This patient guideline is based on the Estonian treatment guideline “Perioperative treatment of acute pain” approved in 2016. The management's wishes for treatment were compiled based on a literature review based on scientifically proven facts. The purpose of the patient guide is to help patients manage postoperative pain and answer questions related to acute pain. Knowledge of pain treatment options helps patients actively participate in treatment. The importance of the topics covered in the patient guide, as well as the accessibility of the text, were appreciated by patients with acute postoperative pain. The patient guide explains the following topics: what acute postoperative pain is, why it is important to treat acute pain, and how to evaluate it. Various chapters describe treatment options for acute postoperative pain. The reader will receive answers to the following questions: why the use of oral medications is preferred for treating pain, whether different painkillers can be taken together, and what else can be done besides medications to relieve pain. Recommendations are also given on how you can manage post-operative pain at home. You can read more about the topics covered in this patient guide on the web pages at the end of the guide (see Appendix 1).
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What is acute postoperative pain?
Pain is a subjective and unpleasant sensation that affects consciousness and impairs well-being. Acute pain is short-lived, most often has a clearly defined area, a specific onset time, and subjective and objective physical signs: heart rate and breathing become faster and blood pressure rises. Severe pain interferes with sleep and creates feelings of fear and anxiety. Acute postoperative pain occurs due to a surgical procedure or surgery. The severity of pain depends both on the severity of the operation and the size of the surgical wound, and on the person’s pain threshold. People feel and react to pain differently. Pain sensations may also be influenced by the patient's early experiences with pain, his age, gender, cultural background, and psychological factors. In the case of children, their parents' attitude towards pain may also influence pain sensations.
Reminder after hernia removal: two important additions
We will not list all the points of the instructions; you know it, since it is always given to you upon discharge from the hospital. But we consider it necessary to inform about some requirements that are not covered in the issued instructions, which patients most often ask on forums. So, the two most common questions are: is a bath allowed after surgery and when can you have sex?
- Somewhere you can read that the bath is effective against the adhesive-scarring process after removal of a vertebral hernia. Attention! This fact has no confirmation . Moreover, it is forbidden to go to the bathhouse after the operation for at least 6 months, or even better, a year. Temperature procedures are stimulants of metabolism and normalization of body functions, and if there is at least a small sign of internal or external inflammation in the area of the surgical field, they can also intensively stimulate the progression of the inflammatory reaction. The steam room can cause swelling of the surgical wound and divergence of “fresh” sutures. And this is a favorable environment for the entry of pathogenic bacteria and the development of purulent-infectious pathogenesis.
- As for sex, it should be excluded for a while . Doctors usually do not advise resuming sexual activity for at least 14 days from the date of intervention. And even from this moment, until you finally recover, sexual contact should be as safe as possible. You must be a passive partner. In order not to cause injury to the operated part of the ridge, gentle sex is allowed, not characterized by high tension. The rule of no excessive load on the spine, in particular on the lumbosacral region (hernias are most often removed in this segment), should be observed for approximately 6 months.
Important! To achieve a full restoration of your quality of life and avoid consequences, strictly follow all contraindications and indications that are set out in the leaflet given to you upon discharge from the surgical hospital. And be sure to continue your recovery in the rehabilitation center. The standard period of mandatory rehabilitation, subject to positive dynamics, is 3 months.
Why is it necessary to treat acute postoperative pain?
Postoperative pain should not be tolerated, as pain may increase the incidence of postoperative complications: recovery after surgery will be slower and therefore the length of hospital stay may increase. If pain is left untreated, chronic postoperative pain is more likely to occur. Effective treatment of postoperative pain eases the functioning of the heart and lungs, reduces the risk of vein thrombosis and helps normalize digestion.
Intervertebral hernia: surgery and rehabilitation
The rehabilitation course is prescribed 1-1.5 months after the operation. Rehabilitation after removal of a sequestered hernia begins later, since removal of a complicated hernia requires a longer period to restore tissue integrity. Rehabilitation begins after agreement with the attending physician and the surgeon being operated on. The recovery process occurs under the supervision of an orthopedic surgeon, traumatologist and neurologist. Together, doctors draw up a treatment plan that will need to be followed throughout the rehabilitation period. The treatment process will include daily procedures to promote healing and restoration of spinal function.
The main goals of rehabilitation after removal of an intervertebral hernia are:
- strengthening the muscles of the spine;
- restoration of vertebral mobility;
- normalization of metabolic processes in the operated area.
