Orthopedic Surgery and Traumatology Service, Virgen Macarena University Hospital, Seville, Spain; Department of Surgery, University of Seville, Spain.
Department of Surgery, Health and Medical Sciences, University of Alcaláde Henares, Alcalá de Henares, Madrid, Spain; Area of Traumatology and Orthopedics, CEU San Pablo University, Madrid, Spain; Shoulder and Elbow Unit, Ramón y Cajal University Hospital, Madrid, Spain.
J Shoulder Elbow Surg. 2024 Jul;33(7):e364-e376. doi: 10.1016/j.jse.2023.11.011. Epub 2024 Jan 3.
Appropriate preoperative management of patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis may improve surgery and patient outcomes, but published evidence in this regard is scarce. Therefore, the availability of recommendations on preoperative interventions based on expert consensus may serve as guidance.
A Delphi study was conducted to develop a preoperative management algorithm based on a national expert consensus. A Delphi questionnaire was developed by a scientific committee following a systematic review of the relevant literature published during the past 10 years using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) criteria. It consisted of 48 statements divided into 5 blocks (block I, assessment and diagnosis of preoperative pain; block II, preoperative function and psychosocial aspects; block III, therapeutic objectives; block IV, treatment; and block V, follow-up and referral), and 28 experienced shoulder surgeons from across the country were invited to answer.
All participants responded to the Delphi questionnaire in the first round, and 25 responded in the second round (89.3% of those invited). Overall, 46 of 49 final statements reached a consensus, on the basis of which a final preoperative management algorithm was defined by the scientific committee. First, surgeons should assess shoulder pain intensity and characteristics, shoulder functionality, and psychosocial aspects using specific validated questionnaires. Preoperative therapeutic objectives should include shoulder pain control, depression and/or nocturnal sleep improvement, opioid consumption adjustment, and substance abuse cessation. Postoperative objectives regarding the degree of shoulder pain reduction or improvement in functionality and/or quality of life should be established in agreement with the patient. Treatment of preoperative chronic moderate to severe shoulder pain should comprise nonpharmacologic as well as pharmacologic interventions. Follow-up of the shoulder pain levels, treatment adherence, and mental health status of these patients may be carried out by the surgical team (surgeon and anesthesiologist) together with the primary care team. Patients with very intense shoulder pain levels may be referred to a pain unit following specific protocols.
A preoperative management algorithm for patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis was defined based on a national expert consensus. Main points include comprehensive patient management starting with an objective assessment of shoulder pain and function, as well as quality of life; establishment of preoperative and postoperative therapeutic targets; prescription of individualized therapeutic interventions; and multidisciplinary patient follow-up. Implementation of these recommendations into clinical practice may result in better preoperative shoulder pain management and more successful surgical outcomes and patient satisfaction.
对于因肩袖疾病或肩关节炎而需要手术的慢性中重度肩痛患者，进行适当的术前管理可能会改善手术和患者的结局，但这方面的证据有限。因此，基于专家共识制定的术前干预建议可能会提供指导。
本研究采用德尔菲法（Delphi method），基于全国专家共识制定术前管理算法。德尔菲法由一个科学委员会制定，该委员会在对过去 10 年发表的相关文献进行系统回顾的基础上，使用 PRISMA（系统评价和荟萃分析的首选报告项目）标准制定了德尔菲问卷。该问卷包含 48 个条目，分为 5 个部分（第 I 部分，术前疼痛评估和诊断；第 II 部分，术前功能和心理社会方面；第 III 部分，治疗目标；第 IV 部分，治疗；第 V 部分，随访和转诊），并邀请全国 28 名经验丰富的肩部外科医生回答。
所有参与者均在第一轮回复了德尔菲问卷，25 名参与者在第二轮回复（受邀者的 89.3%）。总体而言，49 个最终条目中的 46 个基于专家共识达成一致，科学委员会据此定义了最终的术前管理算法。首先，外科医生应使用特定的验证问卷评估肩部疼痛的强度和特征、肩部功能和心理社会方面。术前治疗目标应包括控制肩部疼痛、改善抑郁和/或夜间睡眠、调整阿片类药物的使用以及戒除物质滥用。与患者共同确定术后肩部疼痛减轻或功能和/或生活质量改善的程度。慢性中重度肩部疼痛的治疗应包括非药物和药物干预。可由手术团队（外科医生和麻醉师）与初级保健团队一起对这些患者的肩部疼痛水平、治疗依从性和心理健康状况进行随访。疼痛水平非常剧烈的患者可能需要根据特定方案转至疼痛科。
基于全国专家共识，为因肩袖疾病或肩关节炎而需要手术的慢性中重度肩痛患者制定了术前管理算法。主要内容包括从肩部疼痛和功能以及生活质量的客观评估开始的全面患者管理；确定术前和术后治疗目标；个体化治疗干预措施的处方；以及患者的多学科随访。将这些建议付诸临床实践可能会改善术前肩部疼痛管理，提高手术成功率和患者满意度。
