DN4 Questionnaire Research Articles

Characteristics of Pain Assessed with Visual Analog Scale and Questionnaire in Burning Mouth Syndrome Patients: A Pilot Study

To test the validity of the use of the Douleur Neuropathique en 4 Questions (DN4) questionnaire for burning mouth syndrome (BMS) patients, and to differentiate patients by measuring the time course of the pain in BMS patients over a period of 7 days with a visual analog scale (VAS). Patients completed the DN4 questionnaire and a VAS every hour for 7 days. The data were expressed as mean ± SEM. Correlations were searched using the Spearman correlation test with a significance level at P < .05. Data were fully analyzed for the 22 patients (21 females, 1 male, mean [± SEM] age 62.7 ± 2.3 years) for the DN4 and 17 patients for the VAS. DN4 scores ranged from 2 to 7 (mean score: 3.9 ± 0.3), and 59% of the patients had a DN4 score ≥ 4. Burning was found in all the patients, followed by pricking pain (pins and needles) and allodynia (pain on brushing) (both 68%), tingling (45%), numbness (32%), itching (27%), and electrical discharges (23%). Monitoring the hourly time-course of the pain led to the identification of two groups with intermittent or constant pain. In the latter, averaging the VAS for 7 days enabled plotting a curve, the slope of which could be calculated. The range of the slopes was 0.00 to 0.59, and a regular increase of pain during the day was seen for the majority of the patients. The findings support the use of DN4 as a tool for screening BMS and reinforce the view that BMS is a clinical manifestation of a neuropathic disease. The methodology of this study can be used for a better description of the patients and the identification of subgroups.

MULTIMODAL ANALGESIA AFTER TOTAL HIP ARTHROPLASTY

Purpose - to assess the effect of multimodal analgesia in the early rehabilitation of patients after hip replacement. Materials and methods. A prospective single-centre randomized research, which included 32 patients. Patients of the 1st group received paracetamol, ketorolac and tramadol, the 2nd group of patients - ketorolac intravenously and the 3rd group of patients - etoricoxib and gabapentin. Patients of the 2nd and the 3rd groups underwent epidural analgesia with ropivacaine. Multimodal analgesia was carried out for 48 hours after the surgery. Assessment of pain intensity was performed by the VAS (visual analogue scale), a neuropathic pain component - on the DN4 questionnaire . Time was recorded during the first and second verticalization of patients, using the distance walkers and by fixing the distance covered with in 2 minutes. Results. The intensity of pain for more than 50 mm on VAS at movement at least once every 48 hours after the surgery was occurred among 9% of the 1st group, 22% of patients from the 2nd group and 8% of patients of the 3rd group. Number of patients with neuropathic pain component decreased from 25% to 3% (p ≤ 0.05). The first verticalization was performed 10 ± 8 hours after the surgery, the second - 21 ± 8 hours later. Two-minute walk distance was 5 ± 3 and 8 ± 4 m, respectively. It is noted more frequent adverse events in patients of the 1st group was noted compared to patients of the 2nd and the 3rd groups during first (91%, 33% and 25%, p ≤ 0.05) and the second verticalization (70%, 25% and 17%, p ≤ 0.05). Multimodal analgesia allows to proceed with the successful activation of patients after hip replacement with in the first day after the surgery. The 3rd group patients are noted with a tendency for the optimal combination of efficient and safe of analgetic therapy.

Socio‐demographic and clinical profile of chronic pain with neuropathic characteristics in sub‐Saharan African elderly

Data on characteristics of neuropathic pain (NP) in sub-Saharan Africa are scarce, especially in the elderly. We conducted this study to appreciate the socio-demographic and clinical profile of chronic pain (CP) with neuropathic characteristics in sub-Saharan African elderly with musculoskeletal pain. From January to December 2011, we performed a cross-sectional study in all Rheumatology outpatients over 60 years at the Center for Gerontology and Geriatrics, Dakar, Senegal. In this study, we included patients who experienced musculoskeletal pain for 3 months or longer (CP) and with a DN4 score ≥ 4 (NP). A complete clinical examination was performed to make the diagnosis of NP 'definite' or 'probable', and to identify the aetiologies of NP. During the study period, 698 outpatients were examined. There were 394 out of the 549 patients over 60 years who reported CP. Among them, 28 patients (7.1%) scored ≥4 on the DN4 questionnaire. Female patients, low educational attainment, manual professions, non-workers and diabetes were associated with NP (p < 0.05). The symptoms described by patients with NP, often intricate, were lumboradiculalgia (n = 9), cervico-brachial neuralgia (n = 3), polyneuropathy (n = 12) and mononeuropathy (n = 6). The presumed aetiologies in patients with NP were: chronic spine diseases (n = 14), painful diabetic peripheral neuropathy (n = 8), Sjögren's syndrome (n = 1), tarsal tunnel syndrome in rheumatoid arthritis (n = 1) and bone metastasis (n = 1). No aetiology was identified among three patients. Chronic spine diseases associated with radiculopathies and diabetic neuropathy are the main causes of NP, well detected by DN4 questionnaire and clinical examination in Senegalese sub-Saharan African elderly.