At the initial stage, the patient will be prescribed physical therapy and massage. The intensity of the load will increase gradually so as not to overstrain the spine. In the future, various types of physiotherapy and dosed traction of the spine are used.
How is the severity of pain assessed?
Assessing the severity of pain after surgery is a routine part of patient monitoring. Pain is assessed regularly, and the frequency of assessment depends on the patient's condition and the severity of the operation. Since the sensation of pain is individual and subjective, only you yourself can assess the strength of the pain you experience. The nurse will assess your pain regularly both before and after taking pain medications, both while you are at rest and when moving. Based on the information received, it will be possible to create a pain treatment plan that suits you personally. Various pain scales are used to assess pain. For example, a scale for digital assessment is used in adults. It is used to rate the severity of pain on a scale of ten, where zero means no pain and 10 means the worst pain you can imagine. The patient is asked to rate the pain experienced over the past 24 hours using three different methods. Rate:
- the severity of the existing pain,
- the weakest feeling of pain and
- the strongest feeling of pain.
The arithmetic mean of the obtained scores will show the strength of the patient's feeling of pain during the last 24 hours. Sometimes you are asked to choose words that describe your pain. These words could be:
- no pain
- slight pain
- moderate pain
- strong pain
- very severe pain
- unbearable pain
Figure 1. Numerical Pain Rating Scale Sometimes the face scale (FPS-R) (see Figure 2) or the so-called face scale is used to evaluate pain. This scale can be used, for example, with older children. The face scale will need to be explained to the child so that they can use it to rate their pain. The child will need to explain the scale as follows: “This face (point to the face on the far left) shows that there is no pain at all. Other faces (point to each face from left to right) show that the pain is getting worse and worse. The face on the far right shows that he is in great pain.” After the explanation, you can ask the child which face shows how much pain he is now? According to the child's choice, the rater will be able to give the indicated pain a score of 0, 2, 4, 6, 8, or 10 points, counting from right to left: 0 = not painful at all. 10 = very painful. When evaluating, you cannot use the words “sad” or “happy.” It is imperative to clarify that we are talking only about how the child feels, and not about the external facial expression.
Figure 2. Facial Pain Rating Scale (FPS-R) The above scales are used not only to assess pain in older children, but also for patients with mild to moderate mental illness. For small children, infants and patients with severe mental illness, a behavior scale is used, in which the severity of pain is assessed by a nurse. These scales take into account the patient's vital signs such as heart rate, blood pressure, blood oxygen levels and behavior (facial expression, restlessness, sleep) to assess the severity of pain.
| For best results in pain management, tell your nurse right away if you feel pain—even if the pain is mild or if it occurs at night. Don't endure the pain! |
How to treat pain after surgery?
In the treatment of post-operative pain, different medications are used with different methods of administration. In addition, the use of alternative methods is permitted, which can be used in case of mild to moderate pain. To prescribe appropriate pain treatment, it is important to know what medications (including painkillers) you have already used, whether you are allergic to medications, and whether you have had any side effects. When prescribing medication, we take into account modern medical principles related to the operation you performed and pain medications. The choice of an appropriate painkiller, the dose of the drug and the duration of treatment depend on the severity of the pain (mild, moderate or severe pain), the type of pain (whether there was, for example, wound pain or nerve pain), the person himself (elderly, child, pregnant woman, etc.) ), as well as from concomitant diseases. To achieve the best effect of painkillers, take your medications regularly (at regular intervals). Painkillers of different effects are often combined.
Groups of painkillers
Medicines are used as painkillers, which are divided according to the type of mechanism of action into three main groups:
- Simple painkillers. For example paracetamol, ibuprofen and diclofenac.
- Opioids. Medicines in this group are divided into weak opioids - for example, tramadol, codeine, and strong opioids - for example, morphine.
- Maintenance medications. They are used, for example, to treat nerve pain.
Paracetamol
Paracetamol is often the first choice for mild to moderate pain. Paracetamol differs from other painkillers (for example, ibuprofen and diclofenac) primarily in that it does not irritate the mucous membrane of the digestive tract. Side effects are rare when taking paracetamol. The most severe possible side effect is liver damage, which is rare and most often occurs due to an overdose of the drug. Paracetamol should be used cautiously in cases of liver or kidney failure, chronic malnutrition or alcoholism. Paracetamol should be prescribed to a child according to his age and weight. If additional medications are used (for example, so-called flu teas), which include paracetamol in combination with an anesthetic, you need to ensure that the amount of paracetamol taken per day does not exceed the permitted daily dose (for adults, 4 grams per day).
