Management of Persistent Pain Six Months After Capsule Release Surgery

Initial Evaluation

Pain persisting beyond 3 months after surgery meets the definition of chronic postsurgical pain according to the International Classification of Diseases 11th Revision (ICD-11) 1
Radiographs should be obtained as the first-line imaging modality to rule out mechanical complications or infection 2, 3
MRI or CT imaging may be necessary to evaluate for potential causes of persistent pain, including inadequate decompression or adjacent tissue issues, although this fact is from a less preferred source, a more preferred source is not available 4
Laboratory tests, including ESR, CRP, and interleukin-6, should be considered to rule out infection 3

Active physical therapy focusing on core strengthening and joint stabilization should be implemented rather than passive modalities, although this fact is from a less preferred source, a more preferred source is not available 4
Non-opioid medications, such as NSAIDs, should be tried first for pain management, as recommended by the British Journal of Anaesthesia 5
Anticonvulsants and antidepressants may also be used for pain management, although these facts are from a less preferred source, more preferred sources are available for NSAIDs 4
Cognitive behavioral therapy, biofeedback, and relaxation training have demonstrated relief of chronic pain, although this fact is from a less preferred source, a more preferred source is not available 4

Image-guided injections may be used as part of a multimodal treatment regimen for patients with persistent pain, although this fact is from a less preferred source, a more preferred source is not available 4
Consider referral for interventional pain procedures if conservative measures fail, although this fact is from a less preferred source, a more preferred source is not available 4

If the patient is taking opioids at 6 months post-surgery, this requires further assessment, as recommended by the British Journal of Anaesthesia 5, 6
Persistent opioid use at >90 days post-surgery warrants a medical evaluation and exclusion of chronic post-surgical pain, as recommended by the British Journal of Anaesthesia 5, 6
If opioids are necessary, immediate-release formulations are preferred over long-acting preparations to decrease risk of respiratory impairment and long-term continuation, as recommended by the British Journal of Anaesthesia 6

Night pain or pain at rest is characteristic of infection, whereas pain on weight bearing is more characteristic of mechanical issues, as reported in the Journal of the American College of Radiology 2, 3