Updating postoperative pain management: from multimodal to context-sensitive treatment

Although a wealth of evidence exists on effective postoperative pain (POP) treatment, surgical patients still suffer from inadequate analgesic regimens, and outcomes have been shown to improve only within the context of tightly controlled, randomized trials. The pathophysiology of pain seems to suggest that analgesic regimens aimed at inhibition of neurotransmission and neuroplastic phenomena should be instituted immediately before the painful stimuli are applied. Several protocols have been proposed, but the final choice should be made according to patients' needs, surgical indications, and institutional resources. Optimal POP management may succeed in improving outcomes only when combined with hospital-wide protocols for early rehabilitation and recovery; in the absence of adequate monitoring, equipment, motivation and coordination, even state-of-the-art techniques may fail to show results in terms of returning to daily life. Analgesic efficacy should always be balanced against safety and the ability to monitor patients in order to reduce complications that may actually impair recovery. A ''context-sensitive'' approach to POP, therefore, is suggested. Context-sensitive analgesia should be instituted as early as deemed necessary to avoid persistent pain, and it should be continued, with different modalities, until full recovery from surgery. In this way, it should constitute a ''bridge'' therapy from surgery to full healing. The use of neuroprotective agents to reduce the risk of postoperative hyperalgesia and other sensory disturbances should be considered in the context of specific surgical interventions.