DS04: Patient anxiety levels do not predict postoperative or intraoperative pain in Mohs micrographic surgery

Amaani Hussain,^1,2 Catherine Quinlan¹ and Thomas Oliphant¹

¹Royal Victoria Infirmary and ²Newcastle University, Newcastle upon Tyne, UK

Mohs micrographic surgery (MMS) is well tolerated, with simple analgesic measures generally being adequate for postoperative pain relief (Sniezek PJ, Brodland DG, Zitelli JA. A randomized controlled trial comparing acetaminophen, acetaminophen and ibuprofen, and acetaminophen and codeine for postoperative pain relief after Mohs surgery and cutaneous reconstruction. Dermatol Surg 2011; 37: 1007–13). A randomized controlled trial of patients undergoing MMS demonstrated that combined paracetamol and ibuprofen is superior in analgesic effect to paracetamol alone or paracetamol and codeine (Sniezek et al.). There is limited dermatology-specific data exploring patients’ anxiety preoperatively, the pain they expect to experience following MMS, and how these factors relate to intraoperative and postoperative pain. Our aim was to evaluate levels of preoperative anxiety, expected levels of pain postoperatively, intraoperative pain during local anaesthetic administration, and pain levels and analgesia use during days 0–2 postoperatively. Pre- and postoperative questionnaires were distributed between December 2020 and February 2021 and between November and December 2021; they incorporated visual analogue scales (VAS) to assess these factors. In total, 174 patients received questionnaires; 138 pre-MMS (80%) and 105 post-MMS questionnaires were returned (61%). Mean respondent age was 73 years (range 35–92); 59% were men (n = 101) and 41% were women (n = 70). Surgery was predominantly performed on basal cell cancers (79%). Thirty-seven (27%) patients were taking regular analgesia for pre-existing pain conditions. Mean anxiety levels before MMS was 3/10 (range 0–10). Mean expected levels of pain were 4/10 (range 0–10). Most patients (54%) reported no pain during local anaesthetic administration (mean 1/10, range 0–4/10). Mean pain score was greatest at bedtime on the day of surgery (2·3/10). Fifty-one per cent of patients took analgesia during days 0–2, with the majority taking paracetamol alone. Greater pain was reported following surgery involving the forehead (mean 2·0/10) and following flap repair (mean 2·2/10). Tumour size did not significantly correlate with pain. Despite patients with higher anxiety levels expecting to experience greater pain (Pearson correlation 0·42; P = 0·001), this was not borne out by the data; higher anxiety levels did not significantly correlate with intraoperative or postoperative pain. For the first time, we have demonstrated that patients with higher anxiety levels expect to experience greater pain, but do not report significantly higher levels of intraoperative or postoperative pain. Previous studies across specialities have found variable results when investigating the relationship between anxiety and pain. Contrary to our findings, a 2015 study reported that higher anxiety is predictive of greater postoperative pain in MMS (Chen AF, Landy DC, Kumetz E et al. Prediction of postoperative pain after Mohs micrographic surgery with 2 validated pain anxiety scales. Dermatol Surg 2015; 41: 40–7). This study did not assess expected or intraoperative pain. Larger studies could clarify this relationship and determine if anxiety-reducing strategies could be beneficial in reducing overall pain and improving patient experience.