Keene David J, Knight Ruth, Bruce Julie, Dutton Susan J, Tutton Elizabeth, Achten Juul, Costa Matthew L
Kadoorie Research Centre, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Bone Joint J. 2021 Jun;103-B(6):1047-1054. doi: 10.1302/0301-620X.103B.BJJ-2020-2204.R1. Epub 2021 Apr 27.
To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.
Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care.
The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain.
Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: 2021;103-B(6):1047-1054.
确定下肢骨折手术后神经性疼痛的患病率，评估其与疼痛严重程度、生活质量和残疾的相关性，并确定受伤后3个月和6个月时慢性神经性疼痛的基线预测因素。
对英国一项多中心随机对照试验（创伤手术中的伤口愈合；WHiST）数据集进行二次分析，该数据集包括16岁及以上的成年人，他们因下肢严重创伤接受了手术。该试验从24个创伤中心招募了1547名参与者。在3个月和6个月时使用神经病理性疼痛问卷（DN4）测量神经性疼痛；701名参与者在3个月时提供了DN4评分，781名在6个月时提供了评分。总体而言，933名参与者至少在一个时间点提供了DN4评分。测量了身体残疾（残疾评定指数（DRI）0至100）和健康相关生活质量（欧洲五维五水平量表；EQ-5D-5L）。神经性疼痛的候选预测因素包括性别、年龄、体重指数、损伤机制、并发损伤、糖尿病、吸烟、饮酒、受伤前使用镇痛药情况、索引手术部位、固定类型、损伤严重程度评分、开放性损伤和伤口护理。
参与者的中位年龄为51岁（四分位间距35至64岁）。受伤后3个月和6个月时，分别有32%（222/702）和30%（234/787）患有神经性疼痛，56%（396/702）和53%（413/787）患有无神经性特征的慢性疼痛，其余无疼痛。神经性疼痛患者的疼痛严重程度更高。线性回归分析发现，与无神经性特征的患者相比，受伤后6个月患有神经性疼痛的患者身体残疾更多（DRI调整后平均差异11.49（95%置信区间（CI）7.84至15.14；p<0.001）），生活质量更差（EQ-5D效用-0.15（95%CI-0.19至-0.11）；p<0.001）。逻辑回归确定，年龄较小、当前吸烟者、膝关节以下骨折、并发损伤以及受伤前定期使用镇痛药等预后因素与受伤后神经性疼痛的较高几率相关。
下肢骨折手术后具有神经性特征的疼痛很常见，并持续至受伤后6个月。持续性神经性疼痛与恢复明显较差相关。表明需要进一步关注识别下肢损伤后的神经性疼痛、预测有风险的患者并针对性地进行干预。引用本文：2021；103-B(6):1047-1054。
