, 1.2;95% CI, 1.4-2.0; Fig. 1, Table I). There were no painintensities reported between 4 and 5. The 6wpp demon-strated a peak, with most patients reporting pain intensity ofbetween 0 and 1 and no pain between 3 and 5 (Fig. 1). Only17 patients reported pain greater than 1. The mean was 0.8

(SD, 0.9; 95% CI, 0.6-1.0; Table I). The least amount ofpain experienced by patients was at the 6wpp score. The3dpp was significantly higher than the 6wpp but less thanthe APP and PP.

The Pearson correlation coefficients were as follows onthis PPI scale: between PP and APP, 0.4 (P ¼ .001);between PP and 3dpp, 0.3 (P ¼ .006); between PP and6wpp, 0.2 (P ¼ .096); between APP and 3dpp, 0.4 (P <.001); and between APP and 6wpp, 0.2 (P ¼ .05; Table II).The P value of the APP and 3dpp on the PPI scale was<.0045, which was the Bonferroni adjustment, therebyhaving the most significant power.

VAS scores

The APP on the VAS demonstrated a peak between 5 and 6,with a relatively bell-shaped distribution (Fig. 2). The meanwas 4.9 (SD, 2.7; 95% CI, 4.3-5.5;Table III). The 3dppshowed a peak between 0 and 1 and a gradual decrease inreported pain intensity (Fig. 2); however, the mean was 3.2(SD, 2.7; 95% CI, 2.6-3.8; Table III). The 6wpp alsopeaked at 0 to 1 but with a larger majority (Fig. 2)producing a mean of 1.6 (SD, 2.2; 95% CI, 1.1-2.1).

The Pearson correlation coefficient between APP and3dpp on the VAS was 0.2 (P ¼ .08). The APP and 6wppcame to 0.3 (P ¼ .02; Table IV). Both P values were greaterthan the Bonferroni adjustment of 0.0045.

SF-MPQ sensory pain

The APP on the sensory pain portion of the SF-MPQshowed a trimodal distribution, with peaks between 0 and 5,10 and 15, and 25 and 33 (Fig. 3); however, the mean was14.1 (SD, 10.4; 95% CI, 11.8-16.4; Table V). The 3dpp hada peak of between 0 and 5, followed by a steep drop, afterwhich it fluctuated between the 5 and 33 range (Fig. 3). Themean was 9.4 (SD, 8.7; 95% CI, 7.4-11.4; Table V). The6wpp peak was between 0 and 5, with only 14 patientsreporting pain greater than 5 (Fig. 3). The mean was 2.5(SD, 3.9; 95% CI, 1.6-3.4; Table V).

The Pearson correlation coefficient between APP and3dpp on the sensory pain scale was 0.6 (P < .001). This Pvalue is less than the 0.0045 Bonferroni adjustment,thereby demonstrating its significant power. It was 0.2between APP and 6wpp (P ¼ 0.04; Table VI), which wasgreater than the Bonferroni adjustment.

SF-MPQ affective pain

The APP on the affective scale of the SF-MPQ (maximum12) demonstrated a monomodal peak between 0 and 3 anda steady drop after, with only 22 patients reporting APPgreater than 3 (Fig. 4). The mean was 2.5 (SD, 2.8; 95% CI,1.9-3.1; Table VII). The 3dpp had a peak between 0 and�3, with only 11 patients reporting pain greater than 3

Figure 1 Histogram shows the number of patients surveyed on the present pain intensity (PPI) scale from the Short-Form McGill PainQuestionnaire (range, 0-5) for preoperative pain (PP), anticipated postoperative pain (APP), and postoperative pain at 3 days (3dpp) and at 6weeks (6wpp).

Table I Outcome scores for pain on the present painintensity scale

Time of score Mean SD 95% CI

Preoperative pain 2.8 1.4 2.5-3.1Anticipated postoperative pain 2.4 1.2 2.1-2.73-day postoperative pain 1.7 1.2 1.4-2.06-week postoperative pain 0.8 0.9 0.6-1.0

CI, confidence interval; SD, standard deviation.

Table II Pearson correlation coefficients between timeintervals on the present pain intensity scale

Correlations Pearsoncoefficient

P

Preoperative pain vsAnticipated postoperative pain 0.4 .0013-day postoperative pain 0.3 .0066-week postoperative pain 0.2 .096

Anticipated postoperative pain vs3-day postoperative pain 0.4 <.0016-week postoperative pain 0.2 .05


(Fig. 4). The mean was 1.5 (SD, 2.2; 95% CI, 1.0-2.0(Table VII). The 6wpp histogram demonstrated that mostscores were between 0 and 3, with only 1 patient with paingreater than 3 (Fig. 4). The mean was 0.2 (SD, 0.7; 95% CI,0.0-0.4; Table VII).

