EVALUATION OF A POST-OPERATIVE PAIN
MANAGEMENT PROTOCOL

David Lincoln Nelson, MD, Greenbrae, CA

PURPOSE Post-operative pain is of great interest to patients, yet it has been virtually ignored
in the hand surgery literature. The goal of this study was to evaluate the effectiveness of a
post-operative pain management protocol based on current research into acute pain.

METHOD
The study was an IRB-approved, prospective study of a consecutive series of patients from the
practice of one hand surgeon over a 35 month period (December 11, 1998, to October 26,
2001). Inclusion criterion was having a hand surgical procedure. Exclusion criteria were (1)
narcotic addiction or obtaining narcotic medication from multiple physicians, (2) patients
having non-hand surgery at the same time as the index hand procedure, and (3) failure of the
patient to remember the number of narcotic pills taken. The pain management protocol
consisted of: (1) preoperatively: discussion of the expected post-operative pain, including
dispensing of a pain medication prescription (five tablets of hydrocodone [5 mg] plus
acetamenophen [500 mg)] [Vicodin] were given, with refills of five at a time); (2)
intra-operatively: pre-incision injection of Lidocaine and post-surgery injection of bupivicaine
(Marcaine); and (3) post-operative elevation, NSAID on a regular basis for 48 hours and
thereafter on a PRN basis, Vicodin PRN, and a telephone call to the patient within the first 24
hours after surgery. Patients were given as much Vicodin as they requested. Post-operative pain
was measured by the number of post-operative Vicodin tablets taken within 10 days of surgery
(first post-operative visit).

RESULTS 181 patients were treated surgically during the study
period and fit the inclusion/exclusion criteria. 51 patients were excluded (18 for chronic
narcotic use, 8 for multiple procedures, and 25 for inability to remember the number of pills
taken [but took less than 5, based on quantity of prescribed medication]). There were 121 soft
tissue procedures and 60 bone procedures. The mean number of Vicodin tablets taken for the
study group as a whole was 2.26 pills, with 84 patients taking no Vicodin. The soft-tissue
procedures averaged 1.1 pills, with 72 taking none. The bone procedures averaged 4.6 pills,
with 12 taking none. CONCLUSION A pain management protocol, based on a current
understanding of acute pain, can be very effective in managing post-operative hand surgery
pain.