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Cohen SP, Caterina MJ, Yang SY, Socolovsky M, Sommer C. Pain in the Context of Sensory Deafferentation. Anesthesiology 2024; 140:824-848. [PMID: 38470115 DOI: 10.1097/aln.0000000000004881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Pain that accompanies deafferentation is one of the most mysterious and misunderstood medical conditions. Prevalence rates for the assorted conditions vary considerably but the most reliable estimates are greater than 50% for strokes involving the somatosensory system, brachial plexus avulsions, spinal cord injury, and limb amputation, with controversy surrounding the mechanistic contributions of deafferentation to ensuing neuropathic pain syndromes. Deafferentation pain has also been described for loss of other body parts (e.g., eyes and breasts) and may contribute to between 10% and upwards of 30% of neuropathic symptoms in peripheral neuropathies. There is no pathognomonic test or sign to identify deafferentation pain, and part of the controversy surrounding it stems from the prodigious challenges in differentiating cause and effect. For example, it is unknown whether cortical reorganization causes pain or is a byproduct of pathoanatomical changes accompanying injury, including pain. Similarly, ascertaining whether deafferentation contributes to neuropathic pain, or whether concomitant injury to nerve fibers transmitting pain and touch sensation leads to a deafferentation-like phenotype can be clinically difficult, although a detailed neurologic examination, functional imaging, and psychophysical tests may provide clues. Due in part to the concurrent morbidities, the physical, psychologic, and by extension socioeconomic costs of disorders associated with deafferentation are higher than for other chronic pain conditions. Treatment is symptom-based, with evidence supporting first-line antineuropathic medications such as gabapentinoids and antidepressants. Studies examining noninvasive neuromodulation and virtual reality have yielded mixed results.
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Affiliation(s)
- Steven P Cohen
- Departments of Anesthesiology, Neurology, Physical Medicine and Rehabilitation, Psychiatry and Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Departments of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Michael J Caterina
- Neurosurgery Pain Research Institute and Department of Biological Chemistry, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Su-Yin Yang
- Psychology Service, Woodlands Health, and Adjunct Faculty, Lee Kong Chian School of Medicine, Singapore
| | - Mariano Socolovsky
- Department of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
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Haldane C, Frost G, Ogalo E, Bristol S, Doherty C, Berger M. A systematic review and meta-analysis of patient-reported outcomes following nerve transfer surgery for brachial plexus injury. PM R 2022; 14:1368-1381. [PMID: 35100499 DOI: 10.1002/pmrj.12778] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis was to determine the effect of nerve transfer surgery for brachial plexus injury (BPI) on patient-reported outcomes. LITERATURE SURVEY MEDLINE, EMBASE, and CINAHL were searched and screened in duplicate for relevant studies on September 25, 2019 and repeated June 24, 2020. METHODOLOGY The patient population included male and female patients who received nerve transfer surgery for BPI. Further inclusion criteria were: (1) all levels of evidence; (2) published in English; (3) conducted in humans; and (4) report of patient-reported outcome. Two reviewers independently abstracted data regarding injury type, surgical technique, surgical timing, follow-up duration, strength, and patient-reported outcome measures. Quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. SYNTHESIS Twenty-one studies involving 464 participants were included in analyses. The mean age ± SD was 32.4 ± 1.8 (range: 5-77) and 89.2% of included participants were male. The mean time to surgery was 5.6 ± 0.6 months and the mean follow-up time was 48.1 ± 8.4 months. The most used patient-reported outcome was the Disabilities of Arm, Shoulder and Hand (DASH), where scores variably improved postoperatively, although the degree of disability remained high. Return to work was reported in five studies, with 66.0% of participants returning to work. Patient satisfaction was assessed in four studies with an overall satisfaction proportion of 64.0%. Pain was assessed in 12 studies using various measures. In studies reporting pain intensity postoperatively, 29.3% of patients were "pain-free" or had "no pain." CONCLUSIONS Patient-reported outcomes following nerve transfer for BPI are infrequently reported in the literature. Although patient-reported outcomes demonstrate variable postoperative improvement, there is evidence of ongoing limitations and postoperative DASH scores report a high degree of ongoing disability. Future studies with greater reporting as well as validation of patient-reported outcomes within BPI are warranted.
