下肢截肢后残肢痛及症状性神经瘤的患病率：系统回顾和荟萃分析（五）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自List EB, Krijgh DD, Martin E, Coert JH. Prevalence of residual limb pain and symptomatic neuromas after lower extremity amputation: a systematic review and meta-analysis. Pain. 2021;162(7):1906-1913. 本次学习由王珺楠副主任医师主讲。

4.3. Treatment and prevention of residual limb pain and symptomatic neuromas 

Residual limb pain is used as a collective term for multiple etiologies with different treatment options. In case of ulceration in nondiabetic and diabetic vascular patients, regulation of the underlying condition is an important element of care. These ulcerations are often more troublesome and heal slower than ulcerations caused by pressure and friction between the stump and prosthesis. A well-fitted prosthesis is important in the prevention of RLP, but in case of severe bone spur formation and soft tissue or bone infections, revision stump surgery is regularly required. 

Whenever RLP is based on a symptomatic neuroma, both surgical and nonsurgical treatment options are available. Nonsurgical management of postamputation symptomatic neuromas includes the administration of various medications, phenol or alcohol injections, radiofrequency ablation, and cryoablation. The effectiveness of these treatments is questionable, and reliable evidence is lacking. In case of persistent neuroma pain, surgical alternatives tend to be more suitable than the nonsurgical approach. There is evidence supporting the effectiveness of traditional neuroma excision, followed by muscle implantation of the remaining nerve end. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) are 2 newer surgical therapies for symptomatic neuroma of sensory nerves, yielding promising results. These techniques are used in neuroma management and can be used as preventative measures. However, TMR and RPNI are not (yet) part of the standard procedure of a lower extremity amputation. Because of the lack of high-level comparative studies, no consensus has been reached regarding the best symptomatic neuroma treatment.

4.3.残肢痛及症状性神经瘤的治疗与预防

残肢痛是作为一个综合术语，有多种病因与不同的治疗方案。在非糖尿病和糖尿病血管病变的溃疡患者中，调整内在状态是一个重要的护理因素。这些溃疡通常比由残端和假体之间的压力和摩擦引起的溃疡更难处理且愈合速度更慢。一个合适的假体对于预防RLP十分重要，但如果出现严重的骨刺形成，软组织或骨感染，通常需要进行残端翻修手术。

当RLP是由于症状性神经瘤产生时，可以采用手术和非手术治疗方案。截肢后症状性神经瘤的非手术治疗包括各种药物，苯酚或酒精注射，射频消融和冷冻消融。这些治疗方法的有效性尚不确定，且缺乏可靠的证据。在持续性神经瘤疼痛的情况下，手术方案往往比非手术方法更合适。有证据支持传统的神经瘤切除并神经残端肌肉植入的有效性。靶点肌肉神经移植术(TMR)和周围神经再生(RPNI)是感觉神经的症状性神经瘤的两种新型手术方法，取得良好的效果。这些技术可用于神经瘤的治疗和预防措施。然而，TMR和RPNI还不是（尚未）下肢截肢的标准程序的一部分。因为缺乏高水平的对比研究，症状性神经瘤的最佳治疗方案尚未达成共识。

4.4. Strengths and limitations 

Limitations to this study include the heterogeneity among included studies. The articles differed regarding study design and methods of data collection. It is important to note that the prevalence of RLP and symptomatic neuroma was often based on a dichotomous question about the presence or absence of these conditions. This presence or absence was not linked to a pain scale and therefore the clinical impact of the presence of RLP or symptomatic neuroma is unclear. Only 7 articles were included in the meta-analysis for symptomatic neuroma prevalence, and it was not possible to perform a subgroup analysis. Also, no subgroup analysis of the influence of sex on the prevalence of RLP could be performed because of the lack of studies focusing exclusively on women. Subgroup analysis showed a significant higher prevalence of RLP in studies with a geographic location within the United States compared with Europe or Asia. These outcomes must be interpreted with care as the results were based on studies that were not comparative between countries, which may have led to a reporting bias. Studies included used different methods of data collection. Face-to-face or phone interviews may be more likely to obtain the most realistic prevalence because better distinctions could be made in terms of complaint relevance. In only 3 of the included studies a physical examination was part of the diagnostic process. The other studies were solely based on the interviews, self-administered questionnaires, or medical records. We believe that a physical examination as part of the diagnostic process in RLP and symptomatic neuroma is essential. Finally, 2 studies only included patients wearing prostheses, which may increase the risk of a selection bias. Patients who could not tolerate a prosthesis because of pain were possibly excluded, resulting in an underestimation of the RLP prevalence. 

