Factors Contributing to Lingering Pain After Surgery

The Role of Patient Expectations

Mark D. Willingham, M.D.; Molly R. Vila, M.D.; Arbi Ben Abdallah, D.E.S., Ph.D.; Michael S. Avidan, M.B.B.Ch.; Simon Haroutounian, M.Sc.Pharm., Ph.D.


Anesthesiology. 2021;134(6):915-924. 

In This Article

Abstract and Introduction


Background: Pain that lingers beyond the early weeks after the acute postoperative period is an important risk factor for chronic postsurgical pain. This study examined the hypothesis that patients' expectations about their postsurgical pain would be independently associated with lingering postsurgical pain.

Methods: The study included 3,628 patients who underwent diverse surgeries between February 2015 and October 2016 in a single U.S. tertiary hospital and participated in the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) observational study. Preoperatively, patients were asked about their expectations about pain 1 month after surgery. Patients were considered to have lingering postsurgical pain if they endorsed having pain in the area related to their surgeries during a follow-up survey obtained 1 to 3 months postoperatively. The independent associations between preselected perioperative variables and lingering postsurgical pain were evaluated.

Results: Of the cohort, 36% (1,308 of 3,628) experienced lingering postsurgical pain. Overall, two thirds (2,414 of 3,628) expected their postsurgical pain to be absent or improved from baseline, and 73% of these had their positive expectations fulfilled. A total of 19% (686 of 3,628) expected new, unabated, or worsened pain, and only 39% (257 of 661) of these had their negative expectations fulfilled. Negative expectations were most common in patients with presurgical pain unrelated to the reason for surgery, undergoing surgeries not typically performed to help alleviate pain. Endorsing negative expectations was independently associated with lingering postsurgical pain (odds ratio, 1.56; 95% CI, 1.23 to 1.98; P < 0.001). Additional major factors associated with lingering postsurgical pain included recollection of severe acute postoperative pain (odds ratio, 3.13; 95% CI, 2.58 to 3.78; P < 0.001), undergoing a procedure typically performed to help alleviate pain (odds ratio, 2.18; 95% CI, 1.73 to 2.75; P < 0.001), and preoperative pain related to surgery (odds ratio, 1.91; 95% CI, 1.52 to 2.40; P < 0.001).

Conclusions: Lingering postsurgical pain is relatively common after diverse surgeries and is associated with both fixed surgical characteristics and potentially modifiable factors like pain expectations and severe acute postoperative pain.


IT is estimated that 10 to 50% of surgical patients suffer from chronic postsurgical pain, which is pain in the surgical area that persists after the surgical insult has healed.[1,2] These patients require more healthcare resources, suffer impaired quality of life, and often become chronic opioid users in the months after their surgeries.[1,3–6] Subacute pain that lingers throughout the first weeks to 3 months after surgery is a strong predictor of chronic postsurgical pain, which is typically assessed at least 3 to 6 months after surgery.[7–9] Identifying reliable risk factors for lingering postsurgical pain is important because it may help refine potential interventions (educational, pharmacologic, behavioral, and procedural) before pain becomes chronic in those most vulnerable.

A growing body of evidence suggests that patients' attitudes and expectations about their pain may be associated with their general health outcomes.[10–16] For example, optimistic pain expectations have been associated with better quality of life, increased functionality, and overall superior clinical outcomes.[16–19] Patients who believed their chronic pain was due to an injury or medical mismanagement had lower pain thresholds, poorer response to treatment, and increased deconditioning.[20,21] In addition, fear of surgery has been associated with increased pain, poorer recovery, and worse quality of life 6 months after surgery.[17] However, the association between patients' expectations about their postoperative pain and their actual lingering postsurgical pain outcomes has not been evaluated.

The primary aim of this study was to investigate the independent associations between certain perioperative characteristics (preoperative baseline pain, patients' expectations about their postoperative pain, and other proposed factors) and lingering postsurgical pain in a diverse surgical cohort. We hypothesized that patients' expectations about their postsurgical pain would be independently associated with lingering postsurgical pain.