Persistent Incisional Pain After Noncardiac Surgery

An International Prospective Cohort Study

James S. Khan, M.D., M.Sc.; Daniel I. Sessler, M.D.; Matthew T. V. Chan, M.B., B.S., Ph.D.; C. Y. Wang, M.B.Ch.B., F.R.C.A.; Ignacio Garutti, M.D., Ph.D.; Wojciech Szczeklik, M.D., Ph.D.; Alparslan Turan, M.D.; Jason W. Busse, D.C., Ph.D.; D. Norman Buckley, M.D.; James Paul, M.D., M.Sc.; Michael McGillion, R.N., Ph.D.; Carmen Fernández-Riveira, M.D., Ph.D.; Sadeesh K. Srinathan, M.D.; Harsha Shanthanna, M.D., Ph.D.; Ian Gilron, M.D., M.Sc.; Michael Jacka, M.D., M.B.A.; Paul Jackson, B.Sc., M.Sc., M.S., M.D.; James Hankinson, M.D.; Pilar Paniagua, M.D., Ph.D.; Shirley Pettit, R.N.; P. J. Devereaux, M.D., Ph.D.


Anesthesiology. 2021;135(4):711-723. 

In This Article

Abstract and Introduction


Background: The purpose of this study was to determine the incidence, characteristics, impact, and risk factors associated with persistent incisional pain. The hypothesis was that patient demographics and perioperative interventions are associated with persistent pain.

Methods: This was a secondary analysis of an international prospective cohort study from 2012 to 2014. This study included patients who were 45 yr of age or older who underwent major inpatient noncardiac surgery. Data were collected perioperatively and at 1 yr after surgery to assess for the development of persistent incisional pain (pain present around incision at 1 yr after surgery).

Results: Among 14,831 patients, 495 (3.3%; 95% CI, 3.1 to 3.6) reported persistent incisional pain at 1 yr, with an average pain intensity of 3.6 ± 2.5 (0 to 10 numeric rating scale), with 35% and 14% reporting moderate and severe pain intensities, respectively. More than half of patients with persistent pain reported needing analgesic medications, and 85% reported interference with daily activities (denominator = 495 in the above proportions). Risk factors for persistent pain included female sex (P = 0.007), Asian ethnicity (P < 0.001), surgery for fracture (P < 0.001), history of chronic pain (P < 0.001), coronary artery disease (P < 0.001), history of tobacco use (P = 0.048), postoperative patient-controlled analgesia (P < 0.001), postoperative continuous nerve block (P = 0.010), insulin initiation within 24 h of surgery (P < 0.001), and withholding nonsteroidal anti-inflammatory medication or cyclooxygenase-2 inhibitors on the day of surgery (P = 0.029 and P < 0.001, respectively). Older age (P < 0.001), endoscopic surgery (P = 0.005), and South Asian (P < 0.001), Native American/Australian (P = 0.004), and Latin/Hispanic ethnicities (P < 0.001) were associated with a lower risk of persistent pain.

Conclusions: Persistent incisional pain is a common complication of inpatient noncardiac surgery, occurring in approximately 1 in 30 adults. It results in significant morbidity, interferes with daily living, and is associated with persistent analgesic consumption. Certain demographics, ethnicities, and perioperative practices are associated with increased risk of persistent pain.


Surgery appears to be a major cause of chronic pain, as 22% of patients seeking care at a chronic pain clinic attribute their pain to a surgical procedure.[1] Persistent postsurgical pain has been defined as the presence of pain after the usual healing time of surgery (3 months), localized to the surgical incision or referred pattern of pain (e.g., along a nerve distribution or dermatome), and not due to any organic cause of pain (i.e., infection, malignancy).[2] Because chronic pain is often refractory to treatment, efforts have been directed toward identifying preventative therapies within the perioperative period.[3] Unfortunately, no definitive interventions have been identified, and chronic postsurgical pain continues to be a significant source of long-term physical, psychologic, emotional, and social distress.[4] Chronic pain contributes to concurrent depression and anxiety, and 10% of patients with chronic pain will attempt suicide.[5–9] Economic hardships are common in those with chronic pain due to disability and reduced work productivity.[10] Additionally, chronic opioid use is associated with long-term morbidities (overdose, tolerance, hyperalgesia), and surgery and trauma are responsible for chronic opioid use in 2.6% of opioid-naïve adults.[11]

Although surgery is known to be a trigger for chronic pain, there is substantial variation in the reported incidences of persistent pain after noncardiac surgery. The majority of studies have been conducted within specific surgical populations and provide estimates ranging from 0 to 60%.[12,13] Variation is likely due to a number of factors including differences in regional surgical and perioperative practices, small sample sizes (100 to 300 patients), time of outcome assessment after surgery, and inconsistent definitions.[2]

Using data from a large, international, prospective cohort study (the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation [VISION] Study; identifier NCT00512109), we aimed to identify the incidence, characteristics, impact, and risk factors associated with the development of persistent incisional pain after noncardiac surgery. Our hypotheses for this analysis were that demographics and perioperative pain interventions would influence the risk of developing persistent pain.