Antidepressant therapy in complex treatment of painful diabetic polyneuropathy

Aims. Comparative efficiency and safety analysis of antidepressant agents from different pharmacological classes (pipofezine and venlafaxine)in combination with carbamazepine for treatment of neuropathic pain (NP) in patients with diabetic polyneuropathy (DP). Materials and methods. We examined 21 male and 27 female patients with painful DP (mean age 54.3?14.2 years; mean duration ofdiabetes mellitus (DM) 8.9?5.1 years; mean duration of DP - 3.8?2.1 years). DP was diagnosed clinically and by electromyographymethod. Pain syndrome was assessed with DN4 questionnaire, visual analogue scale (VAS) and McGill Pain Questionnaire. Psycho-vegetative status was evaluated by Spielberger test with reactive and personal anxiety (RA and PA) assessment and Beck depressioninventory. All patients received symptomatic pharmacotherapy with anticonvulsant and antidepressant agent. First group (DP-1)included 23 patients on carbamazepin and pipofezine. Second group (DP-2) included 25 patients on carbamazepin and venlafaxine. Results. Following treatment, pain syndrome was completely compensated in 8.7% of patients from DP-1 group and 12.5% from DP-2.Decrease in pain intensity?50% from initial level was achieved in 73.9% (DP-1) and 75% (DP-2) of cases. Mean pain intensityaccording to VAS reduced from 5.2?2.1 points to 2.3?1.4 points (DP-1) and from 5.8?2.3 points (DP-2) with equal statistical significance(p

Prevalence, Characteristics, and Factors Associated With Chronic Pain With and Without Neuropathic Characteristics in São Luís, Brazil

ContextChronic pain (CP) with and without neuropathic characteristics is a public health problem. This is the first population-based study in South America, and the third in the world, to use the Douleur Neuropathique 4 Questions (DN4) tool in epidemiologic studies. ObjectivesThe objectives were to estimate the prevalence and associated factors of CP with and without neuropathic characteristics in São Luís, Brazil. MethodsWe surveyed 1597 people. The DN4 questionnaire was applied. Poisson regression was used to analyze the risk factors. ResultsThe prevalence of CP was 42%, and 10% had CP with neuropathic characteristics (CPNC). The results showed that female sex and age ≥30 years were associated with an increased prevalence of CP (P<0.001) and education ≥12 years with a reduction in the prevalence of CP. The sensations listed in the DN4 were more common in people with CPNC and most frequent were pins and needles (87.9%). The cephalic region (36%) and limbs (51%) were the locations most affected. Most respondents felt pain between six months and four years (51.6%), with daily frequency (45%). Pain intensity, the impediments caused by pain, and sadness were more prevalent in people who had CPNC (P<0.001). Health status was regular for most, 50.9% did not know the cause of their pain, 64.1% used drugs, and only 7% had consulted with a pain specialist. Dissatisfaction with treatment was reported by 55%. ConclusionCP with and without neuropathic characteristics is a public health problem in Brazil, with high prevalence and great influence on people's daily lives.

