Eur J Anaesthesiol 2017; 34:650651
INVITED COMMENTARY
Acute and chronic neuropathic pain after surgery
Still a lot to learn
Arnaud Steyaert and Patricia Lavandhomme
European Journal of Anaesthesiology 2017, 34:650651
This Invited Commentary accompanies the follow-
ing original article:
Beloeil H, Sion B, Rousseau C, et al. Early post-
operative neuropathic pain assessed by the DN4
score predicts an increased risk of persistent postsur-
gical neuropathic pain. Eur J Anaesthesiol 2017;
34:652657.
More than 300 million surgical procedures are performed
worldwide every year and a substantial proportion of
patients still report severe pain during the first
2448 h, even after minor procedures.1 Moreover,
11.8% [95% confidence interval (CI): 9.7 to 13.9%] will
suffer from chronic post-surgical pain (CPSP), defined as
pain that persists longer than the normal healing period
of 3 months.2 CPSP can be severe in 2.2% of patients
and, depending on the type of surgery, is often neuro-
pathic. In patients with severe CPSP, some 30% (range,
6 to >54%) have signs of neuropathic pain.3,4 When
neuropathic pain is present, pain intensity and its impact
on quality of life are generally higher.2,4
For International Association for the Study of Pain,
2017 is the Global Year against Pain after Surgery.
In the light of the aforementioned problems regarding
the control of both acute and chronic pain after surgery,
and keeping in mind that poorly relieved postoperative
pain is a major risk factor for the development of
persistent pain after surgery,4,5 the presence of a
neuropathic component in acute pain and its relation-
ship with severe persistent post-surgical pain certainly
deserves attention.
In this issue of the journal, Belloil et al.6 from the Societe
Francaise dAnesthesie-Reanimation Research Network
From the Department of Anaesthesiology and Acute Pain Service, Cliniques Universitaires Saint-Luc, Brussels, Belgium (AS, PLH)
Correspondence to Patricia Lavandhomme, Department of Anaesthesiology and Acute Pain Service, Cliniques Universitaires Saint-Luc, Brussels, Belgium
E-mail: Patricia.Lavandhomme@uclouvain.be
0265-0215 Copyright 2017 European Society of Anaesthesiology. All rights reserved.
Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
have assessed the presence of a neuropathic component
in acute postoperative pain within the first 48 h after
surgery and again at 2 months. In a cohort of 593 patients,
using the DN4 (Douleur Neuropathique 4) questionnaire,7
the authors found neuropathic pain to be present in 5.6
and 12.9% of patients suffering from acute postoperative
pain on days 0 and 2, respectively. At 2 months, 39% of
patients still had pain and a neuropathic component was
present in 33% of these.
These results deserve comment, as studies on the pre-
valence of neuropathic pain immediately after surgery are
extremely scarce. However, care is required when inter-
preting this 13% prevalence of acute neuropathic pain as
reported by the authors as this determination was based
on the DN4 alone, a screening tool that has not been
validated in this setting. Of note, a prospective study of
all patients referred to an Australian acute pain service
identified patients with neuropathic pain using clinical
history and examination only: they found an overall
incidence of 1.04%.8 The diagnosis of neuropathic
pain in patients with acute postoperative pain is chal-
lenging, as many of the characteristics considered by pain
experts as useful for the diagnosis of acute postoperative
neuropathic pain (e.g. burning pain, allodynia and
hyperalgesia) can also be encountered in postoperative
inflammatory pain, or as a consequence of primary and
secondary hyperalgesia.9 Moreover, the criteria used to
diagnose neuropathic pain10 are not always applicable in
the immediate postoperative setting. In addition, neuro-
logical examination is difficult in patients with limited
mobility or with dressings that interfere with sensory
assessment, and confirmatory tests are rarely available
or contributive early after nerve injury. Similarly, the
DN4 has not been specifically validated for neuropathic
pain screening 2 months after surgery. Nevertheless, the
DN4 has been used in large epidemiological studies,3,4
and some small studies show similar sensitivity and
specificity for the detection of clinically diagnosed
DOI:10.1097/EJA.0000000000000682

neuropathic pain in both subacute11 and chronic post-
operative pain patients.12,13
The second objective of Beloeil et al.6 was to confirm, in
a general population, the association between acute
neuropathic pain after surgery and persistent post-
surgical neuropathic pain (PPSNP) at 2 months, as has
been previously reported for chronic post-surgical neuro-
pathic pain after thoracic14 and iliac crest surgery15 after
3 months. The authors found that acute postoperative
neuropathic pain identified on day 2 was associated with
severe persistent post-surgical pain still involving a
neuropathic component 2 months after surgery. These
findings support the fact that early neuropathic pain as
identified by a DN4 questionnaire may be a risk factor for
PPSNP (OR 4.22; 95% CI 2.19 to 8.12).
These results raise the question of the use of screening
questionnaires in the acute postoperative phase in the
hope of improving patient outcomes. If at-risk patients
can be identified early in the postoperative period, one
could speculate, as do the authors, that tailored treatment
at this stage could prevent the development of chronic
pain. Such interventions will probably necessitate a lon-
ger follow-up period than the 2 months in the present
study, especially as CPSP is not a static phenomenon but
rather fluctuates with time. Pain can resolve or appear,
even several years after surgery.16 It is also well known
that there can be a pain-free interval between a nerve
injury and the onset of neuropathic pain.17 Moreover,
pain characteristics can vary over time. A large prospec-
tive study recently found that the neuropathic character
(evaluated with the DN4) of persistent pain after various
types of surgery changes between 3 and 6 months in 25%
of patients.3 Similar findings have been reported up to
3 years after knee surgery.18
So, what is the way forward? From a research agenda
point of view, to understand the dynamic nature of
CPSP better, we need longitudinal studies with a long
follow-up and assessments at multiple time points.
Ideally, in addition to screening questionnaires, these
studies should incorporate standardised sensory testing
to assess pain characteristics more reliably. The role of
neuropathic pain screening questionnaires and their
performance in this setting should also be clarified.
Finally, we should set up randomised studies to test
tailored, multidisciplinary interventions aimed at at-risk
patients, for example those displaying neuropathic pain
symptoms in the acute postoperative phase. From a
clinical point of view, this study adds a positive DN4
score in the immediate postoperative period to the
already known risk factors for CPSP5 and underscores
the need to set up pain management programmes
Eur J Anaesthesiol 2017; 34:650651
Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Neuropathic pain after surgery 651
dedicated to the follow-up of surgical patients, not just
in the acute postoperative period but also after their
discharge from the hospital.19
Acknowledgements relating to this article
Assistance with the commentary: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Comment from the Editor: this Invited Commentary was checked
by the editors but was not sent for external peer review. PL is an
Associate Editor of the European Journal of Anaesthesiology.
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