Yang Michael M H, Riva-Cambrin Jay, Cunningham Jonathan, Jetté Nathalie, Sajobi Tolulope T, Soroceanu Alex, Lewkonia Peter, Jacobs W Bradley, Casha Steven
Departments of1Clinical Neurosciences, Section of Neurosurgery.
2Community Health Sciences, and.
J Neurosurg Spine. 2020 Sep 15;34(1):3-12. doi: 10.3171/2020.5.SPINE20347. Print 2021 Jan 1.
Thirty percent to sixty-four percent of patients experience poorly controlled pain following spine surgery, leading to patient dissatisfaction and poor outcomes. Identification of at-risk patients before surgery could facilitate patient education and personalized clinical care pathways to improve postoperative pain management. Accordingly, the aim of this study was to develop and internally validate a prediction score for poorly controlled postoperative pain in patients undergoing elective spine surgery.
A retrospective cohort study was performed in adult patients (≥ 18 years old) consecutively enrolled in the Canadian Spine Outcomes and Research Network registry. All patients underwent elective cervical or thoracolumbar spine surgery and were admitted to the hospital. Poorly controlled postoperative pain was defined as a mean numeric rating scale score for pain at rest of > 4 during the first 24 hours after surgery. Univariable analysis followed by multivariable logistic regression on 25 candidate variables, selected through a systematic review and expert consensus, was used to develop a prediction model using a random 70% sample of the data. The model was transformed into an eight-tier risk-based score that was further simplified into the three-tier Calgary Postoperative Pain After Spine Surgery (CAPPS) score to maximize clinical utility. The CAPPS score was validated using the remaining 30% of the data.
Overall, 57% of 1300 spine surgery patients experienced poorly controlled pain during the first 24 hours after surgery. Seven significant variables associated with poor pain control were incorporated into a prediction model: younger age, female sex, preoperative daily use of opioid medication, higher preoperative neck or back pain intensity, higher Patient Health Questionnaire-9 depression score, surgery involving ≥ 3 motion segments, and fusion surgery. Notably, minimally invasive surgery, body mass index, and revision surgery were not associated with poorly controlled pain. The model was discriminative (C-statistic 0.74, 95% CI 0.71-0.77) and calibrated (Hosmer-Lemeshow goodness-of-fit, p = 0.99) at predicting the outcome. Low-, high-, and extreme-risk groups stratified using the CAPPS score had 32%, 63%, and 85% predicted probability of experiencing poorly controlled pain, respectively, which was mirrored closely by the observed incidence of 37%, 62%, and 81% in the validation cohort.
Inadequate pain control is common after spine surgery. The internally validated CAPPS score based on 7 easily acquired variables accurately predicted the probability of experiencing poorly controlled pain after spine surgery.
30%至64%的患者在脊柱手术后疼痛控制不佳，导致患者不满且预后不良。术前识别高危患者有助于开展患者教育并制定个性化临床护理路径，以改善术后疼痛管理。因此，本研究的目的是开发并在内部验证一个用于预测择期脊柱手术患者术后疼痛控制不佳的评分系统。
对连续纳入加拿大脊柱结局与研究网络登记处的成年患者（≥18岁）进行一项回顾性队列研究。所有患者均接受择期颈椎或胸腰椎脊柱手术并入院治疗。术后疼痛控制不佳定义为术后首24小时静息时疼痛数字评定量表平均评分>4分。通过系统评价和专家共识选取25个候选变量，先进行单变量分析，再对其进行多变量逻辑回归分析，利用70%的随机抽样数据建立预测模型。该模型被转化为一个基于风险的八级评分，进一步简化为三级的卡尔加里脊柱手术后疼痛评分（CAPPS），以最大限度地提高临床实用性。使用其余30%的数据对CAPPS评分进行验证。
总体而言，1300例脊柱手术患者中有57%在术后首24小时疼痛控制不佳。与疼痛控制不佳相关的7个显著变量被纳入预测模型：年龄较小、女性、术前每日使用阿片类药物、术前颈部或背部疼痛强度较高、患者健康问卷-9抑郁评分较高、手术涉及≥3个活动节段以及融合手术。值得注意的是，微创手术、体重指数和翻修手术与疼痛控制不佳无关。该模型在预测结果方面具有鉴别力（C统计量为0.74，95%可信区间为0.71 - 0.77）且校准良好（Hosmer-Lemeshow拟合优度检验，p = 0.99）。使用CAPPS评分分层的低风险、高风险和极高风险组经历疼痛控制不佳的预测概率分别为32%、63%和85%，验证队列中观察到的发生率分别为37%、62%和81%，两者非常接近。
脊柱手术后疼痛控制不足很常见。基于7个易于获取的变量进行内部验证的CAPPS评分能够准确预测脊柱手术后疼痛控制不佳的概率。
