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Long-Term Outcomes in the Management of Central Neuropathic Pain Syndromes: A Prospective Observational Cohort Study

  • Michael D. Staudt (a1), Alexander John Clark (a2), Allan S. Gordon (a3), Mary E. Lynch (a2), Pat K. Morley-Forster (a4), Howard Nathan (a5), Catherine Smyth (a5), Larry W. Stitt (a6), Cory Toth (a7), Mark A. Ware (a8) and Dwight E. Moulin (a1)...

Abstract

Background: Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, traumatic spinal cord injury, or multiple sclerosis. These syndromes are distinctly less common than peripheral neuropathic pain, and less is known regarding the underlying pathophysiology, appropriate pharmacotherapy, and long-term outcomes. The objective of this study was to determine the long-term clinical effectiveness of the management of central neuropathic pain relative to peripheral neuropathic pain at tertiary pain centers. Methods: Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified for analysis from a prospective observational cohort study of patients with chronic neuropathic pain recruited from seven Canadian tertiary pain centers. Data regarding patient characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome measure was the composite of a reduction in average pain intensity and pain interference. Secondary outcome measures included assessments of function, mood, quality of life, catastrophizing, and patient satisfaction. Results: At 12-month follow-up, 13.5% (95% confidence interval [CI], 5.6-25.8) of patients with central neuropathic pain and complete data sets (n=52) achieved a ≥30% reduction in pain, whereas 38.5% (95% CI, 25.3-53.0) achieved a reduction of at least 1 point on the Pain Interference Scale. The proportion of patients with central neuropathic pain achieving both these measures, and thus the primary outcome, was 9.6% (95% CI, 3.2-21.0). Patients with peripheral neuropathic pain and complete data sets (n=463) were more likely to achieve this primary outcome at 12 months (25.3% of patients; 95% CI, 21.4-29.5) (p=0.012). Conclusion: Patients with central neuropathic pain syndromes managed in tertiary care centers were less likely to achieve a meaningful improvement in pain and function compared with patients with peripheral neuropathic pain at 12-month follow-up.

Évolution à long terme de l’état de santé de patients pris en charge en raison de douleurs neuropathiques avec atteinte du système nerveux central.Contexte: Les syndromes de douleurs neuropathiques avec atteinte du système nerveux central résultent d’un dommage causé au système nerveux central. Un tel dommage est le plus couramment relié à un AVC, à une lésion traumatique de la moelle épinière ou à la sclérose en plaques (SP). Fait à souligner, de tels syndromes sont nettement moins fréquents que ceux présentant des douleurs neuropathiques du système nerveux périphérique ; ils sont aussi moins connus en ce qui a trait à leur physiopathologie sous-jacente, à un traitement pharmacologique qui leur serait approprié et à l’évolution à long terme des patients atteints. L’objectif de cette étude était donc de déterminer, dans des centres de soins tertiaires spécialisés dans la douleur, l’efficacité clinique à long terme de la prise en charge de ces douleurs neuropathiques avec atteinte du système nerveux central par rapport aux douleurs neuropathiques avec atteinte du système nerveux périphérique. Méthodes: Dans le cadre d’une étude observationnelle de cohorte prospective, on a ainsi identifié à des fins d’analyse des patients chez qui l’on avait diagnostiqué des douleurs neuropathiques chroniques avec atteinte du système nerveux central (n=79) ou du système nerveux périphérique (n=710). À noter que ces patients avaient été recrutés dans sept centres de soins tertiaires canadiens spécialisés dans la douleur. Au début de l’étude et lors d’un suivi effectué 12 mois plus tard, on a alors collecté des données concernant leurs caractéristiques, leur usage d’analgésiques et l’évolution, rapportée par eux-mêmes, de leur état de santé. Le critère d’évaluation principal de l’étude a résulté d’un amalgame établi entre la réduction de l’intensité des douleurs et le degré d’interférence lié à ces dernières. Des critères d’évaluation secondaires ont inclus une évaluation des fonctions, de l’humeur, de la qualité de vie, de la prégnance de pensées catastrophiques et de la satisfaction des patients. Résultats: Au moment du suivi effectuée 12 mois plus tard, 13,5 % (IC 95 % : 5,6-25,8) des patients souffrant de douleurs neuropathiques avec atteinte du système nerveux central et dont les données étaient complètes (n=52) donnaient à voir une réduction de la douleur ≥30 %. Fait à noter, 38,5 % d’entre eux (IC 95 % : 25,3-53,0) ont aussi donné à voir une réduction d’au moins 1 point à l’échelle d’interférence de la douleur (Pain Interference Scale). Cela dit, la proportion de patients souffrant de douleurs neuropathiques avec atteinte du système nerveux central ayant atteint ces scores, et satisfaisant donc à notre principal critère d’évaluation, a été de 9,6 % (IC 95 %: 3,2-21.0). Enfin, les patients souffrant de douleurs neuropathiques avec atteinte au système nerveux périphérique et dont les données étaient complètes (n=463) étaient plus susceptibles de satisfaire au critère principal 12 mois après les débuts de l’étude (25,3 % d’entre eux; IC 95 %: 21,4-29,5; p = 0,012). Conclusions: En somme, les patients atteints d’un syndrome de douleurs neuropathiques avec atteinte du système nerveux central et pris en charge dans un centre de soins tertiaires étaient moins susceptibles, lors d’un suivi effectué 12 mois après les débuts de l’étude, de parvenir à une amélioration notable de leur état (douleurs et fonctions) si on les compare aux patients souffrant de douleurs neuropathiques avec atteinte du système nerveux périphérique.

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Corresponding author

Correspondence to: D. E. Moulin, Department of Clinical Neurological Sciences, Victoria Hospital, 800 Commissioners Rd E, London, ON, Canada, N6A 5W9. Email: dwight.moulin@lhsc.on.ca

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Keywords

Long-Term Outcomes in the Management of Central Neuropathic Pain Syndromes: A Prospective Observational Cohort Study

  • Michael D. Staudt (a1), Alexander John Clark (a2), Allan S. Gordon (a3), Mary E. Lynch (a2), Pat K. Morley-Forster (a4), Howard Nathan (a5), Catherine Smyth (a5), Larry W. Stitt (a6), Cory Toth (a7), Mark A. Ware (a8) and Dwight E. Moulin (a1)...

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