Davies Huw T O, Crombie Iain K, Macrae William A
Department of Epidemiology and Public Health, University of Dundee, DundeeUK Department of Anaesthetics, Ninewells Hospital and Medical School, DundeeUK.
Pain. 1993 Sep;54(3):341-346. doi: 10.1016/0304-3959(93)90035-N.
This study aimed to identify areas of disagreement in the management of neurogenic pain. A short questionnaire was mailed to 179 consultants with an interest in chronic pain (response rate 89%). The questionnaire listed 11 specific conditions involving nerve pain (e.g., post-herpetic neuralgia, causalgia) together with 11 treatments (e.g., antidepressants, neurectomy). Consultants were asked to rate the use of each treatment for each condition as 'appropriate', 'no value or positively harmful' or 'no opinion'. Much disagreement emerged about the value of each therapy for each condition: in almost every instance at least some consultants disagreed with the majority view. The dissenting minority was greater than 20% of those who gave an opinion for 48 of the 121 applications of therapy asked about. The appropriateness of treatments for trigeminal neuralgia, amputation stump pain and phantom pain was most often in dispute and there was little consensus on the value of nerve blocks. There were a few areas of near agreement. Antidepressants and anticonvulsants were mostly identified as appropriate for all the conditions listed and there was some agreement that strong opioids and the neuroablative techniques were appropriate for cancer pressure or infiltration of nerves but, with a few exceptions, of no value for all other neurogenic pain conditions. Divergence of views about treatments may indicate a lack of credible evidence on the value of therapies or a lack of professional knowledge. Where published evidence is clear, the consequences for patients may be under-use of useful therapies or potential iatrogenic harm.
本研究旨在确定神经源性疼痛管理中存在分歧的领域。一份简短的问卷被邮寄给了179名对慢性疼痛感兴趣的顾问（回复率为89%）。问卷列出了11种涉及神经疼痛的具体病症（如疱疹后神经痛、灼性神经痛）以及11种治疗方法（如抗抑郁药、神经切除术）。顾问们被要求将每种病症的每种治疗方法的使用情况评为“合适”“无价值或有积极危害”或“无意见”。对于每种病症的每种治疗方法的价值，出现了很多分歧：几乎在每种情况下，至少有一些顾问不同意多数人的观点。在被问及的121种治疗应用中，有48种的持不同意见的少数派超过了发表意见者的20%。三叉神经痛、截肢残端痛和幻肢痛治疗方法的适当性最常受到争议，对于神经阻滞的价值几乎没有共识。有一些几乎达成一致的领域。抗抑郁药和抗惊厥药大多被认为适用于列出的所有病症，并且对于强阿片类药物和神经毁损技术适用于癌症压迫或神经浸润达成了一些共识，但除了少数例外，对所有其他神经源性疼痛病症无价值。关于治疗方法的观点分歧可能表明缺乏关于治疗价值的可靠证据或缺乏专业知识。在已发表的证据明确的情况下，对患者的后果可能是有用的治疗方法未得到充分利用或潜在的医源性伤害。
