A painful scar
It’s normal to expect some pain after a surgical operation. The normal process of wound healing entails some itching, discomfort and sometimes just normal post operative pain but this will subside and resolve generally over 6 weeks.
However, in some cases the pain persists long after the scar has healed and the maturation process is well over. There are a variety of common and sometimes uncommon etiologies for this pain but there is always a solution to the problem.
In our practice, the most common presentation of the painful scar is that of a female that has undergone a c-section. Other common causes of pain are those in the lower abdomen – after hernia surgery, appendectomy or bladder surgery. However, any operation of any type – and at any part of the body can result in a chronically painful scar.
There are many reasons why the scar is painful and there are many solutions, however the correct diagnosis needs to be made prior to treatment.
Neuropathic pain can be the cause of a painful scar due to the fact that at the time of wound closure, a nerve was sutured or even cut inadverdantly. This can be remedied by re-exploring the wound and removing the stitch or even fixing the nerve that was damaged.
These changes cause the nerve pathways to become super sensitive to touch – causing hypersensitive skin and a medical phenomenon called allodynia where the pressure of even light clothing can be agony for the patient.
Features of scar pain after surgery
Scar pain is situated next to the scar or very near by in most cases – but it may spread widely from there.
Scar pain is often shooting or stabbing in nature and made worse by movement. Coughing or sneezing or straining on the toilet can also aggravate things.
These painful scars are often very sensitive to temperature changes – reflecting the fact that the sympathetic nerves have been damaged.
Even though the scar is painful, it often looks well healed when the doctor examines it. It may sometimes by thicker than normal but this is by no means always true. The scar is often very tender when touched – along either part of its length or over the whole area. Sometimes the surgeon can feel a small dense nodule of nerve endings and this is called a neuroma.
The skin near the scar is often hypersensitive to touch.
Treatment of the painful scar
There are several treatment options when dealing with a painful scar. In our practice we use a step wise pattern for the treatment of the painful scar and here are the options:
- Injections with steroid and local anesthetic – this often works well and may be repeated two or three times if needed. Each successive injection tends to provide longer lasting relief from the pain but a limit is always eventually reached because too many steroid injections can damage the skin
- Nerve destruction – some pain specialists use cold or radio waves to kill off the painful nerve endings in the way described for phenol injections above. Again, this works best in cases that have previously responded well to steroid injection
- Surgical exploration – this is usually reserved for cases where the surgeon suspects that there is a problem in the way the wound has been stitchedor other causes of incisional pain refractory to to other treatments.
- Medication Normal analgesics or NSAID drugs are usually not effective for this kind of pain. Amitryptilline is a drug that works very well indeed for scar pain. Even in low dose it can have a dramatic effective and is probably the first choice treatment for the condition Gabapentin or Pregabalin are often useful but sometimes create unpleasant side effects
- Psychological support – some doctors believe that depression and anxiety play a part in scar pain after surgery – and this may be particularly true if the scars appear disfiguring to the patient.