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Affiliation(s)
- Chloe Haldane
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey Frost
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emmanuel Ogalo
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Bristol
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Doherty
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Berger
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
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Liu Y, Zhuang Y, Wei R, Tan Z, Chen C, Yang D. Comparison of characteristics between neuropathic pain and non-neuropathic pain in patients with diabetic carpal tunnel syndrome: A cross-sectional study. Front Surg 2022; 9:961616. [PMID: 35983551 PMCID: PMC9379137 DOI: 10.3389/fsurg.2022.961616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe aim of the study was to compare the clinical characteristics of diabetic carpal tunnel syndrome between patients with neuropathic pain (NeuP) and non-NeuP.MethodsWe enrolled 276 patients with diabetic carpal tunnel syndrome. Pain symptoms were evaluated using a visual analog scale. Douleur Neuropathique 4, the Neuropathic Pain Symptoms Inventory questionnaire, and the body map were used to assess neuropathic symptoms. Baseline information, clinical manifestations, electrophysiological test results, and psychological status were compared between the neuropathic pain (NeuP) and non-NeuP to identify the risk factor for NeuP occurrence.ResultsResults showed that the degree of pain was more severe in NeuP patients than in nociceptive pain patients (p = 0.025). The frequencies of light touch and pinprick were more pronounced in the NeuP group than in the non-NeuP group (light touch: p = 0.001; pinprick: p = 0.004). There were 48 and 27 NeuP patients with extramedian and proximal spread, respectively, whereas in the non-NeuP group, there were 11 and 9 patients, respectively (p = 0.03). Electrophysiological results showed that patients in the NeuP group exhibited greater sensory nerve conduction velocity impairment compared with the non-NeuP group (p = 0.033). Pain Catastrophizing Scale total scores of the NeuP group were significantly higher than those of the non-NeuP group (p = 0.006).ConclusionOf the 276 diabetic carpal tunnel syndrome patients studied, the majority had NeuP. Furthermore, light touch, electrophysiological test results, and psychological factors were found to be related to NeuP occurrence in patients with diabetic carpal tunnel syndrome.
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Affiliation(s)
- Yingnan Liu
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Hand and Microvascular Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Yongqing Zhuang
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Hand and Microvascular Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Ruihong Wei
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Hand and Microvascular Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Zhouyong Tan
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Hand and Microvascular Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Chao Chen
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Hand and Microvascular Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Dazhi Yang
- The Second Clinical Medical College of Jinan University, Shenzhen, Guangdong, China
- Department of Spine Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, China
- Correspondence: Dazhi Yang
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Wu Y, Liu X, Han Y, Li L, Jian M, Sun G, Nie J. Peripheral Blood Mononuclear Cells Regulate Differentially Expressed Proteins in the Proximal Sciatic Nerve of Rats after Transection Anastomosis. Neuroscience 2022; 491:146-155. [PMID: 35395357 DOI: 10.1016/j.neuroscience.2022.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
Peripheral nerve injury (PNI) is a common disease that causes the partial loss of sensory, exercise, and autonomic nervous function. In clinical practice, accurate end-to-end neurorrhaphy of the epineurium without tension is the ideal treatment when there is no nerve defect. We have confirmed that peripheral blood mononuclear cells (PBMCs) can effectively improve nerve regeneration and functional recovery after PNI. However, the global protein profile and signaling conduction pathways regulated by PBMCs remain unclear. This study employed the transection anastomosis model to detect the walking track analysis, gastrocnemius wet weight rate, and morphological examination in order to validate the effect of PBMCs on sciatic nerve injury in rats. Results showed that PBMCs improved nerve regeneration after sciatic nerve dissociation and anastomosis in rats, which reflected in the improvement of the sciatic nerve function index, wet weight rate of gastrocnemius muscles, muscle fiber structure, and the number of axons. We then used TMT labeling quantitative proteomics to explore the underlying mechanism by which PBMCs ameliorated sciatic nerve injury. Results showed that PBMCs regulated 40 differential proteins and the regulated proteins were primarily involved in the complement and coagulation cascade pathways, the notch signaling pathway, the renin angiotensin system, DNA replication, histidine metabolism, β-alanine metabolism, and other types of O-glycan biosynthesis. Immunohistochemical results supported our findings on the changes in expression of Kininogen 1 and Psen1, the relationships between PNI and the notch pathway and the complement and coagulation level pathways.
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Affiliation(s)
- Yajuan Wu
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi 563000, China
| | - Xuejia Liu
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi 563000, China
| | - Yu Han
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi 563000, China
| | - Luxi Li
- Department of Burn and Plastic Surgery, The Second Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi 563000, China
| | - Mingjiang Jian
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi 563000, China
| | - Guangfeng Sun
- Department of Burn and Plastic Surgery, The Second Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi 563000, China.
| | - Jing Nie
- Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi 563000, China.
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