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Anesthesia

SEVERE Muscle and Joint Pain after Surgery

02/21/2005

Question:

I had breast surgery a few years ago and will have to undergo a similar procedure again. I experienced severe muscle and joint pain 8 to 10 hours after the surgery and the pain lasted for about 36 hours.

I had never experienced anything so painful before, and I am more than a little concerned about this happening again. What accounts for this pain?

Answer:

Thanks for your question. The severe muscle and joint discomfort you experienced after breast surgery is known as "postoperative myalgia". This is a fairly common, quite distressing, but rather interesting condition. It usually appears on the first day after surgery, is often described as feeling similar to the pain one might suffer after unaccustomed physical exercise, and is usually located in the neck, shoulder and upper abdominal muscles. There are a few theories about the cause of postoperative myalgia, but it is usually attributed to the use of a muscle relaxant drug called succinylcholine. Hence this is sometimes referred to as "scoline pain".

Although the problem of postoperative myalgia has been recognized for many years, the exact way in which succinylcholine causes this muscle pain is not fully understood. Most believe that it is due to uncoordinated contraction of muscles that occurs a few seconds before the muscle relaxation that is the desired effect of the drug.

It is also not clear how best to prevent scoline pain, short of avoiding the use of this drug altogether. It is natural to ask then why we continue to use this medication, and the reason is that succinylcholine, despite a few significant side-effects, is a very reliable and quick-acting muscle relaxant that helps the anesthesiologist "secure" the airway (place a breathing tube).

Myalgia from succinylcholine is most common in young female patients, especially those undergoing ambulatory surgery (going home the same day as the surgery). The incidence of myalgia with succinylcholine ranges widely - in some reports it's as low as 1.5% but can be as high as 80 - 90%. To add to the mystery, some patients experience myalgia even when they are not given succinylcholine at all!

Naturally you would like to avoid this very unpleasant experience at your forthcoming surgery. The good news is that there are other muscle relaxant drugs than can almost always be used instead of succinylcholine. This will not guarantee that you do not have the myalgia again but probably makes it much less likely.

If the use of succinylcholine cannot be avoided, (this is rare), there are methods for decreasing the incidence and severity of the muscle pain, such as giving a very small dose of another muscle relaxant before the succinylcholine, or by giving a local anesthetic medication called lidocaine.

Typically the pain lasts 2 or 3 days and it can be quite severe, as you've described. Fortunately it does go away without specific treatment. Standard pain medicines, such as acetaminophen can be prescribed.

You or your anesthesiologist may be able to obtain the records of your previous anesthetic and hospital stay. This will supply clues about what happened to you during your last surgery. Be sure to discuss your concerns with your anesthesiologist, whose job is to evaluate you thoroughly and come up with a plan to provide you with a safe anesthetic, with minimum side-effects. Good luck!

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Response by:

Gareth S Kantor, MD Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University