Julien-Marsollier Florence, David Raphaelle, Hilly Julie, Brasher Christopher, Michelet Daphné, Dahmani Souhayl
Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France; Denis Diderot University, Paris VII, 10 avenue de Verdun, Paris, France.
Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia.
Scand J Pain. 2017 Oct;17:339-344. doi: 10.1016/j.sjpain.2017.09.002. Epub 2017 Sep 22.
Numerous publications describe chronic pain following surgery in both adults and children. However, data in the paediatric population are still sparse and both prevalence of chronic pain after surgery and risk factors of this complication still undetermined.
We prospectively evaluated the prevalence of chronic pain and its neuropathic pain component at 1 year following correction of idiopathic scoliosis in children less than 18 years of age. Pain was defined as the presence of pain (numerical rating scale - NRS≥4), the presence of signs of neurologic damage within the area of surgery and the presence of the neuropathic symptoms as a DN4 (Douleur Neuropathique 4) questionnaire ≥4. Factors investigated as potentially associated with the presence of a persistent neuropathic pain were: age, weight, the presence of continuous preoperative pain over the 3 months before surgery, surgical characteristics, pain scores during the first five postoperative days, and DN4 at day 3. Statistical analysis employed univariate analysis and a multivariate logistic regression model.
Thirty six patients were included in the study. Nineteen (52.8%) had pain at one year after surgery. Among them 17 (48.2%) had neuropathic pain. Logistic regression found continuous pain over the 3 months preceding surgery and day 1 morphine consumption ≥0.5mgkg as independent predictors of persistent chronic pain with a neuropathic component. The overall model accuracy was 80.6 and the area under the curve of the model was 0.89 (95% confidence interval 0.78-0.99).
The present study found a high proportion of paediatric patients developing chronic persistent pain after surgical correction of scoliosis diformity. It allows identifying two factors associated with the occurrence of persistent chronic pain with a neuropathic component: the presence of persistent preoperative pain during the 3 months preceeding surgery and postoperative opioid consumption at day 1 ≥0.5mgkg.
Patients scheduled for spine surgery and presenting with preoperative pain should be considered at risk of chronic pain after surgery and managed accordingly by the chronic and/or acute pain team. Postoperative opioid consumption should be lowered as possible by using multimodal analgesia and regional analgesia such as postoperative epidural analgesia.
众多出版物描述了成人和儿童手术后的慢性疼痛。然而，儿科人群的数据仍然稀少，手术后慢性疼痛的患病率及其并发症的危险因素仍未确定。
我们前瞻性评估了18岁以下儿童特发性脊柱侧弯矫正术后1年慢性疼痛及其神经性疼痛成分的患病率。疼痛定义为存在疼痛（数字评分量表 - NRS≥4）、手术区域内存在神经损伤体征以及存在作为DN4（神经病理性疼痛4）问卷≥4的神经病理性症状。作为可能与持续性神经性疼痛存在相关的因素进行调查的有：年龄、体重、手术前3个月内持续存在的术前疼痛、手术特征、术后前五天的疼痛评分以及第3天的DN4。统计分析采用单因素分析和多因素逻辑回归模型。
36名患者纳入研究。19名（52.8%）在术后1年有疼痛。其中17名（48.2%）有神经性疼痛。逻辑回归发现手术前3个月内的持续疼痛和第1天吗啡消耗量≥0.5mg/kg是持续性慢性疼痛伴神经性成分的独立预测因素。总体模型准确率为80.6，模型曲线下面积为0.89（95%置信区间0.78 - 0.99）。
本研究发现，相当比例的儿科患者在脊柱侧弯畸形手术矫正后出现慢性持续性疼痛。它能够识别与持续性慢性疼痛伴神经性成分发生相关的两个因素：手术前3个月内存在持续性术前疼痛以及术后第1天阿片类药物消耗量≥0.5mg/kg。
计划进行脊柱手术且有术前疼痛的患者应被视为术后有慢性疼痛风险，并由慢性和/或急性疼痛团队进行相应管理。应通过使用多模式镇痛和区域镇痛（如术后硬膜外镇痛）尽可能降低术后阿片类药物的消耗量。