Neuropathic pain during tuberculosis treatment in Bamako (Mali)

The incidence of tuberculosis is high in Africa. It is treated with medications that can trigger neuropathic pain and thus negatively affect patients' quality of life and treatment compliance. The aim of this study was to investigate neuropathic pain due to antituberculosis drugs in patients without HIV infection. This prospective study, conducted in the pulmonology department of the University Hospital of Point G, Mali, included patients taking antituberculosis drugs who had negative HIV tests and no other potential cause of neuropathic pain. Diagnosis of neuropathic pain relied on the DN4 questionnaire (4 questions for neuropathic pain) and its assessment on a visual analog scale (VAS) and the Lattinen test. During the study period, 423 subjects were admitted to our department, 103 (24.4%) with tuberculosis. Eighty met the inclusion criteria. The sex ratio (male to female) was 2.5. Their mean age was 39 years (range: 13-80). In all, 13 (16.25%) reported neuropathic pain. Burning sensations in the plantar region, with or without paresthesia, were the presenting symptoms in 10 of them. All patients began a treatment based on amitriptyline, vitamin B6, and physical therapy and all reported improvement within 2 months. Neuropathic pain occurs independently of age, sex or the specific antituberculosis regimen, as long as it includes isoniazid. Stopping or modifying the treatment regimen is not necessary. In our context, in view of the difficulties in identifying slow acetylators, the routine addition of vitamin B6 to all treatment protocols should be discussed.

Risk factors predictive of chronic postsurgical neuropathic pain: The value of the iliac crest bone harvest model

Nerve lesions and secondary hyperalgesia may both be present after surgery, and their relative contributions to chronic postsurgical neuropathic pain (CPSNP) remain unclear. This prospective study explored the roles of these factors in the development of CPSNP after iliac crest bone harvest. CPSNP was defined as pain in the area of hypoesthesia, with a positive Douleur neuropathique 4 questionnaire (DN4) score 3months after iliac crest bone harvest. The location, intensity, and neuropathic characteristics of pain were evaluated in 82 patients who were followed for 6months. Neuropathic characteristics were assessed by clinical examination and DN4 questionnaire. The area of secondary hyperalgesia was evaluated 48h and 1month after surgery. The area of mechanical hypoesthesia, detection, and mechanical pain threshold were evaluated at 48h and at 1 and 3months. Nineteen patients (23%) had CPSNP at 3months. The patients who developed CPSNP had a larger area of secondary hyperalgesia at 48h (88cm2 vs 33cm2; P=.001), higher pain intensity (numerical rating scale 6.7 vs 4.7; P=.02), and higher neuropathic characteristics score on the DN4 questionnaire (4.3 vs 2.3; P=.001). However, neither the area nor the severity of hypoesthesia differed significantly between patients with and without CPSNP. Two independent, additive predictors of CPSNP were identified: area of secondary hyperalgesia (odds ratio 1.02; P=.004) and DN4 score (odds ratio 1.94; P=.001). These findings suggest that both nerve lesions and central sensitization are involved in CPSNP development and could be seen as early warning signs.

Chemotherapy‐Induced Neuropathic Pain and Its Relation to Cluster Symptoms in Breast Cancer Patients Treated with Paclitaxel

The majority of patients with breast cancer receiving chemotherapy report multiple symptoms. Compelling evidence has shown that subgroups of patients can be clustered by the severity of symptoms. Recent studies demonstrate that chemotherapy with such substances as paclitaxel can cause neuropathic pain (CINP) and consequently neural damage. the present study examined the relationship between symptom clusters and CINP among 40 patients with breast cancer. The study was based on 2 sessions conducted before and during paclitaxel treatment. In each session, neuropathic pain was assessed by the DN4 Questionnaire. In the second session, the Lee Fatigue Scale, the General Sleep Disturbance Scale, and the Center for Epidemiological Studies-Depression Scale were also administered, and the worst pain intensity was assessed. Using cluster analysis, 2 symptom clusters were identified on the basis of the severity of the 4 symptoms scores. Patients in the High Cluster (37%) experienced a high level of all symptoms, whereas patients in the Low Cluster (63%) experienced a low level of all symptoms. Twenty patients (50%) were diagnosed with CINP. A subgroup of patients (23%) from the High Cluster was identified as having CINP; 35% were in the Low Cluster and free of CINP. In conclusion, there appears to be a specific subgroup of patients with hypersensitive cancer who need greater attention to symptom management. Early detection of symptoms, together with careful dose selection and assessment of early stages in the development of neuropathic pain, are essential for preventing the simultaneous occurrence of severe multiple symptoms and CINP.

Evaluation of HLA polymorphisms in relation to schizophrenia risk, infectious exposure and cognition

Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-polyneuropathy patients’ family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.

Meningoencephalitis as the cause of dementia and psychosis in chronic late neurosyphilis and Lyme neuroborreliosis

Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-polyneuropathy patients’ family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.

P2RX7 SNP genotypes associated with psychiatric disorders

Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-polyneuropathy patients’ family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.

