Nampiaparampil Devi E
Department of Internal Medicine, Veterans Affairs Central California Healthcare System, Fresno, CA 93703, USA.
JAMA. 2008 Aug 13;300(6):711-9. doi: 10.1001/jama.300.6.711.
The Centers for Disease Control and Prevention estimates that approximately 1.4 million US individuals sustain traumatic brain injuries (TBIs) per year. Previous reports suggest an association between TBI and chronic pain syndromes (eg, headache) thought to be more common in patients with mild TBI and in those who have sustained brain injury from violent rather than unintentional trauma. Comorbid psychiatric disorders such as posttraumatic stress disorder (PTSD) may also mediate chronic pain symptoms.
To determine the prevalence of chronic pain as an underdiagnosed consequence of TBI and to review the interaction between chronic pain and severity of TBI as well as the characteristics of pain after TBI among civilians and combatants.
The Ovid/MEDLINE database was searched for articles published between 1951 and February 2008 using any combination of the terms brain injury, pain, headache, blast injury, and combat (combat disorders, war, military medicine, wounds and injuries, military personnel, veterans). The PubMed and MD Consult databases were searched in a similar fashion. The Cochrane Collaboration, National Institutes of Health Clinical Trials Database, Meta-Register of Current Controlled Trials, and CRISP databases were searched using the keyword brain injury. All articles in peer-reviewed journals reporting original data on pain syndromes in adult patients with TBI with regard to pain prevalence, pain category, risk factors, pathogenesis, and clinical course were selected, and manual searches were performed of their reference lists. The data were pooled and prevalence rates calculated.
Twenty-three studies (15 cross-sectional, 5 prospective, and 3 retrospective) including 4206 patients were identified. Twelve studies assessed headache pain in 1670 patients. Of these, 966 complained of chronic headache, yielding a prevalence of 57.8% (95% confidence interval [CI], 55.5%-60.2%). Among civilians, the prevalence of chronic pain was greater in patients with mild TBI (75.3% [95% CI, 72.7%-77.9%]) compared with moderate or severe TBI (32.1% [95% CI, 29.3%-34.9%]). Twenty studies including 3289 civilian patients with TBI yielded a chronic pain prevalence of 51.5% (95% CI, 49.8%-53.2%). Three studies assessed TBI among 917 veterans and yielded a pain prevalence of 43.1% (95% CI, 39.9%-46.3%). PTSD may mediate chronic pain, but brain injury appears to have an independent correlation with chronic pain.
Chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain.
美国疾病控制与预防中心估计，每年约有140万美国人遭受创伤性脑损伤（TBI）。既往报告提示，TBI与慢性疼痛综合征（如头痛）之间存在关联，据认为，这在轻度TBI患者以及因暴力而非意外伤害导致脑损伤的患者中更为常见。创伤后应激障碍（PTSD）等共病性精神障碍也可能介导慢性疼痛症状。
确定慢性疼痛作为TBI未被充分诊断的后果的患病率，并综述慢性疼痛与TBI严重程度之间的相互作用，以及平民和参战人员TBI后疼痛的特征。
在Ovid/MEDLINE数据库中检索1951年至2008年2月发表的文章，使用脑损伤、疼痛、头痛、爆炸伤和战斗（战斗障碍、战争、军事医学、创伤和损伤、军事人员、退伍军人）等术语的任意组合。以类似方式检索PubMed和MD Consult数据库。使用关键词脑损伤检索Cochrane协作网、美国国立卫生研究院临床试验数据库、当前对照试验的Meta注册库和CRISP数据库。选择所有同行评审期刊中报告成年TBI患者疼痛综合征原始数据的文章，包括疼痛患病率、疼痛类别、危险因素、发病机制和临床病程，并对其参考文献列表进行手工检索。汇总数据并计算患病率。
确定了23项研究（15项横断面研究、5项前瞻性研究和3项回顾性研究），共4206例患者。12项研究评估了1670例患者的头痛疼痛。其中，966例主诉慢性头痛，患病率为57.8%（95%置信区间[CI]，55.5%-60.2%）。在平民中，轻度TBI患者的慢性疼痛患病率（75.3%[95%CI，72.7%-77.9%]）高于中度或重度TBI患者（32.1%[95%CI，29.3%-34.9%]）。20项研究纳入3289例平民TBI患者，慢性疼痛患病率为51.5%（95%CI，49.8%-53.2%）。3项研究评估了917例退伍军人的TBI，疼痛患病率为43.1%（95%CI，39.9%-46.3%）。PTSD可能介导慢性疼痛，但脑损伤似乎与慢性疼痛存在独立关联。
慢性疼痛是TBI的常见并发症。它独立于PTSD和抑郁症等心理障碍，甚至在脑部明显轻伤的患者中也很常见。
