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High Preoperative Pain and Symptom Profile Predicts Worse Pain Outcomes for Children After Spine Fusion Surgery
背景与目的
术前疼痛能够预测脊柱融合术后的持续疼痛，然而，很少有人了解那类疼痛的本质，相关症状，及这些症状如何与术后疼痛结局相关联。这项前瞻性研究分析了儿童的基础疼痛和症状及明显症状和术后结局之间的关联。
方 法
70名计划施行特发性脊柱侧凸矫正术（年龄在10-17岁）的儿童术于前访视期间完成疼痛及疼痛症状调查（即[ 0-10数字疼痛强度评分]，2011纤维肌痛调查标准的儿科版本[包括疼痛部位和症状严重程度量表]，神经病理性疼痛的症状[painDETECT调查问卷]，及病人主诉的评价系统，评价内容包括疲劳、抑郁、功能、疼痛干预和剧烈疼痛）。术后每天记录疼痛强度和镇痛药物使用总量并持续到出院后2周。用分层聚类分析在基线上水平区分疼痛高低和症状，用多元主效应回归模型分析疼痛状况与出院后疼痛和镇痛结局的关联。
结 果
以2组儿童的基线水平特点区分的分层聚类分析报告。30%（95%置信区间[ CI ]，20.2% - 41.8%）有明显的症状（高）的儿童伴有较高的抑郁，疲劳，疼痛干预，儿科版纤维肌痛症状调查标准，神经性疼痛和恐惧。女孩比男孩（比值比[OR]，5.76 [ 95% CI，1.20-27.58 ]；P = 022），以及那些术前疼痛持续3个月的儿童（比值比3.42 [ 95% CI，1.21-9.70 ]；P = 018）更可能划为在高症状。调整性别，年龄，和医院内阿片类药物的总用量后，被划为高症状的与出院后有较高的主诉疼痛独立相关（均差﹢1.13分[97.5% CI, 0.09-2.17]; P = 0.015）。与低症状组比较，出院后2周高症状群的儿童更可能被报告持续使用阿片类药物（87% vs50%; OR, 6.5 [95% CI, 1.30-33.03]; P =0 .015）。6个月内，高症状群成员与更高的疼痛强度，更高的疼痛干预，持续镇痛药物的使用相关（P ≤ .018）。
结 论
30%特发性脊柱侧凸儿童术前疼痛伤害的脆弱状态与脊柱融合术后较差的及潜在的慢性疼痛结局独立相关。这种高症状群类似于前面描述的儿童和成人的慢性疼痛及中枢性疼痛，并在女孩和那些长期存在疼痛的人群中更为普遍。需要进一步的研究来阐明我们的观测背后的潜在机制。
原始文献摘要
Voepel-Lewis T1, Caird MS, Tait AR, Malviya S, Farley FA, Li Y, Abbott MD, van Veen T, Hassett AL, Clauw DJ.
Anesth Analg. 2017 May;124(5):1594-1602. doi:10.1213/ANE.0000000000001963.
BACKGROUND:Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes.
METHODS:Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes.
RESULTS:The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018).
CONCLUSIONSA behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.
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