Is inflammation-induced depression mediated by activation of NMDA receptor signalling or deficient serotoninergic neurotransmission?

Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-polyneuropathy patients’ family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.

Persistent pain after lymph node excision in patients with malignant melanoma is neuropathic

Persistent postoperative pain is a common complication of surgery, including surgical interventions for cancer. So far, there is limited information about the prevalence and clinical characteristics of pain after lymph node biopsy and dissection in patients with malignant melanoma. In this study, a questionnaire was sent out to all surviving patients (n = 402) after surgery for cutaneous malignant melanoma at the Aalborg Hospital Department of Plastic Surgery, Aalborg, Denmark. Of patients responding, sentinel node biopsy (SNB) and/or lymph node dissection (LND) was performed in 175 patients. All patients with pain and a control group were invited to a clinical examination. Altered sensation and pain were significantly more common after LND (82% and 34%, respectively) than after SNB (32% and 14%, respectively). In patients with LND, 12% reported at least moderate pain and 14% impact of pain on quality of life, while in patients with SNB, 3% reported at least moderate pain and 2% pain impact on quality of life. The most important predictor of pain was sensory abnormalities. At the clinical follow-up, 10 out of 12 patients with pain both met the criteria of the recently proposed grading system for probable neuropathic pain and used descriptors on the DN4 questionnaire suggestive of neuropathic pain. Different patterns of sensory profiles were observed in single patients, suggesting heterogeneous sensory processing within single patients. This study suggested that nerve injury was the main underlying mechanism of persistent pain after lymph node excision.

The Neuropathic Components of Chronic Low Back Pain: A Prospective Multicenter Study Using the DN4 Questionnaire

The present study investigated the neuropathic components of chronic low back pain (LBP) in patients with and without lower limb pain using the DN4 questionnaire and confirmed its psychometric properties. Patients (n = 132) from 11 French multidisciplinary pain or rheumatology centers were classified by a first investigator into 4 groups derived from the Quebec Task Force Classification of Spinal Disorders (QTFSD): group 1 (pain restricted to the lumbar area); group 2 (pain radiating proximally); group 3 (pain radiating below the knee without neurologic signs); and group 4 (pain radiating towards the foot in a dermatomal distribution, with neurological signs, corresponding to typical radiculopathy). A second investigator applied the DN4 questionnaire to the lower limb (groups 2 to 4) and lower back. A comparison of groups 1 and 4 confirmed the psychometric properties of DN4 (sensitivity 80%; specificity 92%, for a cutoff of 4/10, similar to other neuropathic conditions). In the lower limb, the proportion of patients with neuropathic pain (NP) was related to the distality of pain radiation (15, 39, and 80% in groups 2, 3 and 4, respectively; P < .0001). In the lower back, the proportion of patients with NP was higher for patients with typical radicular pain compared with the other groups ( P = .006). Thus, typical radiculopathy has similar characteristics as other neuropathic conditions and is confirmed as the commonest neuropathic syndrome in LBP patients. The observation that neuropathic and nociceptive components of LBP vary in the back and lower limb probably accounts for the discrepancies of reported prevalence rates of NP in LBP. As this study was essentially based on a questionnaire, future studies combining standard clinical sensory testing, specific questionnaires, and more objective assessment of the sensory lesion are now required to further investigate the neuropathic component of chronic LBP. Perspective This study confirms the psychometric properties of the DN4 questionnaire to assess neuropathic pain in patients with low back pain. Neuropathic mechanisms largely contribute to pain in the lower limb as compared to the back, but neuropathic pain is not restricted to typical radiculopathy. This may have significant implications for the choice of treatment strategy in these patients.

Prevalence of neuropathic pain among black African patients suffering from common low back pain

