Ask Dr. Sleep: Surgery, Pain and Sleep

Scott Brenson, Naperville, IL

A. Dear Scott,

To respond to your concern first, I recommend you at this point to see a sleep specialist who will find an appropriate combination of sleeping aids and pain medication. It will be also good to have a sleep study to rule out a possible primary sleep disorders, like sleep apnea and restless leg syndrome, which are common after surgeries, and cause sleep disruptions.

I agree hundred percent that Pain, Surgery and Sleep is a really serious combination.

Severe pain in neck, shoulders, back, hips, knees, and feet might dramatically and chronically disturb night sleep multiplying damaging effects of pain itself.

The life style of these patients is enormously tough: they sleep by small portions in the wrong time; eating, taking care of basic needs is a great challenge. Work, family, and friends – the world normal for all of us is outside of them. Irritability is increased due to the low tolerance. Emotions are swings from high to dull.

The common notion that pain stops in sleep is a myth – it is still there and doing its job. Sudden body jerks in sleep, causing increased heart rate, blood pressure surge, sugar drops, multiple and prolong awakenings, jaw clenching, neck stiffness, etc. – all are effects of hidden pain.

To be more specific, let me briefly describe two real life cases of relationships between pain, surgery and sleep.

Case 1. A 63-year-old woman who could not sleep due to severe pain in her knees.

Every move in bed caused awakening and the only comfortable position was on the back in a semi-sitting position. She gained 72 pounds within the last three years and developed obstructive sleep apnea syndrome (stops breathing in sleep) with a significant decrease in blood oxygen. She was placed on the breathing machine called CPAP with moderately good results and was told that it is for life.

After orthopedic surgeries both knees were replaced, her sleep condition dramatically improved. Although, pain was still there but it was in less degree. The most important is that she was able to move in bed and changed comfortable body position. She lost 37 pound. The control sleep study showed minimal apneas and she was able to stop using CPAP. The effect of surgery in this case was a wonder.

Case 2. A 58-year-old man with mild Parkinson’s symptoms was seen in our sleep clinic for his nightmares and restless legs before sleep. His sleep study uncovered significant degree of the so-called periodic limb movement disorder when limbs and body periodically jerk in sleep and REM Behavior Disorder (RBD) when the person is acting out his dreams. The treatment for these conditions is known and very helpful, but in this case it was postponed because the patient was scheduled for reconstructive surgery on his feet. The surgery included multiple metallic shunts and was technically very complex but successful. On the night after the patient was discharged, he woke up in excruciating pain to find out that the surgical areas were damaged and he was rushed back to the hospital. A sleep study discovered sudden increase of his movement activity due to reactivation of RBD. He was fighting in a dream with kicking, pushing, knocking and, of cause, damaged his wounds. If only the treatment of his RBD started before surgery, he would not go through these troubles. Surgeons too had the lesson about sleep medicine.

The effect of technically successful surgery was negative due to untreated underlying sleep disorder.