Oberlander T F, O'Donnell M E, Montgomery C J
Division of Developmental Pediatrics, Sunny Hill Health Centre for Children, University of British Columbia, Vancouver, Canada.
J Dev Behav Pediatr. 1999 Aug;20(4):235-43. doi: 10.1097/00004703-199908000-00006.
The pain experience in the child with a significant neurological impairment is complex and confusing, and it raises many questions about the very nature of pain itself. Early work in this field suggests that the pain experience may be blunted. The neurological impairment associated with conditions such as cerebral palsy may alter the neurological system and hence the ability to comprehend and communicate pain; there is no evidence to date that this reflects true pain insensitivity or indifference. From recent work, the emerging body of evidence supports a relationship between the pain system and the motor, sensory, and autonomic systems and demonstrates how alterations to these systems may have a profound and unique impact on the pain experience. Beyond the altered neurological substrate, communication disabilities and social/environmental factors also seem to alter the pain experience. Establishing a clear pain history, including baseline information of child-specific patterns of behaviors and ongoing comparative use of this information over time, can provide clinically meaningful measures. Pain management should be directed at the underlying sources of pain and should include the analgesic ladder for everyday pain, opioids for acute/procedural pain (+/- benzodiazepine adjuvants), and antispasticity medications for high tone. With appropriate monitoring, demand and regional analgesic techniques can provide effective and safe postoperative pain control. The lack of basic and clinical knowledge in this field, however, adds another challenge to the clinician.
患有严重神经功能障碍的儿童的疼痛体验复杂且令人困惑，这引发了许多关于疼痛本质的问题。该领域的早期研究表明，疼痛体验可能会减弱。与脑瘫等疾病相关的神经功能障碍可能会改变神经系统，进而影响理解和表达疼痛的能力；迄今为止，没有证据表明这反映了真正的疼痛不敏感或冷漠。从最近的研究来看，越来越多的证据支持疼痛系统与运动、感觉和自主神经系统之间的关系，并表明这些系统的改变可能会对疼痛体验产生深远而独特的影响。除了神经基质改变外，沟通障碍以及社会/环境因素似乎也会改变疼痛体验。建立清晰的疼痛史，包括儿童特定行为模式的基线信息以及随着时间推移对这些信息的持续比较使用，可以提供具有临床意义的测量方法。疼痛管理应针对疼痛的潜在根源，应包括针对日常疼痛的镇痛阶梯、用于急性/程序性疼痛的阿片类药物（±苯二氮䓬类辅助药物）以及用于缓解高肌张力的抗痉挛药物。通过适当的监测，按需镇痛和区域镇痛技术可以提供有效且安全的术后疼痛控制。然而，该领域缺乏基础和临床知识给临床医生带来了另一项挑战。
