Vergne-Salle Pascale
Service de rhumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
Joint Bone Spine. 2016 Dec;83(6):657-663. doi: 10.1016/j.jbspin.2016.06.001. Epub 2016 Jul 15.
Chronic postsurgical pain (CPSP) affects 10 to 30% of surgical patients overall and 16 to 20% of patients after knee surgery. Patients report persistent pain in the absence of infection, mechanical disorders, or complex regional pain syndrome type I. In many cases, the mechanism is neuropathic pain related to an intraoperative nerve injury or impaired pain modulation with central sensitization. The clinical risk factors and pathophysiology of CPSP are being actively investigated. Risk factors include preoperative pain; diffuse pain; severe pain during the immediate postoperative period; anxiety, depression, or cognitive distortions such as catastrophizing; and comorbidities. The diagnosis rests on clinical grounds and should be established as early as possible to optimize the chances of improvement. The management of CPSP combines a number of perioperative prophylactic strategies and the treatment of chronic neuropathic pain. Local treatments consist of transcutaneous electrical nerve stimulation and lidocaine patches combined with tramadol. When this treatment is inadequately effective, an antidepressant or anticonvulsant can be added. A capsaicin patch is the third-line treatment, and step III opioids are the last option. Rehabilitation therapy and physical exercises are beneficial. Psychological counseling and/or cognitive behavioral therapy should be offered, if indicated, by the results of the evaluation.
慢性术后疼痛（CPSP）总体上影响10%至30%的手术患者，膝关节手术后患者中的比例为16%至20%。患者报告在无感染、机械性疾病或I型复杂性区域疼痛综合征的情况下存在持续性疼痛。在许多情况下，其机制为与术中神经损伤或伴有中枢敏化的疼痛调制受损相关的神经性疼痛。CPSP的临床危险因素和病理生理学正在积极研究中。危险因素包括术前疼痛；弥漫性疼痛；术后即刻的重度疼痛；焦虑、抑郁或诸如灾难化等认知扭曲；以及合并症。诊断基于临床依据，应尽早确立以优化改善机会。CPSP的管理结合了多种围手术期预防策略以及慢性神经性疼痛的治疗。局部治疗包括经皮电刺激神经疗法和利多卡因贴片联合曲马多。当这种治疗效果欠佳时，可加用抗抑郁药或抗惊厥药。辣椒素贴片为三线治疗，III级阿片类药物为最后选择。康复治疗和体育锻炼有益。如有指征，应根据评估结果提供心理咨询和/或认知行为疗法。
