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Pain Medicine 2014; 15: 1222–1229
Wiley Periodicals, Inc.
ACUTE PAIN & PERIOPERATIVE PAIN SECTION
Original Research Article
Incidence of Chronic Postsurgical Pain (CPSP)
after General Surgery
Christian J.P. Simanski, MD, PhD,*# Astrid Althaus,
Dr Dipl Psych,†# Sascha Hoederath, MD,‡
Kerry W. Kreutz, MD,† Petra Hoederath, MD,§
Rolf Lefering, PhD,¶ Carolina Pape-Köhler, MD,**
and Edmund A.M. Neugebauer, PhD†
*Department of Trauma and Orthopaedic Surgery,
Cologne-Merheim Medical Center (CMMC), University
of Witten/Herdecke; †Institute for Research in
Operative Medicine (IFOM), University of
Witten/Herdecke, Cologne, Germany; ‡Clinic of
Surgery and Orthopaedics, Kantonales Spital Grabs,
Grabs; §Clinic of Neurosurgery, Kantonsspital St.
Gallen, St. Gallen, Switzerland; ¶Biometrics and
Statistics, Institute for Research in Operative Medicine
(IFOM); **Department of Abdominal, Vascular, and
Transplant Surgery, Cologne Merheim Medical Center
(CMMC), University of Witten/Herdecke, Cologne,
Germany
Reprint requests to: Christian Johannes Paul
Simanski, MD, Department of Trauma and Orthopedic
Surgery, Cologne-Merheim Medical Center (CMMC),
University of Witten/Herdecke, Ostmerheimerstrasse
200, Cologne 51109, Germany. Tel:
0049-221-8907-13018; Fax: 0049-221-8907-3085;
E-mail: Christian.Simanski@uni-koeln.de.
#Both authors contributed equally.
The authors declare no conflicts of interest in the
publication of this study.
Author’s contributions : CJPS, EAMN, KK, SH, and PH
developed the study, design, and research. CJPS,
EAMN, and RL supervised conduction of the study.
CJPS, KK, SH, PH, and RL collected and managed
the data. CJPS and AA drafted the manuscript,
contributing equally. All other authors contributed
substantially to its revision. CJPS takes responsibility
for the paper as a whole. RL provided statistical
advice on the study design and analyzed the data
along with CJPS, KK, SH, CP-K, and AA.
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Abstract
Objective. This study investigated the incidence
and determinants of chronic postsurgical pain
(CPSP) in a general surgical patient population.
Design. This is a prospective cross-sectional study
at a university-affiliated clinic/level 1 trauma center.
Patients were followed at least 1 year postopera-
tively. By surgical discipline, procedures were
50% orthopedic/trauma, 33% general (abdominal/
visceral), and 17% vascular.
Setting. All patients admitted during one year
(N = 3020) were eligible. Exclusion criteria were cog-
nitive impairment, communication/language barrier,
nonoperative treatment, and refusal to participate. A
CPSP questionnaire was completed. Step-by-step
analysis followed with a 2nd questionnaire to detect
CPSP with numeric rating scale (NRS) pain intensity
≥3. Finally, individual follow-up examinations were
performed.
Results. 911 patients responded (30.2%). 522 com-
plained of pain intensity ≥3 on NRS (scale 0–10). The
second step identified 214 patients with chronic
pain (NRS ≥3, mean 29 months postoperatively). On
final examination, 83 CPSP patients (14.8%) were
identified. By surgical discipline, 28% were general,
15% vascular, and 57% trauma/orthopedic surgery.
Most oftenly cited pain sites were joint (49.4%),
incisional/scar (37.7%), and nerve pain (33.7%).
By procedure, patients underwent pelvic surgery,
colon surgery, laparoscopies, inguinal herniorrha-
phies, arthroscopies, and hardware extractions. All
patients in the “laborer” and “unemployed” catego-
ries reported chronic pain.
Conclusion. Bias due to study design and/or het-
erogeneity of patients is possible, but there was a
high CPSP rate after 2 years both generally and
particularly in orthopedic/trauma (57%) patients.
Both “major” and “minor” surgical procedures led
to CPSP.

