Humble Stephen R, Varela Nicolas, Jayaweera Asantha, Bhaskar Arun
Imperial College Healthcare NHS Trust, Pain Management Clinic, Charing Cross Hospital.
Imperial College, London, UK.
Curr Opin Support Palliat Care. 2018 Jun;12(2):118-123. doi: 10.1097/SPC.0000000000000341.
Chronic postsurgical pain (CPSP) is an important and well recognized cause of much long-term suffering, which in some cases may be preventable and affects many people living with cancer. Unfortunately, general consensus is lacking as to how best reduce the risk of developing CPSP.
Cancer is now not always a short-lived, fatal disease and is now moving towards a chronic illness. Poorly managed perioperative pain is the greatest risk factor for CPSP. Recent trials have examined preventive strategies for CPSP associated with breast surgery and thoracotomy, two operations used in cancer treatment. Standard antinociceptive drugs, 5% lidocaine patches and ketamine do not prevent CPSP. The evidence for gabapentinoids is conflicting. Intravenous lidocaine and, separately, regional anaesthesia appear beneficial.
Well-managed pain, irrespective of technique, reduces the risk of CPSP. The literature is inconclusive regarding an 'optimal approach.' Regional anaesthesia, intravenous lidocaine and the aggressive management of perioperative pain using multimodal analgesia including antineuropathic pain agents such as gabapentinoids and certain antidepressants are recommended. Clinicians should not rely on general anaesthesia, opioids, NSAIDs and ketamine to prevent CPSP. A blanket approach using gabapentinoids for all patients undergoing major surgery is not indicated. Instead, the presence of perioperative neuropathic pain should be checked for regularly.
慢性术后疼痛（CPSP）是导致长期痛苦的一个重要且广为人知的原因，在某些情况下可能是可预防的，并且影响着许多癌症患者。不幸的是，对于如何最好地降低发生CPSP的风险，目前尚未达成普遍共识。
癌症现在并不总是一种短期致命疾病，正逐渐转变为一种慢性病。围手术期疼痛管理不善是CPSP的最大风险因素。最近的试验研究了与乳腺癌手术和开胸手术相关的CPSP预防策略，这两种手术用于癌症治疗。标准的抗伤害性药物、5%利多卡因贴剂和氯胺酮不能预防CPSP。加巴喷丁类药物的证据存在矛盾。静脉注射利多卡因以及区域麻醉似乎有益。
无论采用何种技术，良好的疼痛管理都能降低CPSP的风险。关于“最佳方法”，文献尚无定论。建议采用区域麻醉、静脉注射利多卡因以及使用包括加巴喷丁类药物和某些抗抑郁药等抗神经性疼痛药物的多模式镇痛积极管理围手术期疼痛。临床医生不应依赖全身麻醉、阿片类药物、非甾体抗炎药和氯胺酮来预防CPSP。不建议对所有接受大手术的患者一概使用加巴喷丁类药物。相反，应定期检查围手术期神经性疼痛的存在情况。
