Postamputation pain: epidemiology, mechanisms, and treatment.
Postamputation pain: epidemiology, mechanisms, and treatment.
复制标题
DOI：
10.2147/jpr.s32299
复制
发表时间：
2013
影响因子：
2.7
通讯作者：
Cohen SP
中科院分区：
文献类型：
--
作者：
Hsu E;Cohen SP
截肢后疼痛（PAP）在肢体截肢后非常普遍，但仍然是一种治疗起来极具挑战性的疼痛状况。其难治性很大一部分源于多种病理生理机制。对截肢后现象的病理生理学基础的最新理解可以大致分为脊柱上、脊柱和外周机制。脊柱上机制涉及代表失传入肢区域的体感皮质重组，并且在幻肢痛和幻觉中占主导地位。周围神经损伤导致传入神经阻滞后，背角的脊柱重组就会发生。在周围，轴突神经损伤引发炎症、再生萌芽和增加“异位”传入输入，许多人认为这是导致残肢疼痛或神经瘤疼痛的主要机制，但也可能导致幻觉现象。为了优化治疗结果，治疗应根据个体情况进行调整并以机制为基础。治疗方式包括注射疗法、药物疗法、补充和替代疗法、手术疗法以及预防干预措施。不幸的是，缺乏高质量的临床试验来支持大多数这些治疗方法。大多数 PAP 随机对照试验都评估了药物治疗，其中注意到氯胺酮和阿片类药物的短期疗效趋势。使用肉毒杆菌毒素和脉冲射频进行外周注射治疗残肢疼痛的证据仅限于非常小的试验和病例系列。镜像疗法是一种安全且经济有效的 PAP 替代治疗方式。使用植入运动皮层刺激的神经调节已显示出对难治性幻肢痛有效的趋势，尽管证据很大程度上是轶事。旨在使用硬膜外和神经周围导管预防 PA P 的研究产生了不一致的结果，尽管与非优化替代方案相比，术前超过 24 小时开始输注可能对硬膜外预防有一些益处。需要进一步研究 PAP 发生的机制和相关因素，为指导当前和未来的治疗方法提供循证基础。
Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentataion from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased “ectopic” afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term Efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PA P using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.