Key Words. Risk Factors; Pain Management;
Chronic Post-Surgical Pain (CPSP); Persistent Pain;
Prospective Study
Introduction
The development of chronic postsurgical pain (CPSP)
appears to be a multifactorial process. It is influenced by
physical, psychological, genetic, and social factors [1,2].
Numerous studies have investigated the process of “how
acute pain becomes chronic” after various interventions
[2–4]. Multiple surgical procedures within a single periph-
eral nerve distribution lead to high incidence of CPSP
[2,3]. Patients complain of CPSP in 5–65% after thora-
cotomy [5,6], 30–50% after cardiac surgery [7,8], 5–63%
after hernia surgery [9,10], 11–57% after mastectomy
[11,12], and 30–85% after amputations [13]. Quoted rates
of incidence for CPSP vary widely, depending on study
design, single or multi center participation, clinic level of
care, surgical expertise, etc. Severe acute postoperative
pain seems to be a risk factor for the development of
chronic pain [3,4]. In more than 115,000 patients,
Gerbershagen et al. found that very high pain intensity on
the first postoperative day was reported after “minor”
interventions, e.g. appendectomy, cholecystectomy, hem-
orrhoidectomy, and tonsillectomy, as well as after major
orthopedic surgery [14]. Analysis of the literature con-
firmed high incidence rates of CPSP after these proce-
dures [15–17].
In many studies patients were recruited from tertiary
centers with specialized surgeons, or pain intensities were
measured only on the first postoperative day [14]. It is thus
possible that the results exhibit bias, and do not reflect
actual CPSP incidence. In addition, it is important to
examine such rates in the general surgical departments of
primary and secondary care centers, since in our nation at
least, patients are generally treated there and not in spe-
cialized surgical centers [18,19]. The aim of this study was
to determine the incidence of chronic postoperative pain
(CPSP) in a general surgical patient population of an aca-
demic university-affiliated hospital, and to analyze this
data for specific contributing factors.
Patients and Methods
For this cross-sectional study, we included all 3,020
patients admitted to our facility (vascular, abdominal/
visceral, orthopedic/trauma) over a one year period
(1st August until 31st July). Relative to surgical specia-
lity, the patient distribution was 50% undergoing or
thopedic/trauma, 33% abdominal/visceral, and 17% vas-
cular procedures.
Development of the Questionnaire
The questionnaire was tested for comprehensiveness,
clarity, and completion time with a first draft in our clinic
during a pilot phase of the study. After extensive discus-
sions by the “integrated acute pain working group” of our
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Incidence of CPSP After General Surgery
hospital, the questionnaire was modified. The study was
approved by our local ethics committee. All patients were
treated under the conditions of the Helsinki II declaration
and all subjects provided informed consent to partici-
pate. Exclusion criteria were cognitive impairment,
communication/language barrier in non-native speakers,
non-operative treatment, and refusal to participate. To
clarify whether the pain reported on the first questionnaire
(mean 19 months post OP, Range: 13–26 months;
SD ± 3.5 months) required further investigation (numerical
rating scale NRS ≥3; scale 0–10), and whether it appeared
related to surgery, a second analysis was performed by
examining patient charts and performing telephone inter-
views (Figure 1). Thus, we differentiated patients treated
operatively versus non-operatively, and whether a nonex-
istent, possible, or definite connection between the surgi-
cal intervention and current pain symptoms was present.
Patients with possible or definite chronic pain related to
surgery were invited to return to our clinic where a follow
up examination was performed to assess the symptoms
of CPSP (mean 29 months post OP, Range: 24–35
months; SD ± 3.5 months).
Definition of CPSP
We defined CPSP similarly to Macrae [20]: 1) Pain that
develops after surgery, 2) where other etiologies have
been ruled out, and 3) exacerbation of a pre-existing
problem as cause for the pain has been ruled out. Unlike
Macrae, we defined CPSP as postoperative pain lasting
longer than 12 months, according to recommendations of
other sources [21].
Evaluation
Evaluation of the questionnaires, telephone interviews, and
physical examinations was primarily descriptive. Percent-
ages refer to the total number of patients with pain requiring
intervention, i.e. with intensities on VAS/NRS ≥3 (scale
0–10 where 0 = no pain, 10 = maximum imaginable pain)
[22]. Differences in frequency were tested with the Fisher’s
exact test, and ranking with the Mann-Whitney U test
(P < 0.05). Analysis was carried out using the SPSS soft-
ware package (version 17.0, SPSS Inc., Chicago, Ill.,
United States).
Standardized Pain Measurement, Documentation,
and Therapy
An independent “study nurse” explained the study back-
ground and benefits of the routine daily pain measurement
and documentation procedures to all patients. The routine
clinical documentation of pain intensity comprised assess-
ments at least twice daily (morning and evening) using a
visual analog scale (VAS, 0–10) at rest and with movement
(0 = no pain, 10 = worst pain imaginable) [23]. Pain
measurement on weight bearing was performed during
physiotherapy or mobilization on the hospital floor,
and included coughing, stair climbing, or standing for
more than 30 minutes. The VAS pain intensity scores
were documented by the responsible nursing staff on
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 Simanski et al.

