Background & Aims

Fibromyalgia syndrome (FMS) is a prevalent chronic pain disorder affecting 2-4% of the population, characterised by widespread pain, fatigue, sleep disturbances, and cognitive issues. [17] Its aetiology remains uncertain, with evidence suggestive of peripheral small fibre polyneuropathy and central amplification, along with an emerging autoimmune component. [8,9,13,16,14] The recent UK Royal College of Physicians’ FMS Guidance emphasises robust communication for diagnosis and ongoing care, particularly in surgery, which can present unique challenges due to heightened pain sensitivity in patients. [2] Patient engagement activities revealed concerns about perioperative incidents, prompting a systematic review to inform anaesthetic and surgical practices around pain management. This review aimed to address key questions regarding perioperative pain, the effectiveness of local anaesthesia, complications, and postoperative functional outcomes in FMS patients undergoing non-cancer surgeries.

Methods

A systematic review, following PRISMA guidelines, was conducted to explored pain experiences of FMS patients after elective surgery, focussing on the first 30 days post operation. Registered on Prospero (CRD: 42022309297), searches were conducted in Embase, MEDLINE, and Cochrane Library (1990 onwards), and were limited to the English language. Iteratively developed search terms were managed through Rayyan.ai. Two reviewers independently screened article titles and abstracts, followed by full-text analysis based on inclusion criteria. All types of studies, describing adult FMS patients, undergoing elective non-cancer surgery, were included. Data extraction covering study characteristics and methodology was performed. Postoperative pain, medication use, function, hospital stay, experience, and quality of life were assessed. Data were entered into an Excel-based form, and risk of bias was evaluated using The Newcastle Ottawa Scale, with discrepancies resolved among authors.

Results

This narrative synthesis found eleven studies from 1999 to 2023 that explored perioperative outcomes in FMS patients. [1,3,4,5,6,7,10,11,12,15,18] No randomised controlled trials were found. Most studies focused on orthopaedics (6/11) [1,3,4,7,10,15], with fewer on general [5,6], gynaecological [12], and maxillofacial surgeries [18]. Four studies evaluated systemic FMS symptoms using the 2011 FM Survey Criteria score without categorising based on a definitive FMS diagnosis. [3,4,12,15] Evidence was sparse, but that which existed suggested that immediate postoperative pain was worse than controls, noted in laparoscopic cholecystectomy and knee arthroscopy, with heightened sensory thresholds immediately after surgery. [5,6,10] There were no reports examining local anaesthetic efficacy. Complications within 30 days were higher in FMS patients undergoing spinal surgery, including anaemia and readmission rates. [7] However, overall, for all types of surgery, there was no increase in cardiovascular complications. [11] Beyond 30 days, pain reduction and functional improvement trends varied. [1,10] Opioid use during hospitalisation was higher in FMS patients and higher FM Survey Criteria scores correlated with increased opioid use and postoperative pain.[3,12]

Conclusions

Surprisingly, a scarcity of data across all queried aspects was revealed. Postoperative pain outcomes at the surgical site and generally, were worse in FMS patients, compared to controls, with heightened sensitivity post-surgery. Evidence on the efficacy of local anaesthetics was absent, and further investigation is needed to assess onset and duration in FMS. It is reassuring that complication rates across all surgery were not increased by FMS, but spinal surgery is a notable exception. Higher FM survey scores correlated with increased opioid use. Be this due to tolerance or increased perceived pain, it mandates robust analgesic management including higher inpatient analgesic availability, with plans for subsequent down-titration. Additionally, evidence suggested potential benefits of surgery in reducing ongoing visceral pain generators for FMS patients. [5,6,15] Future research priorities should focus on elucidating the postoperative journey to better inform and consent FMS patients.

References

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[3] Brummett CM, Janda AM, Schueller CM, Tsodikov A, Morris M, Williams DA, Clauw DJ. Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study. Anesthesiology 2013;119(6):1434-1443.

[4] Cheng J, Kahn RL, YaDeau JT, Tsodikov A, Goytizolo EA, Guheen CR, Haskins SC, Oxendine JA, Allen AA, Gulotta LV, Dines DM, Brummett CM. The Fibromyalgia Survey Score Correlates With Preoperative Pain Phenotypes But Does Not Predict Pain Outcomes After Shoulder Arthroscopy. Clin J Pain 2016;32(8):689-694.

[5] Costantini R, Affaitati G, Massimini F, Tana C, Innocenti P, Giamberardino MA. Laparoscopic Cholecystectomy for Gallbladder Calculosis in Fibromyalgia Patients: Impact on Musculoskeletal Pain, Somatic Hyperalgesia and Central Sensitization. PLoS One 2016;11(4).

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[12] Janda AM, As-Sanie S, Rajala B, Tsodikov A, Moser SE, Clauw DJ, Brummett CM. Fibromyalgia survey criteria are associated with increased postoperative opioid consumption in women undergoing hysterectomy. Anesthesiology 2015;122(5):1103-1111.

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[14] Sarzi-Puttini P, Giorgi V, Marotto D, Atzeni F. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nature Reviews Rheumatology 2020;16(11):645-660.

[15] Schrepf A, Moser S, Harte SE, Basu N, Kaplan C, Kolarik E, Tsodikov A, Brummett CM, Clauw DJ. Top down or bottom up? An observational investigation of improvement in fibromyalgia symptoms following hip and knee replacement. Rheumatology (Oxford) 2020;59(3):594-602.

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Presenting Author

Richard Berwick

Poster Authors

Richard Berwick

BSc(Hons)

University of Liverpool

Lead Author

Sara Siew

Liverpool University Hospitals NHS Foundation Trust

Lead Author

Sarah Curtis

Liverpool University Hospitals NHS Foundation Trust

Lead Author

Michelle Maden PhD

University of Liverpool

Lead Author

Ruaraidh Hill PhD

University of Liverpool

Lead Author

Andreas Goebel MD

PhD

University of Liverpool

Lead Author

Topics

  • Assessment and Diagnosis