From preemptive to preventive analgesia

Purpose of review Much effort has been taken to prove that a treatment initiated before surgery is more effective in reducing postoperative pain compared with the same intervention started after surgery. Clinical studies failed to demonstrate major clinical benefits of preemptive analgesia, however, and the results of recent systemic reviews are equivocal. The present review will discuss recent clinical as well as experimental evidence of preemptive analgesia and examine the implications of a preventive postoperative pain treatment. Recent findings Recent preclinical and clinical studies give strong evidence that neuronal hypersensitivity and nociception after incision is mainly maintained by the afferent barrage of sensitized nociceptors across the perioperative period. This is in contrast to pain states of other origin in which prolonged hypersensitivity is initiated during the injury. Therefore, not timing but duration and efficacy of an analgesic and antihyperalgesic intervention are most important for treating pain and hyperalgesia after surgery. Summary Extending a multimodal analgesic treatment into the postoperative period to prevent postoperative pain may be superior compared with preemptive analgesia. In the future, appropriate drug combinations, drug concentrations and duration of preventive strategies need to be determined to be most beneficial for the management of acute and chronic pain after surgery.