Time point of analysis (TP)

All surgical patients TP O: Hospital stay
n = 3020

First Questionnaire TP 1: Ø 19 months

n = 911 post OP

Pain No pain
NRS-pain intensity ≥3 pts. NRS-pain intensity <3 pts.:
n = 522 n = 389

Pain Pain
Pain
- unclear reason
+ - unclear reason TP 2: Ø 29
n=337 n = 185 months
n = 16 post OP
No
CPSP
n = 83
Chronic pain
n = 115
pain Pain
- unclear reason
+
n= 123
25.9% 35.8% 38.3% n =201

calculated calculated calculated

Chronic pain CPSP No pain
n =72 n = 52 n = 77
35.8% 25.9% 38.3%

Chronic pain No pain

CPSP
n = 187 n = 589
n = 135

14.8% 20.5% 64.7%

Figure 1 Flow chart.

postoperative days 1, 2, 3, 5, 7, 9, 12, 15, 20, 25, 30, and
the day of discharge. Standardized pain therapy and pain
management were based on the national guidelines [24]
and available standards for each surgical discipline. Addi-
tional pharmacologic intervention was included if the VAS
intensity was ≥3, or held by explicit request of patients, i.e.
“pain acceptance” [22,25].
Results
All patients admitted to our general surgical university-
affiliated clinic over the period of one year (N = 3,020)
were questioned about the course of postoperative pain
by follow up over an average of 19 months (SD ± 3.5
months). 911 questionnaires were fully completed
(response rate 30.2%). Slightly more men (52.8%) than
women (47.2%) responded. The mean age of patients
was 54 years (±17.6 years). The female average was 5
years older than that of males (56.7 versus 51.7 years).
355 patients (39%) estimated their current state of health
as “not so good” or “bad”. 665 patients (73%) reported
“improved” or “unchanged” activities of daily living post-
operatively. Analysis of the initial questionnaire showed
that 522 patients (57.3%) reported a pain intensity on
NRS ≥3, and 389 patients (42.7%) reported a NRS <3.
The analysis of second questionnaire showed the same
rate of incidence (57.3%), 337 patients reported NRS ≥3
after an average period of 29 months postoperatively
(range 24–35 months, SD ± 3.5 months) (Figure 1). More
women than men showed chronic pain symptoms.
51.8% of the CPSP patients (N = 43) and 58.3% of the
chronic pain patients (N = 67) were of female gender.
The distribution of the 321 “pain patients” (NRS ≥3)
according to the surgical discipline showed that more
than 55% of the trauma/ orthopedic patients suffered
chronic pain (CP) and more than 57% of that group suf-
fered CPSP (Tables 2 and 3). After follow-up examina-
tion, 83 (14.8%) patients exhibited CPSP (Figure 1 and
Table 1), and in 16 patients the relationship between the
chronic pain symptoms and the surgical procedure was
unclear (e.g., burning pain with projection into the ingui-
nal region in a post-herniorrhaphy patient with coexisting
coxarthrosis). These latter patients were referred to a
specialized pain clinic for further workup and treatment.
71.6% of patients in the CPSP group self-reported “not
so good” and “bad” rates to describe their health status
highest compared to the “chronic pain” and the “No
pain” group (Table 4). The patients reporting CPSP, later

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 Incidence of CPSP After General Surgery

Table 1 Incidence of CPSP in general surgical patients

No CPSP (chronic pain,

CPSP (chronic no correlation to surgery)
postsurgical pain) in the vicinity of surgery? No pain

Number of patients N = 321 83 115 123

Percentage of 321 patients 25.9% 35.8% 38.3%
Percentage of 321 patients, total 57.3% of patients with 14.8% 20.5% 22.0%
NRS ≥ 3
Percentage of total respondents (N = 911) with completed 14.8% 20.5% 22.0 % + 42.7
questionnaires % = 64.7%

confirmed on follow-up examination, underwent various
interventions (Tables 1 and 2). Finally, the distribution of
CPSP patients according to surgical discipline was 28%
general (abdominal/visceral) surgery, 15% vascular
surgery and 57% trauma/orthopedic surgery. When
asked for the localization of pain (multiple answers pos-
sible), the most frequent response was joints/lower
extremities and back (Figure 2). The majority of the
patients was married (61.7%) and retired (Figure 3). All
patients who reported themselves as “laborer” or “unem-
ployed” reported pain on NRS ≥3 more than 1 year after
surgery. However, analysis of this social parameter within
the 6 months preceding the second questionnaire
showed, almost 72% (N = 231 of 321) of the respon-
dents had yet returned to work or were retired, 22%
(N = 71) were temporarily incapable of working, and 6%
(N = 19) were signed off work permanently. Analyzing
ethnic factors, 90% of patients were born in our country
and of Caucasian race. According to responses by
CPSP patients (multiple answers possible) over the

