LETTER TO THE EDITOR
Comment on a paper by Von Dincklage et al. entitled ‘Higher
doses of intraoperative analgesia are associated with lower
levels of persistent pain and less analgesic consumption six
months after total hip arthroplasty’
Accepted for publication
13 January 2018
To the Editor,
We read with great interest the article of von Dinck-
lage et al. (2017) in a recent issue of the Journal.
The authors concluded after investigating 110
patients undergoing primary total hip arthroplasty
that greater levels of intraoperative analgesia are
associated with lower levels of persistent pain and
less analgesic consumption 6 months after total hip
arthroplasty. The authors should be congratulated
for performing a well-designed study and for exam-
ining a very important topic in perioperative medi-
cine (Niraj et al., 2017; Piraccini et al., 2017).
Although the authors performed a well-conducted
study, there are some concerns that are important but
not discussed by the authors. First, remifentanil has
been shown to cause postoperative hyperalgesia and
the authors’ ﬁndings are contrary to a large body of
literature in the topic (Fletcher and Martinez, 2014;
Koo et al., 2016; Lee et al., 2017). We were wonder-
ing if the use of a binary outcome for ‘regular’ pain
medication after 6 months is appropriate, as the varia-
tion in dose can be very important especially when
related to opioids. In addition, the use of linear regres-
sion for pain intensity is likely not appropriate given
the ordinal nature of this variable. Lastly, it would be
important for the authors to report any interaction
terms that could have altered the analysis.
We would welcome some comments from the
authors. These comments would further determine
the validity of this important clinical study.
M.C. Kendall, L.J. Castro-Alves
Department of Anesthesiology, Rhode Island
Hospital, The Warren Alpert Medical School of
Brown University, Providence, RI, USA
Mark C. Kendall
Conﬂict of interests
The authors declare that they have no conﬂict of
interests and nothing to disclose.
No funding was sought.
von Dincklage, F., Jakuscheit, A., Weth, J., Lichtner, G., Jurth, C.,
Rehberg-Klug, B. (2017). Higher doses of intraoperative analgesia are
associated with lower levels of persistent pain and less analgesic
consumption six months after total hip arthroplasty. Eur J Pain 22,
Fletcher, D., Martinez, V. (2014). Opioid-induced hyperalgesia in
patients after surgery: a systematic review and a meta-analysis. Br J
Anaesth 112, 991–1004.
Koo, C.H., Cho, Y.J., Hong, D.M., Jeon, Y., Kim, T.K. (2016). Inﬂuence
of high-dose intraoperative remifentanil with intravenous ibuprofen
on postoperative morphine consumption in patients undergoing
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Lee, M., Zhu, F., Moodie, J., Zhang, Z., Cheng, D., Martin, J. (2017).
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T., Rathinam, S. (2017). Audit of postoperative pain management
after open thoracotomy and the incidence of chronic
postthoracotomy pain in more than 500 patients at a tertiary center.
J Clin Anesth 36, 174–177.
Piraccini, E., Byrne, H., Calli, M., Poggi, P., Maitan, S. (2017). Pectoral
nerves and serratus plane block for persistent postsurgical pain after
video-assisted thoracic surgery. Eur J Pain 21, 1618–1619.
Eur J Pain 22 (2018) 822 © 2018 European Pain Federation - EFIC