by: Dr. Edward Loniewski, JointHealing.com
Most patients facing the decision of knee surgery may be nervous not only about the decision to have the surgery, but most have more anxiety about how they may feel after their surgery. You may wonder…will it be painful? Will I be able to tolerate it? Will my surgical team understand my concerns and help me through my recovery? The short answer to these questions is…. YES!
Surgery is naturally painful and if it were not, no one would ever need anesthesia. However, the pain does not need to be overburdening. Modern medicine has very well researched and proven techniques to reduce the pain of surgery to a very tolerable level. In fact, if we really examined the largest contribution to medical science over the past 100 years, anesthesia would be the hands down winner. Before the advent of modern anesthetic techniques, the mortality rates of surgery were over 50%. Today they are well under 1% for most major surgeries. We will walk you through some common pain reducing techniques to help you though your upcoming surgery.
Pain is caused by three common responses that can be easily modified and controlled if you understand the pathways.
The common responses of your body after a knee surgery include:
1.) The response of the pain fibers from the surgical site going to your brain.
2.) The response of the local pain fibers around the knee.
3.) The response of your brain to the two above responses.
We will review each response so you can clearly understand what can be done to control and/or modify each:
The response your pain fibers have from the knee to the brain is one of activation. When the pain fibers around your knee are stimulated, they send impulses up through your spinal cord to your brain. Your brain senses where the pain is located, and thus you are able to identify that your right or left knee is having pain. Spinal and general anesthesia methods block this response. Narcotics also help to reduce the activity of the nerve pathway to your brain as well as helping to slow the response back from your brain to this local stimulus. The medical science of anesthesia is based on identifying methods to reduce this activation response and make you more comfortable. Patients are always rightfully concerned about their choice of the best anesthetic. The correct answer to this concern is the fact that any board certified anesthesiologist will be able to accurately and effectively control this response. Most patients are the most comfortable during the surgery. There are risks and benefits to each type of anesthesia that are out of the scope of this discussion. The anesthesiologists will review these just prior to your surgery.
Methods to control this response:
1.) Discuss the risks and benefits of the different forms of anesthesia with the anesthesiologist. If you are concerned about nausea, ask about techniques to control nausea prior to, during and after the surgery.
2.) Specific blocks such as femoral nerve blocks and intrathecal morphine (morphine placed during your spinal anesthetic) may help reduce the activation response of surgery. However, there are risks of these procedures that your anesthesiologist can discuss with you prior to your surgery.
3.) Pre-medicating before your surgery with a long acting narcotic (Oxycontin™), or an agent that already binds to the central nervous system (Neurontin™) may help reduce this activation response of your body to the surgery.
The response of your local pain fibers at the incision site. Cutting, stretching and pulling on the ligaments, muscles and bones cause bleeding, bruising, swelling and pain. Techniques used by the surgeon can reduce some the severity of the damage, but regardless or the surgeon, or the surgical technique, most people will experience a little bit of each. The area of the surgery will respond to these insults by producing localized swelling, bleeding, bruising and generalized soreness.
Methods to control this response:
1.) Ice, Ice Baby- Not only is this the best song ever made by a white suburban pseudo rapper, but it also helps you remember that ice will make you comfortable as a baby in a bassinet. Cooling your joint and surrounding tissues can help reduce swelling, bleeding, and bruising. Icing the area all the time for the first 48 hrs is critical in reducing these components of local pain. JointHealing.com has multiple options to cool your joints with the greatest of ease. We personally love the Don Joy Iceman because it provides compression along with continuous circulating cool water even when you sleep. Obviously, cooling your joint has benefits, but there are also some risks and complications such as skin damage can occur. These risks and benefits must be considered prior to deciding what is going to be the best way to cool your joint. See our information on the Don Joy Iceman or Cryotherapy. If you can’t afford a cryotherapy unit, no problem. I normally recommend a few bags of frozen peas. I normally recommend buying 4 bags. Keep 2 on your knee and the other two in your freezer. Rotate these about every 90 minutes. Make sure you cover your knee with a DRY cloth so there is no direct contact. After your surgery, you can use the peas for a tasty pea and peanut salad.
2.) Reduce Inflammation- Whenever there is a skin incision, your body starts an inflammatory response. Providing you with medications and supplements that can reduce this response will help control the pain. The problem with providing this medication and supplements prior to your surgery is the fact that some of these can interfere with the way your blood clots causing more bleeding during the surgery and more bruising afterwards. However, there are a few options available which are considered safe and effective in reducing inflammation without affecting the clotting mechanisms of your body. The most common medication provided is known as Celebrex (celecoxib). Do not take these unless you talk with surgeon. Some other options include a cooling unit such as the Don Joy Iceman. Cooling the area will help reduce the inflammatory response by reducing swelling. Again, it is very important that you discuss the risks and benefits of each form of treatment with your surgeon before starting any treatment.
3.) Elevate your extremity- Elevating your leg above your heart is a very simple and effective manner to reduce the normal swelling of your leg after surgery. However, doing this in an effective manner may be difficult. For elevation to be effective, most experts suggest keeping the extremity at least 10 cm above your heart. Thus, you can see that resting your knee on a recliner chair will never achieve this goal. We have selected a simple firm yet comfortable leg elevator used at most major hospitals. We have found this elevator superior to other methods of elevation such as pillow because it prevents your leg from falling over the side and keeps the knee and hip in a foot all in good alignment. See our page on the Leg Elevator. Again, if this is too costly, you can use the cushions off your couch. Take two of these and stack them on your bed. This should be at least 10 cm above your heart.
The response of your brain to the both pain fibers heading toward your brain and the local response to your knee are affected by something loosely termed your mood. For example, when you are upset and frustrated and you stub your toe, you may scream some obscenities that you never knew were inside you. However, if you stub your toe on the way to your favorite sporting event or movie, you may laugh. Why is this? When you are anxious and scared, your entire nervous system is activated and your body response is exaggerated. Think about how many funny home videos you have seen where they scare someone who is already anxious and scared. It is a classic response we can all laugh at, but when we are in pain from this same response, it is rarely funny. When your brain is activated into a mood of fear and anxiety, the receptors of the pain fibers are over excited and respond in an exaggerated response. This is not something you imagine, because it is real and not imagined but yet you can modify this response by reducing the feelings of anxiety. Simple techniques such as listening to your favorite music in the peri-operative period have also been shown to help reduce postoperative pain in well-designed controlled studies. Other patients have found that biofeedback techniques or meditation have helped to reduce the intensity of pain. Prayer and simple visits by family and friends can also help reduce these feelings. So, take out a sheet of paper and write down what causes anxiety, and for each item, write at least two techniques you will use to reduce this anxiety. For example, I might be anxious about having an IV started, but two techniques I will use to reduce this anxiety are imaging my nurse in a clown suit (but not a scary, creepy mass murdering clown) and I will also squeeze my wife’s hand harder than when she gave birth to our 4 children (paybacks are a bitch!)
Hopefully, this brief summary will help you with your upcoming surgery. At JointHealing.com we strive to serve your needs as someone in pain looking for solutions. We plan to provide you with these solutions.