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Shkodra M, Brunelli C, Zecca E, Formaglio F, Bracchi P, Lo Dico S, Caputo M, Kaasa S, Caraceni A. Pain. 2021;162(3):866-874. 本次学习由林小雯副主任医师主讲。
3.3.Comparison between Retrospective Clinical Classification and DN4 results
This analysis was performed on the 325 patients for whom the Retrospective Clinical Classification was available. The estimated NcP prevalence based on the Retrospective Clinical Classification was 28.6%, 95% CI (23.8%-33.9%), whereas it was 20%, 95% CI (15.9%-24.6%) based on the DN4 questionnaire results. Cohen's kappa indicated a moderate concordance (kappa = 0.57, 95% CI [0.47-0.67]). Figure 3 shows an overall agreement between the 2 methods in 84.3% of cases (15.4% on the presence of NcP and 68.9% on absence). In 43 patients (13.2%), the Retrospective Clinical Classification was positive for NcP, but the DN4 was below the threshold of 4; the opposite happened in only 8 patients (2.5%). To examine potential reasons for disagreement in the former 43 patients, we calculated the percentage of discordance (DN4 below threshold vs clinical evaluation positive) by specific pain syndromes (Fig. 4). Higher discordance emerged in patients affected by pain due to damage of soft or nervous tissue, especially for syndromes such as perineal pain due to rectal and perirectal tissue infiltration or infiltration of muscles and fascias of the limbs. In fact, 14 of these 43 patients had a syndrome of perineal pain due to rectal and perirectal tissue infiltration, associated with tenesmus. The DN4 score was 0 for 6 of these 14 patients and 2 for the remaining 8, of whom, only 1 had significant sensory findings in the physical examination. Of the remaining 29 patients, 9, 9, 6, and 5 patients had a DN4 of 3, 2, 1, and 0, respectively, and the pain syndromes included a combination of a bone and nervous tissue damage (11 patients), soft tissue and nervous tissue damage (7 patients), only soft tissue damage (5 pts), bone and soft tissue damage (2 patients), bone, soft tissue, and nervous tissue damage (1 patient), only bone pain (1 patient), and only nervous tissue damage (1 patient). In all of them, the board of experts identified signs of neurological lesion associated with pain distribution.
3.3 回顾性临床分类与DN4结果的比较
这项分析是在325名回顾性临床分类的患者中进行的。根据回顾性临床分类估计的NCP患病率为28.6%，95%CI(23.8%-33.9%)，而根据DN4问卷调查结果，NCP患病率为20%，95%CI(15.9%-24.6%)。Cohen's kappa显示中度一致性(kappa=0.57，95%CI[0.47~0.67])。图3显示，在84.3%的情况下，两种方法之间的总体一致性为15.4%(存在NCP时为15.4%，不存在时为68.9%)。在43例(13.2%)患者中，回顾性临床分类为NCP阳性，但DN4低于阈值4；仅有8例(2.5%)出现相反的情况。为了检查前43名患者不一致的潜在原因，我们计算了不一致的百分比(阈值以下的DN4与临床评估阳性的DN4)。(图4)。软组织或神经组织损伤引起的疼痛患者表现出较高的不协调性，尤其是直肠及直肠周围组织浸润或四肢肌肉筋膜浸润引起的会阴痛等症状。事实上，这43名患者中有14名因直肠和直肠周围组织浸润而出现会阴疼痛综合征，并伴有里急后重。14例患者中有6例DN4评分为0，其余8例为2分，其中仅1例在体检中有明显的感觉改变。在其余29例患者中，DN4=3的患者有9例，DN4=2的患者也有9例，DN4=1的患者有6例，DN4=0的患者有5例，疼痛症状包括骨和神经组织损害(11例)、软组织和神经组织损害(7例)、仅有软组织损害(5例)、骨和软组织损害(2例)、骨、软组织和神经组织损害(1例)、仅骨痛(1例)和仅神经组织损害(1例)。在所有这些病例中，专家委员会确定了与疼痛分布相关的神经损伤迹象。
Table 4 reports the distribution of pain syndromes by the presence/absence of NcP according to the Retrospective Clinical Classification in the group of 325 evaluated patients. Pain due to only bone or only visceral lesions were more frequently encountered in patients without NcP, with a prevalence of 45% and 32%, respectively, over 232 cases compared with 5% and 13% over 93 cases of NcP. Instead, for patients with NcP, the combination of bone and nervous tissue damage (39%) and that of soft tissue and nervous tissue damage (16%) accounted for the most frequent syndromes. For patients without NcP, there was only 1 patient with a combination of bone and nervous tissue damage, whereas there were no cases with both soft and nervous tissue damage. Among patients with NcP, 2 (2%) had evidence of only nervous tissue damage.