The Pearson correlation coefficient between APP and3dpp was 0.5 (P < .001), which is lower than Bonferroniadjustment and thus demonstrates significant power, andwas 0.1 between APP and 6wpp (P ¼ .34), which is higherthan the Bonferroni adjustment (Table VIII).

Age, sex, surgery type, chronicity of pain, andanesthesia type and 3dpp

The mean age in this study was 51. Age and 3dpp showeda correlation coefficient of 0.3 (P ¼ .02) on the VAS, 0.3(P ¼ 0.01) on the PPI scale, 0.3 (P ¼ .01) on the sensorypain scale, and 0.1 (P ¼ .33) on the affective pain scale.Most of the increased reported pain was demonstrated in

the population aged younger than 40 years. For 3dpp forages 18 to 39, the average pain score was 4.1 on the VAS,2.0 on the PPI scale, 2.7 on the sensory pain scale, and 1.7on the affective pain. For 3dpp for ages 40 to 89, theaverage pain score was 2.8 on the VAS; 1.5 on the PPIscale; 7.8 on the sensory pain scale; and 1.2 on the affectivepain scale. All P values exceeded the Bonferroni adjust-ment of .0025. When sex, type of surgery, acute vs chronicpain, and regional vs general anesthesia were comparedwith 3dpp on all four scales, they produced P values >.05.

Discussion

The data showed that the strongest predictive factors forpostoperative pain were PP and APP in the 3dpp period,

Figure 2 Histogram shows the number of patients surveyed on the visual analog scale (VAS) from the Short-Form McGill PainQuestionnaire (range, 0-10.5 cm) for their anticipated postoperative pain (APP) and postoperative pain at 3 days (3dpp) and at 6 weeks(6wpp).

Table III Outcome scores for the visual analog scale


Anticipated postoperative pain 4.9 2.7 4.3-5.53-day postoperative pain 3.2 2.7 2.6-3.86-week postoperative pain 1.6 2.2 1.1-2.1


Table IV Pearson correlation coefficients between timeintervals on the visual analog scale scale


P

Anticipated postoperative pain vs3-day postoperative pain 0.2 .086-week postoperative pain 0.3 .02


when measured on the SF-MPQ.1,35,71 PP was also a strongpredictor of APP. APP was a strong predictor whenmeasured on the SF-MPQ’s PPI, sensory, and affectivescales, but not the VAS. The predictability of PP was onlymeasured and was deemed a significant predictive factoronly on the PPI scale of the SF-MPQ.

The significant correlation between the APP and 3dppcan be deemed from the following correlation coefficientsand their P values: 0.4 (P < .001) on the PPI scale, 0.6 (P <.001) on the sensory pain scale, and 0.5 (P < .001) on theaffective pain scale. Each of these P values had increasedsignificant power because their values were less than0.0045, the Bonferroni adjustment.

However, the APP was not a strong predictor for the6wpp. Overall, patients had little pain at 6 weeks andsignificantly less than they anticipated. The postoperativepain scores were 1.7/5, 3.2/10.5, 9.4/33, and 1.5/12 at 3

days and 0.8/5, 1.6/10.5, 2.5/33, and 0.2/12 at 6 weeks,respectively, on the PPI, VAS, sensory, and affective painscales. Pain management not only been greatly refined, butthe interval from surgery was also 6 weeks. We had pre-dicted that this would be the case. The APP and 6wppcorrelation coefficient and P values were 0.2 (P ¼ .05) onthe PPI scale, 0.02 (P ¼ .04) on the sensory scale, whichalthough significant had little power, and 0.1 (P ¼ .34) onthe affective pain scale (Tables II, IV, VI, and VIII).

The Pearson correlation coefficient between APP and PPwas 0.4, with a significant P ¼ .001, which also proves tohave significant power due to its value being less than theBonferroni coefficient (Table II). Because APP wasdependent on the PP, the APP was higher than the actualpostoperative pain. However, normalization of the valuesdemonstrated that APP and PP are both significant

Figure 3 Histogram shows the number of patients surveyed on the sensory pain scale from the Short-Form McGill Pain Questionnaire(range, 0-33) for their anticipated postoperative pain (APP) and postoperative pain at 3 days (3dpp) and at 6 weeks (6wpp).

Table V Outcomes for scores for the Short-Form McGill PainQuestionnaire Sensory Pain Scale




Table VI Pearson correlation coefficients between timeintervals on the Short-Form McGill Pain Questionnaire SensoryPain Scale


P




predictive values for postoperative pain, especially duringthe 3-day postoperative period. On the PPI scale, thecorrelation between PP and 3dpp was 0.3, with a significantP ¼ .006; but between PP and 6wpp, the correlation was0.2, with an insignificant P ¼ .096 (Table II). Therefore, thecorrelation coefficients showed preoperative pain wasa predictor of APP and also a strong predictor for 3dpp.

