Regional anaesthesia and analgesia in surgical patients with chronic preoperative pain: mechanisms, evidence, and clinical implications

PURPOSE OF REVIEW: Chronic preoperative pain is increasingly recognized as a major determinant of perioperative complexity and postoperative outcomes. This review summarizes current evidence on the role of regional anaesthesia and analgesia (RAA) in adult surgical patients with pre-existing chronic pain, focusing on mechanistic rationale, short-term benefits, and potential long-term effects on persistent postoperative opioid use (PPOU) and chronic postsurgical pain (CPSP). RECENT FINDINGS: Pre-existing chronic pain is common across surgical populations and is consistently associated with higher postoperative pain intensity, increased opioid requirements, delayed recovery, and poorer clinical outcomes. Psychological vulnerability, including anxiety, depression, and pain catastrophizing, further increases the risk of adverse pain trajectories and persistent opioid use. RAA provides effective opioid-sparing analgesia and may attenuate nociceptive transmission, central sensitization, and neuroinflammatory activation. Evidence strongly supports short-term analgesic benefits, whereas effects on PPOU and CPSP remain heterogeneous. SUMMARY: RAA is a key component of individualized perioperative care in patients with chronic preoperative pain. Its greatest value lies in improving acute pain control, reducing opioid exposure, and supporting recovery. Long-term benefits are plausible but inconsistent, and are most likely when RAA is embedded within multimodal, phenotype-driven, and transitional pain care pathways.