Table 2 Distribution of CPSP patients by surgical discipline (N = 83)

Trauma/
Surgical discipline General (visceral/ abdominal) Vascular orthopedic

Size of Minor Major Minor Major Minor Major

procedure
Type of Lap Hern. Ing. hern. Other Colon e.g. e.g. Arthrosc. Poly.
procedure repair rep. procedures Shunt Bypass
No. of 7 5 5 3 3 7 12 7 25 9
procedure
CPSP 8% 6% 6% 4% 4% 8% 15% 8% 30% 11%
Percentage
CPSP 28 15 57
Percentage
per Discipline

Lap = laparoscopy; Hern. repair = hernial repair; Ing.hern.rep. = inguinal hernia repair; Arthrosc. = arthroscopy; Poly. = polytrauma;
CPSP = chronic post surgical pain.

Table 3 Patient-distribution related to the surgical discipline after the second questionnaire, mean 29
months postoperatively (range 24–35 months, SD 3.5 months)

Surgical discipline No pain (N = . . .) CPSP (N = . . .) CP (N = . . .)

General (visceral/abdominal) 53.6% (66) 28.9% (24) 32.2% (37)

Vascular 11.4% (14) 13.3% (11) 13% (15)
Orthopedic 17.1% (21) 22.9% (19) 45.2% (52)
Trauma 17.9% (22) 34.9% (29) 9.6% (11)
N= 123 83 115

CPSP = chronic post surgical pain; CP = chronic pain independent from the surgical site; SD = standard deviation.

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 Simanski et al.

Table 4 How you would describe your health

status in general actually? (Second questionnaire,

Percentage
ø29 months postoperatively)

Patient Group No pain CPSP CP

“Excellent” .8% 0% 0%
“Very good” 4.2% 0% 1.8%
“Not so good” 41.7% 59.3% 50%
“Bad” 4.2% 12.3% 16.7%
Σ = “Not so good”/“Bad” 45.9% 71.6% 66.7%
N= 120 81 114 Occupation

CPSP = chronic post surgical pain; CP = chronic pain indepen- Figure 3 Demographic data by occupation (N =
dent from the surgical site.
337 patients).

subsequent 4 weeks, pain was described as joint

(49.4%), incisional/ scar (37.7%) and nerve pain (33.7%)
(Figure 4).
Discussion
Severe postoperative pain is considered a predictor of
CPSP. Our current study shows that in general surgical
patients admitted to a university-affiliated clinic over a one
year period, despite existing standard pain therapy algo-
rithms (systemic multimodal pain therapy) [24,26], one out
of three patients experienced pain requiring intervention
(VAS/NRS ≥3) longer than one year after clinical dis-
charge. 14.8% of patients reported pain directly related to
surgery, implying a causal relationship after more than 2
years (mean 29.65 ± 3.5 months). Fortier et al. found a
similarly high incidence of CPSP (13%) in children [27].
Social factors may contribute to CPSP. All patients in the
categories “laborer” and “unemployed” reported pain
intensity on NRS ≥3 more than 1 year after surgery [22].
This could be due to the physical and stressful activity
required by this occupational group (construction, metal/
iron processing, etc.) resulting in, for example more joint
degeneration, which is compounded by lower incomes
[28], lower educational levels, or the desire for higher
pensions [29,30]. In contrast to the study by MacWilliam
et al., ethnic factors did not appear to affect CPSP in our
study, however, since 90% of our patients were Cauca-
sian, a study bias due to study design cannot be excluded

Figure 2 Pain localization

(patient-reported) from question-
naire: “Where do you feel
pain?” (multiple answers possible)
(N = 667).