Maintenance medications such as gabapentin, pregabalin.
Maintenance medications are those medications that were not originally developed as pain relievers but were later discovered to be useful in relieving certain types of pain. For example, gabapentin and pregabalin were originally used to treat epilepsy. Often these medications are used to treat chronic nerve pain. They are also effective for treating post-operative pain, reducing pain and the need for other pain medications.
| If any side effects occur, tell your nurse or doctor right away! |
After surgery, painkillers can be taken:
- through the mouth
- through injections into a vein or muscle
- through an epidural catheter
- using a medicinal suppository
After surgery, oral pain medications are preferred. Medicine taken by mouth is as effective as medicine given by injection, and there is no pain or injection-related complications such as bleeding or inflammation at the injection site. Pain medications taken by mouth are suitable for all types of pain, but you must be able to eat and drink.
Injecting medication into a vein
If taking the tablets by mouth is not possible due to surgery, the nurse will give you the medication through a cannula into a vein. The analgesic effect will occur within a few minutes. As soon as you start eating and drinking, you can go back to taking pills. After a major and painful operation, painkillers can be taken using a special pain pump, with which you can regulate the dose of painkiller (opioids) injected into the vein. This method is called patient-controlled pain relief or PCA (short for Patient Controlled Analgesia). To take painkillers, use a special pump that will allow you to receive painkillers as soon as you feel the need. The doctor will calculate the dose of medication that is appropriate for you and enter it into the pump’s memory. If you feel pain, press the button and the pump will inject you with the appropriate amount of medication through a cannula into a vein. There is no danger of overdosing on the medication because the pain pump is programmed according to your needs. You must press the pump button yourself; you must not let anyone else do it. If the dose of medicine calculated for you is not enough and does not reduce your pain, tell your nurse or doctor, who will adjust the dose of the medicine given according to the severity of the pain. The PCA pump is also used for children if the child is old enough to use it and he is able to understand the principle of operation of the pump.
Figure 3. PCA pump
Injecting medication into muscles
They try to avoid administering painkillers by injection, since due to heterogeneous absorption, the effect of anesthesia may be less than the expected effect. In addition, the injection can be painful.
Administration of medication using medicinal suppositories
Sometimes, if taking painkillers by mouth is impossible for some reason, medications can also be taken through the rectum. Medicinal suppositories are often used to relieve pain in young children.
Taking medications through an epidural catheter
Using local anesthesia, if necessary, the anesthesiologist will place a thin plastic probe (epidural catheter) in your epidural space surrounding the spinal canal before surgery. The epidural space is located in the spinal canal, where the roots of the nerves that transmit pain pass. The medicine injected there affects the roots of the nerves and thus prevents the spread of the pain pulse. Therefore, the introduction of drugs into the epidural space is one of the most effective methods of pain relief. Opioids and local anesthetics - a mixture for local anesthesia - are continuously injected into the epidural catheter through an automatic syringe throughout the day. The analgesic effect begins no later than 20 minutes after starting to take the medicine.
Figure 4. Installation of an epidural catheter. Epidural analgesia may cause:
- Nausea and vomiting - anti-nausea medications can help
- Weakness and numbness in the legs - they go away on their own
- Urinary problems - if necessary, a catheter is placed in the bladder
- Lower blood pressure – blood pressure is monitored regularly
- Head or back pain - tell your nurse or doctor. If headaches occur after surgery while you are receiving treatment at home, contact your healthcare provider immediately.
Nerve plexus block
Nerve plexus blocks are most often used to relieve pain in the extremities. Blockades are made either with a single injection or with the use of a catheter, which is installed next to the nerve plexus and is needed for continuous administration of medication (local anesthesia). Medicines are administered through the nerve plexus catheter either with a single injection or with an automatic syringe.
The effect of alternative pain treatment methods on postoperative pain is small, so you should not use such methods alone, but only together with painkillers. Alternative methods can reduce anxiety and tension throughout your hospital stay. Most methods, such as music therapy or distraction, are safe and you can use them without special training or additional equipment. If the pain is mild or moderate, then in addition to painkillers, you can use methods from the list below. You can ask your ward nurse for more information about the different methods.