3.4 根据IASP神经病理性疼痛标准对疼痛症状的回顾性临床分类
表4根据回顾性临床分类报告了325例受评患者中疼痛症状的分布情况。在无NCP的患者中，仅由骨骼或内脏损害引起的疼痛更为常见，有超过232例无NCP的患者对应患病率分别为45%和32%，而超过93例NCP患者的对应患病率分别为5%和13%。相反，对于NCP患者，最常见的症状是骨和神经组织损伤(39%)和软组织和神经组织损伤(16%)。非NCP组仅1例合并骨和神经组织损害，无软组织和神经组织损害。在NCP患者中，有2例(2%)仅有神经组织损伤的证据。
The classification of cancer pain dates back to the pivotal reports by Foley and colleagues in 1979 describing the complexity of pain syndromes caused by cancer direct or metastatic invasion of potentially any body tissue. The diagnosis of the cause and mechanism of cancer pain impacts both analgesics prescription and antineoplastic palliative interventions. An accurate clinical description of the pain-causing lesion and pain clinical characteristics is also necessary for describing homogenous groups when addressing analgesic or palliative therapeutic interventions in clinical trials and in the clinic.
4.讨论
癌症疼痛的分类可以追溯到1979年Foley等人的关键报告，该报告描述了由癌症直接或转移性侵袭任何身体组织引起的疼痛综合征的复杂性。癌症疼痛的病因和机制的诊断对止痛药处方和抗肿瘤姑息干预都有影响。在临床试验和临床中，在进行止痛或姑息治疗干预时，为了描述同质组，还需要对引起疼痛的病变和疼痛的临床特征进行准确的临床描述。
This points to a substantial variability among physicians' identification of NcP, especially for some specific pain syndromes such as those related to pararectal–pelvic soft tissue infiltrations resulting in pain associated with tenesmus. In some cases, this was considered as mixed pain and in others nociceptive, depending on Clinical Impression of the treating physician. In the Retrospective Clinical Classification, perineal and pelvic pain associated with tenesmus and due to soft tissue local relapse was diagnosed as mixed nociceptive and neuropathic pain. A recent systematic review has described the lack of homogeneous understanding of the pathophysiology of tenesmus. Differences between the Clinical Impression and the Retrospective Clinical Classification were also seen in the presence of bone vertebral lesions with pain radiating into the limbs, often defined neuropathic after Clinical Impression (31 cases) but considered to not fulfill the NeuPSIG criteria for probable or definite NP in the Retrospective Clinical Classification. In very few cases, the treating physicians did not clearly separate pain due to cancer from pain due to treatment. The fact that not every pain in an oncological patient is caused by the tumor itself is very important because pain due to antineoplastic treatment or other comorbidities can often be found.
这表明医生对NCP的识别存在很大的差异，特别是一些特定的疼痛综合征，如与直肠旁-盆腔软组织浸润相关的导致里急后重的疼痛。在某些情况下，这被认为是混合性疼痛，而在另一些情况下，这取决于主治医生的临床印象。在回顾性临床分类中，与里急后重和软组织局部复发相关的会阴痛和盆腔痛被诊断为伤害性和神经性混合性疼痛。最近的一篇系统综述描述了对里急后重的病理生理学缺乏一致的了解。临床印象和回顾性临床分类之间的差异也表现在存在骨椎病变时，疼痛辐射到四肢，通常被定义为临床印象后的神经性病变(31例)，但在回顾性临床分类中被认为不符合NeuPSIG关于可能或确定的NP的标准。在极少数情况下，主治医生没有明确区分癌症引起的疼痛和治疗引起的疼痛。事实上，并非所有肿瘤患者的疼痛都是由肿瘤本身引起的，这一事实非常重要，因为经常可以发现抗肿瘤治疗或其他合并症引起的疼痛。
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