Nevertheless, this study found a high prevalence of RLP and symptomatic neuroma among lower extremity amputees. Patients require long-term follow-up after a lower limb amputation because of the possible late onset of RLP, especially caused by symptomatic neuromas. Future research should focus on diagnosing RLP at an early stage, identifying neuromas, and treating them appropriately. Selection criteria that patients must meet when diagnosing RLP and symptomatic neuromas are not yet properly established. Novel treatment modalities, such as TMR or RPNI as a possible part of an amputation to prevent symptomatic neuromas, report favourable results.

4.4.优势和局限性

本研究的局限性包括所纳入研究之间的异质性。这些文章在研究设计和数据收集方法两方面各有差异。值得注意的是，RLP和症状性神经瘤的患病率通常是基于存在或不存在的一个二分法问题。是否存与疼痛量表无关，因此，RLP或症状性神经瘤存在的临床影响尚不清楚。本文中只有7篇症状性神经瘤患病率的文章被纳入，无法进行亚组分析。此外，由于缺乏单一针对女性的研究，因此无法对RLP患病率进行性别影响的亚组分析。亚组分析显示美国境内的RLP患病率显著高于欧洲或亚洲。这些结果必须谨慎地解释，因为这些结果研究没有进行国家之间的对比，这可能导致了报告偏倚。纳入的研究包括了不同的数据收集方法。面对面或电话随访最大可能地获得最实际的患病率，因为医生能够对主诉的相关性进行更好地鉴别。其中只有3项研究将体格检查作为诊断的一部分。其他研究仅仅根据访谈、自我管理调查问卷或医疗记录做出诊断。我们认为体格检查作为RLP和症状性神经瘤诊断的一部分是必要的。最后，有2项研究只包括佩戴假体的患者，这可能会增加选择偏倚的风险。由于疼痛而不能忍受假体的患者可能被排除在外，导致RLP患病率被低估。

然而，本研究发现，在下肢截肢者中，RLP和症状性神经瘤的患病率很高。下肢截肢患者需要长期随访，因为RLP可能起病晚，特别是由症状性神经瘤引起的RLP。未来的研究应集中在早期诊断RLP，识别神经瘤，并适当地治疗。RLP和症状性神经瘤诊断标准尚未正式建立。新的治疗方式，如TMR或RPNI作为截肢术的部分手术步骤来预防症状性神经瘤，取得良好效果。

5. Conclusion 

The prevalence of RLP and symptomatic neuroma in patients with lower extremity amputations is 59% and 15%, respectively. A higher prevalence of RLP was identified in patients aged ＞50 years, with geographic location within the United States, followup ＞2 years, and in studies using a self-administered questionnaire for data collection. Knowledge of their high prevalence may result in better awareness among physicians, in turn providing timely and adequate treatment.

5.结论

下肢截肢患者中RLP和症状性神经瘤的患病率分别为59%和15%。在年龄＞50岁、美国、随访时间＞2年和采用自我管理调查问卷收集数据的研究中，RLP的患病率较高。了解RLP和症状性神经瘤的高患病率可使医生更好地认识此病，进而提供及时和充分的治疗。

往期回顾：

下肢截肢后残肢痛及症状性神经瘤的患病率：系统回顾和荟萃分析（四）

下肢截肢后残肢痛及症状性神经瘤的患病率：系统回顾和荟萃分析（三）

下肢截肢后残肢痛及症状性神经瘤的患病率：系统回顾和荟萃分析（二）