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Figure 4 Questionnaire: “In your opinion, where
does the pain come from?” (multiple answers
possible).
[29]. Patients reported joint pain (49.4%), incisional pain
(37.7%), and nerve pain (33.7%) more than one year after
surgery (multiple answers possible, Figure 4). A recent
systematic review confirmed incisional pain and
neuropathic pain as major causes of CPSP [31]. This is
often associated with an intraoperative nerve injury or
resection [9,32] and a potentially avoidable complication.
Töns and Schumpelick showed less neuropathic pain
after nerve and soft tissue protection was implemented
during inguinal herniorrhaphy [3,33]. Other studies have
confirmed that postoperative incisional pain can become
chronic. Wilder-Smith showed that the pain threshold for
perception of painful stimuli is reduced during revision
procedures (e.g. scar revisions, neuroma resections),
causing allodynia [34]. Furthermore, not only is mechani-
cally induced neuropathy important, but there is also a role
for inflammatory immunological components. Post-
surgical inflammatory neuropathy was found histologically
via nerve biopsy in 21 nerves resected from CPSP
patients, regardless of the presence of mechanical injury
[35]. The most consistent risk factor for CPSP is severe
acute postoperative pain [3,4,9,36,37]. It is hypothesized
that persistent peripheral nociceptive input from injured
nerves causes neuroplastic changes in the CNS, resulting
in nervous hyperexcitability [4,36]. Some authors have
reported that use of intraoperative nerve blocks in proce-
dures known to cause severe postoperative pain (e.g.
thoracotomy) significantly decrease pain up to 6 months
postoperatively [38,39]. Thus, interdisciplinary pain man-
agement allows use of additional regional anesthetic mea-
sures with the goal of disrupting this acute to chronic
transformation mechanism [40]. Our patients received
postoperative pain therapy according to standardized
national S3 guidelines, specific to each surgical discipline
[24]. In an analysis of more than 115,000 patients under-
going 179 surgical procedures, Gerbershagen et al.
reported that high intensity postoperative pain is often
reported after “minor” interventions (e.g., appendectomy,
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Incidence of CPSP After General Surgery
cholecystectomy, etc.), as well as after “major” orthopedic
surgery, (e.g. spinal fusion over more than 3 segments,
internal fixation of the acetabulum, etc.). In addition, of the
top 40 surgical procedures with the highest intensity of
postoperative pain, 22 were trauma/orthopedic interven-
tions [14].. Other studies have confirmed that a large
number of patients develop post-traumatic chronic pain
after thoracic or pelvic injury [41–43]. Our study confirmed
a high percentage of CPSP patients after these proce-
dures, as well as after less invasive procedures (e.g.
laparoscopic cholecystectomy, laparoscopy, inguinal her-
niorrhaphy, arthroscopy, hardware extraction, Table 2).
However, selection bias cannot be excluded due to the
low recurrence rate of the first questionnaire (911 answers
of 3020 patients, 30.2%). In addition, we wanted to
assess the incidence of CPSP in patients treated by a
group of responsible surgeons of all different education
levels within a university-based general surgical depart-
ment to yield a more objective impression of CPSP rates.
The published data of other studies have often been col-
lected in specialized centers with the most experienced
specialists participating.
In the CPSP group, 11% were polytraumatized patients,
requiring multiple operations. A recent study confirmed a
correlation between CPSP and the need for a 2nd proce-
dure after mastectomy [44]. Other authors have also
reported high rates of CPSP in patients after trauma
surgery [28].
Study Limitations
The study design did not enable collection of patient data
regarding preoperative health and pain status. We
achieved a questionnaire response rate of only 30.2%;
thus, selection bias cannot be excluded. Although every
patient was treated using our facility specific multimodal
pain policies, and pain scores were documented using a
specific documentation system, in some cases documen-
tation of the pain intensity was incomplete. We collected
data for over 2 years postoperatively (29 months ± 3.5
months), but the range of follow up dates was wide,
complicated by the difficulties in making follow up
appointments. The follow-up physical examination identi-
fied 83 CPSP patients, but after the 3 patient interviews,
we also confirmed that 123 patients did not experience
chronic pain. The physical examination identified 16 cases
in whom the origin of chronic pain was unclear; these
patients were referred to a special pain clinic.
Conclusion
This study confirms a high incidence of CPSP of 14.8%
more than 2 years postoperatively. Despite standardized
pain therapy algorithms in our facility, one in three patients
experienced severe postoperative pain requiring further
intervention (VAS/NRS ≥3). The rate of patients developing
CPSP after trauma or orthopedic procedures was high
(57%), but because of our study design, selection bias
cannot be excluded. The CPSP patients evaluated their
pain as chronic incisional, articular, or neuropathic pain.
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Thus, our analysis focused on these pain types. An
iatrogenic nerve lesion/therapeutic resection is a poten-
tial cause, as is inflammatory/immunological reactions
without mechanical damage. In addition to major
orthopedic interventions, minor surgical procedures (e.g.
laparoscopies, arthroscopies, hardware extractions, etc.)
can also cause CPSP. Social factors may play a role in the
development of CPSP as well. All “laborer” and “unem-
ployed” patients demonstrated intervention-requiring pain
intensity (NRS ≥3) more than 1 year after surgery.
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