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Preventing persistent postsurgical pain: A systematic review and component network meta-analysis.

Claire Allen1, Andrew M Walker1, Zahra A Premji2

  • 1Cumming School of Medicine, University of Calgary, Calgary, Canada.

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Several treatments, including serotonin-norepinephrine reuptake inhibitors (SNRIs) and neural blocks, effectively reduce persistent postsurgical pain (PPP). Early postoperative pain relief is key to preventing long-term PPP.

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Area of Science:

  • Anesthesiology and Pain Management
  • Pharmacology
  • Evidence Synthesis

Background:

  • Evidence for perioperative methods to prevent persistent postsurgical pain (PPP) is uncertain due to limited direct treatment comparisons.
  • Component network meta-analysis (cNMA) offers a novel approach to evaluate both direct and indirect evidence for various treatments.

Purpose of the Study:

  • To evaluate the efficacy and tolerability of pharmacological and neural block treatments for preventing persistent postsurgical pain (PPP).
  • To compare multiple interventions, including multimodal strategies, using cNMA.

Main Methods:

  • A systematic search of multiple databases (up to January 2021) identified randomized, double-masked, controlled trials reporting PPP prevalence.
  • Frequentist cNMA models were employed to analyze data from 107 trials (13,553 participants) involving 13 treatments.
  • The primary outcome was the relative risk (RR) of PPP, with a clinically important effect size defined as RR = 0.9.

Main Results:

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs), neural block alone, or in combination with NMDA receptor blockers or gabapentanoids demonstrated effectiveness compared to placebo.
  • The effects of complex interventions were analyzed as multiplicative effects of their components.
  • Treatments showing benefit in the immediate postoperative period were associated with a reduced risk of PPP.

Conclusions:

  • Multiple treatments and their combinations effectively reduce the prevalence of persistent postsurgical pain (PPP).
  • Immediate postoperative pain outcomes are a significant mediator in the reduction of PPP.
  • Component network meta-analysis (cNMA) is a viable method for analyzing multimodal interventions.