Complications after removal of a spinal hernia
Everyone wants to get an answer to the most exciting question: is surgery for a herniated disc dangerous? Absolutely every surgical treatment method has risks of possible complications. In our case, the danger of the operation is also not excluded, and in the dominant quantity it consists in the appearance of a relapse, which is solved by repeated intervention. Of course, the quality of the intraoperative session also plays a special role, but, as a rule, in successful clinics the operation goes well.
What may be the intraoperative consequences? Mostly they are associated with injury to the nerve or dura mater of the spinal cord.
- The first complication will be manifested by pain and loss of sensitivity in the legs or arms, depending on the location of the injured nerve. If the nerve structure is severely damaged, the prognosis for its recovery is, unfortunately, disappointing.
- If the dura spinal membrane is damaged, if the surgeon detects the defect in a timely manner, he will suture it. Otherwise, cerebrospinal fluid will leak. Impaired circulation of cerebrospinal fluid will cause problems with intracranial pressure and, as a result, the patient will experience severe headaches. The dura can heal on its own in about 2 weeks.
Negative reactions can be postoperative, early and late:
- Early complications include purulent-septic processes, including epiduritis, osteomyelitis, suppuration of the suture, and pneumonia. In addition, the group of early postoperative consequences includes deep vein thrombosis of the lower extremities and pulmonary embolism.
- Late negative reactions are repeated relapses, secondary degenerative pathologies. This also includes rough scar-adhesive growths, which in turn compress nerve formations, which, as with intervertebral hernias, is manifested by pain and/or paresthesia spreading along the pinched nerve.
If the operation is carried out efficiently, all preventive measures are followed and medical recommendations are flawlessly followed, the likelihood of any consequences occurring is reduced to the very minimum.
Cold compress
Cold causes blood vessels to constrict and bleeding in the injured area slows down. If you have no contraindications, you can use a cold compress to reduce swelling and pain in the surgical area. As a cold compress, you can use special gel packs sold in pharmacies; any package from the freezer is also suitable. Wrap the cold bag in a towel and then place it on the damaged area and apply a compress if necessary. The towel will protect the fabrics from possible local exposure to cold. Keep the cold compress in place for 20-30 minutes at a time, then pause for 10-15 minutes and repeat the procedure if necessary.
Foreign and Russian treatment: what is the prognosis
Domestic clinics sometimes do not have a well-functioning rehabilitation system.
Therefore, it is better to undergo surgery in foreign countries for spine and musculoskeletal surgery (in the Czech Republic, Germany, Israel). Even the most technically complex manipulations will be carried out “cleanly” here; the impeccability of the responsible procedure is ensured. It is very important to receive a high-quality and full rehabilitation benefit, but not all leading foreign countries can provide this part of the treatment process. In addition, the cost of a full-fledged Czech program of highly professional complex treatment is 2-3 times lower than the price in Germany and Israel for only one surgeon’s service. Forecasts for a successful postoperative outcome in the Czech Republic are 95%-100%.
Physiotherapy
Physiotherapy is recommended to be added to the postoperative treatment regimen, as it reduces the risk of complications and facilitates the recovery of the body after surgery. Physiotherapy is carried out by a specialist. He will explain to you why it is necessary to start moving as quickly as possible after surgery, teach you how to take as comfortable and relaxed a position as possible after surgery, and how to support your body with pillows or the surgical area with a bandage. In addition, he will teach you breathing techniques, as well as motor exercises.
Cervical intervertebral disc herniation: consequences and rehabilitation
Rehabilitation after an intervertebral hernia of the cervical spine requires special attention, since any surgical intervention in this area can have serious consequences:
- damage to the meninges;
- infection;
- speech and breathing disorders;
- injury to the esophagus.
In the postoperative period, the patient is prohibited from standing up or making sudden movements. You should also not sit for a long time to avoid additional complications. The patient needs to be very attentive to his condition and at the first signs of deterioration (acute pain, numbness, dizziness) immediately consult a doctor.
Cervical spine rehabilitation will include:
- wearing an orthopedic corset, cervical collar;
- massage;
- physiotherapy;
- physiotherapy.
Music therapy
Listening to music reduces anxiety, slightly reduces the severity of post-operative pain, and with music the stress reaction associated with pain occurs less frequently. Therefore, the need to take opioids is reduced. If you enjoy listening to music and it relaxes and calms you, then we recommend that you take your favorite music with you to the hospital. You just need to remember that other patients may not like your favorite music, so we recommend that you use headphones when listening to music.