The results for the VAS were different than the resultsand trends on other scales. All produced low correlationcoefficients and insignificant P values. These may havebeen due to the nature of the scale, because some data wereretrieved over the phone and patients were asked to givepain ratings on a 1- to -10.5-cm measure similar to a painintensity of 1 to 10, but without an actual visual form tomark, which may have introduced an error. Further inves-tigation is needed.

By using the 2-sample t statistics to determine thesignificance of age, sex, surgery type, chronicity, andanesthesia applied, we found that age had a significant

correlation of 0.3 (P ¼ .01) on the sensory and PPI scaleand a significant correlation of 0.3 (P ¼ .02) on VAS. Theincreased intensity of pain reported on the 3-day post-operative period was found in the younger age group aged18 to 39 years, who had an average pain of 2 of 5 on the PPIscale and 12.7 of 33 on the sensory scale vs the 40 to 89 agegroup, who reported pain of 1.5 of 5 on the PPI scale and7.7 of 33 on the sensory scale. On the VAS, patients aged18 to 39 years reported pain of 4.1 of 10.5, and patientsaged 40 to 89 years reported 2.8 of 10.5. The affective painand age correlation was insignificant. The correlationbetween age and 3dpp needs further investigation.

None of these correlations was of significant powerbecause their P values exceeded the Bonferroni coefficientof 0.0025 in this comparison. The greater pain intensitiesreported in the younger population may be because theolder generation has had previous experiences of pain,increased tolerance, and decreased sensitivity of

Figure 4 Histogram shows the number of patients surveyed on the affective pain scale from the Short-Form McGill Pain Questionnaire(range, 0-12) for their anticipated postoperative pain (APP) and postoperative pain at 3 days (3dpp) and 6 weeks (6wpp).

Table VII Outcome scores for the Short-Form McGill PainQuestionnaire Affective Pain Scale




Table VIII Pearson correlation coefficients between timeintervals on the Short-Form McGill Pain Questionnaire AffectivePain Scale


P



neuropathic pain due to neuronal degeneration and desen-sitization. This would need further investigation if age mayalso have a predictive value for postoperative pain. Sex,type of surgery, chronicity, and anesthesia type were notsignificant (all P > .05).

The study introduced errors due to the variety of surgicaltypes previously listed, but due to the small populationpool, the numbers within each category type were notsignificant. There may be significant correlations betweenpostoperative pain and specific surgical procedures, but thiswas not assessed.

APP is a strong predictor for postoperative pain, espe-cially for the 3-day postoperative period (immediate post-operative period) when measured on the SF-MPQ PPIscale, sensory pain scale, and affective pain scale. Althoughmany pain scores have been used for shoulder and elbowsurgery, each with varying significance and populationsample sizes, the MPQ seemed to be comprehensive aswell as concise in order to provide significant data

results.14,25,27,37,49,52 As a pain measure, the VAS was notas strong in this study, probably due to an error whenconducted over the phone. The telephone assessment mayhave also introduced an overall error amongst all of thevarious scales for the 6wpp period for the 35 of 78 patientswho were surveyed over the phone.

PP was a strong predictor for APP and 3dpp on the PPIscale, it may also be on the VAS, sensory, and affective painscale, but they were not measured. The APP was thehighest overall pain score on all other scales, most likelybecause it was dependent on preoperative pain, at least onthe PPI scale. The 6wpp was not significantly predictablewhen APP or PP were used as factors due to low correlationcoefficients as well as insignificant P values. In addition,age also seemed to be a predictor of pain, with an increasepain intensity reported by the younger group aged 18 to 39years, but this needs further evaluation because the powerwas insignificant when the Bonferroni adjustment wasused.31


Nonetheless, postoperative pain management must bebetter assessed by considering strong predictive factorssuch as anticipated pain and preoperative pain.34 This cansignificantly decrease patient discomfort, postoperativechronic pain and morbidity, and hospital stay, and mayincrease the postoperative ambulatory rate and rate ofcompliance to therapy. Overall, it will benefit patientsatisfaction as well as benefit the entire health care systemnow that proper pain assessment and management hasbecome a priority.23,32,53,70,72

Conclusion

Pain management in the perioperative period is verycrucial in managing morbidities in patients. Orthopedicprocedures have been reported to be the most painfulpostoperatively, but patient pain continues to be poorlymanaged.13,64 Despite the use of opioids and patientcontrolled analgesia after elbow and shoulder surgery,patients continue to have uncontrolled pain. Our workdemonstrates that there are other reasons for this, such asanticipated postoperative pain and preoperative pain,which can be assessed by a pain questionnaire. It wasevident, when patients undergoing elbow and shouldersurgeries were surveyed preoperatively using the SF-MPQ’s various pain scales, one could better predict theirpostoperative pain. Thereby, surgeons can modify painmanagement of their patients through use of post-operative pain predictors, which can significantlydecrease the morbidity associated with elbow andshoulder surgery.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of thisarticle.

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Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study