To study the prevalence and semiotic characteristics of neuropathic pain in the common low back pain to the Black African subject. This was a prospective cross-sectional survey carried on from April 1 2009 to August 31 2009 in consultations of rheumatology, neurology, and neurosurgery at the University Hospital Yalgado Ouédraogo in Ouagadougou (Burkina Faso). All patients with a low back pain or a common lomboradiculalgie were included. DN4 questionnaire was used for the diagnosis of neuropathic pain. One hundred and seven patients have been recruited during the study period; Sixty-four (59.80%) were female (sex ratio M/F: 0.67). The average age was 34.11 ± 13.46 years of age with extremes of 20 and 79. The average duration of disease was 48.53 months with extremes of 10 days and 50 years. Eighty-seven patients (81.31%) had a disease duration, which was 3 months longer. Sixty-six patients (61.70%) had a predominant lomboradiculalgie; among the remaining 41, low back pain predominated. Average intensity of pain was 62.81 ± 22.43 (on a scale of 100). A sign of Lasèque was present in the 41 (38.30%) patients. Fifty-three (49.5%) patients had a neuropathic pain. The prevalence of neuropathy signs according to the DN4 questionnaire was as follows: burning (n = 37; 34.58%), painful cold (n = 13; 12.15%), electric shocks (n = 31; 38.97%), pins and needles (n = 34; 31.77%), tingling (n = 35; 32.71%), numbness (n = 45; 42.05%), itching (n = 18; 16.82%), touch hypoesthesia (n = 35; 32.71%), pinprick (n = 33; 30.84%), and tactile allodynia (n = 21; 19.62%). Among the studied variables, the presence of a radiculalgy was statistically associated with neuropathic pain. The lomboradiculalgie of the Black African subject associates neuropathic pain observed in half of patients. Treatment must therefore always take account of this association. However, further studies are needed before any definitive conclusion.

Validity and Reliability of the Arabic Adapted Version of the DN4 Questionnaire (Douleur Neuropathique 4 Questions) for Differential Diagnosis of Pain Syndromes with a Neuropathic or Somatic Component

Verbal descriptors of pain can provide a basis for distinguishing neuropathic pain (NP) from pain of non-neuropathic origin. Much research has been undertaken to develop screening tools for this purpose. The DN4 questionnaire (NP in four questions), is one of theses tools, which was developed and validated in French in 2005. The purpose of this work is to provide an Arabic, culturally appropriate, reliable, and valid version of the DN4 interview questionnaire for the diagnosis of NP. A study was conducted consisting of two phases. In the first phase, translation and cultural adaptation of the questionnaire into dialectal Arabic according to international guidelines was accomplished. The final version was reviewed by an expert panel, then tested on a group of 30 patients. The second phase was the validation of the translated version. The analysis of psychometric properties included reliability (internal consistency, inter-rater agreement) and validity (receiver operating characteristics curve analysis and determination of sensitivity, specificity, and positive and negative predictive values). A sample of 170 subjects (129 women, 75%; age: 49.5 ± 12.4 years), 94 (55.3%) with NP and 76 with non-neuropathic pain was enrolled. The questionnaire was reliable (Cronbach's alpha coefficient: 0.63, inter-rater agreement coefficient: 0.96 [0.94-0.97]) and valid for a cut-off value ≥3 points, which was the best value to discriminate between NP and NNP subjects. This study represents the second validation DN4 in a language different from the original after the Spanish adaptation. These results support the high discriminatory value of the DN4 questionnaire for identification of NP.

Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair

BackgroundTransversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing ilioinguinal/iliohypogastric nerve (IHN) block with ultrasound-guided TAP block in patients undergoing inguinal hernia repair. MethodsTwo hundred and seventy-three patients undergoing day-case open inguinal hernia repair with a mesh were randomly allocated to receive either ultrasound-guided TAP block or blind IHN block with levobupivacaine 0.5%, before surgery. Patients were monitored for visual analogue scale (VAS) scores at rest (in the post-anaesthesia care unit, and at 4 and 12 h) and at rest and during movement (at 24, 48 h, 3 and 6 months). Pain at 6 months was also assessed using the DN4 questionnaire for neuropathic pain. ResultsMedian VAS pain scores at rest were lower in the ultrasound-guided TAP group at 4 h (11 vs 15, P=0.04), at 12 h (20 vs 30, P=0.0014), and at 24 h (29 vs 33, P=0.013). Pain after the first 24 h, at 3 and 6 months after surgery, and DN4 scores were similar in both groups (P=NS). The proportion of patients with VAS >40 mm on movement at 6 months was comparable {18.2% [95% CI (12.2–26.1%)] vs 22.4% (15.8–30.6%) in the TAP and IHN groups, respectively, P=0.8}. Postoperative morphine requirements were lower during the first 24 h in the TAP block group (P=0.03). ConclusionsUltrasound-guided TAP block provided better pain control than ‘blind’ IHN block after inguinal hernia repair but did not prevent the occurrence of chronic pain.

