Risk Factors Associated With the Progression From Acute to Chronic Neuropathic Pain After Burn-Related Injuries

Surgical Management of Chronic Neuropathic Burn Pain

Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.

Neuropathic pain in burn patients - A common problem with little literature: A systematic review

BACKGROUND

The prevalence of neuropathic pain (NP) in burn patients is reported in the literature to be as high as 80%1. Given the complexity of NP in burn patients and the wide range of treatments available, a systematic review of the literature is warranted to summarize our current understanding of management and treatment of NP in this population.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The following databases were queried to identify relevant articles: PubMed, Cochrane, Embase, Scopus, Ovid, and Web of Science. The main outcome measures were incidence and management of NP. Secondary outcomes included risk factors for NP.

RESULTS

Included articles presented findings from 11 different countries, capturing outcomes for 4366 patients. Risk factors for neuropathic pain in burn patients were identified, including older age, alcohol and substance abuse, current daily smoking, greater % total body surface area burns (TBSA), and longer hospitalizations. Pharmacologic treatments included gabapentin/pregabalin (n = 7), ascorbic acid (n = 1), and lidocaine (n = 1). Overall, the studies showed varied results regarding the efficacy of pharmacological treatments. While certain studies demonstrated gabapentanoids to be effective in reducing neuropathic symptoms, others found conflicting results. With regards to non-pharmacologic treatments, electroconvulsive therapy (n = 1), electropuncture (n = 1), nerve release/reconstruction (n = 2), and somatosensory feedback rehabilitation (n = 1) were used and demonstrated promise in reducing pain intensity and improving functionality.

CONCLUSIONS

Despite NP afflicting the majority of burn patients long after their injury, this systematic review demonstrates insufficient evidence on the pathophysiology, outcomes, and risk factors in NP, as well as the efficacy of various therapies. Future prospective and randomized studies evaluating the etiology of these factors can substantially improve our treatment strategies. This can allow for the development of well-delineated and evidence-based protocols in NP management in hopes of improving quality of life and both psychological and physical function in burn patients.

Pain Management in Burn Patients: Pharmacologic Management of Acute and Chronic Pain

Burn-related pain can contribute to decreased quality of life and long-term morbidity, limiting functional recovery. Burn-related pain should be assessed first by chronicity (acute or chronic), followed by type (nociceptive, neuropathic, nociplastic), to guide multimodal pharmacologic management in a stepwise algorithm approach. Combination therapies increase the efficacy and reduce toxicity by offering a multimodal approach that targets different receptors in the peripheral nervous system and central nervous system. When multimodal pharmacologic management is ineffective, etiologies of burn-related pain amenable to surgical interventions must be considered. It is important to know when to refer a patient to pain management.

Nonpharmacologic Management of Procedural Pain in Pediatric Burn Patients: A Systematic Review of Randomized Controlled Trials

Pain following burn injury is associated with long-term health consequences in the pediatric population. Literature suggests nonpharmacologic treatment may provide improved pain control as an effective adjunct for these patients. This study aims to summarize randomized controlled trials on nonpharmacologic procedural pain management in pediatric burn patients. A systematic review was conducted on nonpharmacologic procedural pain management techniques used in the pediatric burn population. Fifteen studies were included and involved virtual reality, distraction devices, child life therapy, directed play, digital tablet games, cartoons, hypnosis, and music therapy. Treatment was effective in 8 out of 15 studies. Compared to controls, nonpharmacologic treatments reduced mid procedure pain by 19.7% and post procedure pain by 20.1%. This study demonstrates nonpharmacologic therapy can be an effective adjunct in pediatric procedural burn pain management, however further studies are needed to develop standardized algorithms to integrate nonpharmacologic treatments with pharmacologic therapies.

Burn-induced heterotopic ossification from incidence to therapy: key signaling pathways underlying ectopic bone formation

Burn injury is one of the potential causes of heterotopic ossification (HO), which is a rare but debilitating condition. The incidence ranges from 3.5 to 5.6 depending on body area. Burns that cover a larger percentage of the total body surface area (TBSA), require skin graft surgeries, or necessitate pulmonary intensive care are well-researched risk factors for HO. Since burns initiate such complex pathophysiological processes with a variety of molecular signal changes, it is essential to focus on HO in the specific context of burn injury to define best practices for its treatment. There are numerous key players in the pathways of burn-induced HO, including neutrophils, monocytes, transforming growth factor-β1-expressing macrophages and the adaptive immune system. The increased inflammation associated with burn injuries is also associated with pathway activation. Neurological and calcium-related contributions are also known. Endothelial-to-mesenchymal transition (EMT) and vascularization are known to play key roles in burn-induced HO, with hypoxia-inducible factor-1 (HIF-1) and vascular endothelial growth factor (VEGF) as potential initiators. Currently, non-steroidal anti-inflammatory drugs (NSAIDs) and radiotherapy are effective prophylaxes for HO. Limited joint motion, ankylosis and intolerable pain caused by burn-induced HO can be effectively tackled via surgery. Effective biomarkers for monitoring burn-induced HO occurrence and bio-prophylactic and bio-therapeutic strategies should be actively developed in the future.