Neuropathic pain characteristics in patients from Curitiba (Brazil) with spinal cord injury

This was a descriptive cross-sectional study on patients with spinal cord injuries living in Curitiba, Paraná, Brazil. The aim was to evaluate the pain characteristics among such patients seen at referral care centers for spinal cord injury patients in Curitiba. A total of 109 adults with spinal cord injury in this city were evaluated regarding the presence of pain, especially neuropathic pain. Neuropathic pain was evaluated using the DN4 questionnaire, a universal instrument that has been translated and validated for Portuguese. A visual analog scale (VAS) was used to evaluate the intensity of pain. The prevalence of pain among these 109 patients was 31.2% (34 patients). The nociceptive pain presented was classified as musculoskeletal pain (nine patients), visceral pain (four patients) and mixed pain (one patient), thus totaling 14 patients (12.8%). Another 20 patients (18.3%) showed symptoms of neuropathic pain and fulfilled the criteria for neuropathic pain with scores greater than 4 out 10 in the DN4 questionnaire. Regarding the characteristics of the patients with neuropathic pain, most of them were male, younger than 40 years of age and paraplegic with incomplete lesions. They had become injured from 1 to more than 5 years earlier. The predominant etiology was gunshot wounds, and the intensity of their pain was high, with VAS scores greater than 5. This study partially corroborates other studies conducted on this subject. Studies of this type are important for understanding the profile of these patients, for the purpose of designing strategies for their rehabilitation, with a focus on the appropriate treatment and management of pain.

Characteristics of Chronic Pain and Its Impact on Quality of Life of Patients With HTLV-1-associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP)

we describe the prevalence of chronic pain and their characteristics in 43 consecutive patients presenting with human T-lymphotropic virus Type I (HTLV-1) associated myelopathy (HAM) /tropical spastic paraparesis in Salvador, Brazil. in this cross-sectional study, we included 43 consecutive patients with HAM/TSP from Sarah Salvador Unit of the Rehabilitation, in Bahia, Brazil. They were evaluated from September 2007 to July 2008. We used the following scales: Functional disability scales (EDSS, OSAME e HOFFER); visual analogue scale; Hospital Anxiety and Depression Scale; McGill Pain Questionnaire; DN4 Questionnaire and SF-36 Quality-of-Life Questionnaire. chronic pain was highly prevalent (38 patients---88.4%) in this population. We detected an inverse correlation between duration of the disease and the likelihood of patients to present with chronic pain (P<0.05). Individuals with greater neurologic deficits had much more neuropathic, whereas those with lower motor deficit had mainly the characteristics of nociceptive pain (P<0.05). A positive correlation was observed between the score of the dominant pain or the additional pain, and the number of pain descriptors (P<0.05 for both evaluations). The patients with chronic pain had worst Quality-of-Life scores (P<0.05). chronic pain was significantly associated with a higher likelihood of signs/symptoms of anxiety and depression, reflecting a negative impact of pain on patients´ quality of life.

A prospective study of neuropathic pain induced by thoracotomy: Incidence, clinical description, and diagnosis

This study evaluated prospectively the incidence of neuropathic pain after thoracotomy, described its clinical characteristics, and delineated landmarks for its diagnosis in daily practice. We evaluated clinically painful symptoms and sensory deficits in 54 patients after lateral/posterolateral thoracotomy for broncho-pulmonary carcinoma with standardized surgical and analgesic procedures. At 2months, 49 patients suffered from non malignant thoracic pain, and at 6months 38 patients (loss to follow-up for 7) reported persisting pain. In 35 patients, painful symptoms and sensory deficits could be evaluated using a standardized clinical bedside procedure. According to the grading system proposed by Treede et al. [41], neuropathic pain was considered probable in 21 patients, while use of the DN4 questionnaire concluded that neuropathic pain was probable in 17 patients. The two diagnostic procedures provided similar conclusions in 16 patients. Morphine consumption during the early post-operative period (mean 111.3±30.8mg/day) and pain intensity (VAS: mean 5.71±2.1) were significantly higher in patients suffering from neuropathic pain than in other patients with pain (mean 80±21.4mg/day; VAS: mean 3.9±2.4). The clinical picture in most patients with neuropathic pain included electric shocks and severe multimodal hypoesthesia in the sensory area of 5th/6th intercostal nerves. Thus, our results indicate a minimal incidence of chronic post-thoracotomy pain at 70% and that of neuropathic pain at 29%, this latter being clinically suggested by a combination of certain symptoms and reinforced by the DN4 questionnaire when sensory deficit at scar is present.