Año 2024 / Volumen 31 / Número 1

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Artículo de la revista EJP

Valor pronóstico de la hiperalgesia mecánica preoperatoria y cualidades del dolor neuropático en dolor postoperatorio tras artroplastia total de rodilla
Prognostic value of preoperative mechanical hyperalgesia and neuropathic pain qualities for postoperative pain after total knee replacement

Rev. Soc. Esp. Dolor. 2024; 31(1): 47-62 / DOI: 10.1002/ejp.2295

A. D. Vigotsky, O. Cong, C. B. Pinto, J. Barroso, J. Perez, K. Kjaer Petersen, L. Arendt-Nielsen, K. D. Hardt, D. Manning, A. V. Apkarian, P. Branco


RESUMEN

Antecedentes: La artroplastia total de rodilla o remplazo total de rodilla (RTR) es el tratamiento de referencia para el dolor crónico de la osteoartritis en etapa final; sin embargo, muchos pacientes refieren dolor postoperatorio crónico tras el RTR. La búsqueda de predictores preoperatorios del dolor postoperatorio crónico tras el RTR se ha estudiado con resultados contradictorios.
Métodos: Este estudio investiga el valor predictivo de los test sensoriales cuantitativos (QST) y PainDETECT para el dolor postoperatorio a los 3, 6 y 12 meses del RTR. Se evaluaron medidas de QST preoperatorias y postoperatorias (3 y 6 meses) en 77 pacientes con OA de rodilla (KOA) y 41 controles sanos, junto con puntuaciones de dolor neuropático en pacientes (PainDETECT). Los parámetros de QST incluyeron el umbral de dolor a la presión (PPT), el umbral de tolerancia al dolor (PTT), la modulación condicionada del dolor (CPM) y la sumación temporal (TS) mediante algometría de manguito, junto con la hiperalgesia mecánica y la sumación temporal a la estimulación repetida por medio de pinchazo.
Resultados: En comparación con los controles sanos, los pacientes con KOA al inicio del estudio mostraron hiperalgesia a la estimulación con pinchazo en la rodilla medial sometida a RTR, y a la presión del manguito en la pantorrilla. Un menor PTT de la algometría de manguito y la hiperalgesia al pinchazo mecánico se asociaron con la intensidad del dolor preoperatorio de la KOA. Además, la hiperalgesia preoperatoria por pinchazo explicó el 25 % de la variación en la intensidad del dolor 12 meses después del RTR, y las puntuaciones preoperatorias de dolor neuropático también explicaron el 30 % y el 20 % de la variación en el dolor postoperatorio a los 6 y 12 meses, respectivamente. La disminución de la hiperalgesia mecánica por pinchazo desde antes de la intervención hasta 3 meses después del RTR se asoció con un menor dolor postoperatorio a los 12 meses de seguimiento del RTR.
Conclusiones: Nuestros hallazgos sugieren que la hiperalgesia por pinchazo preoperatorio y los síntomas de dolor de tipo neuropático muestran un valor predictivo para el desarrollo de dolor crónico posterior a RTR.
Declaración de importancia: Los hallazgos de este estudio tienen implicaciones significativas para el tratamiento del dolor crónico en pacientes con osteoartritis de rodilla, en particular los que se someten a una artroplastia total de rodilla (RTR). La hiperalgesia mecánica y las características similares al dolor neuropático predicen el dolor postoperatorio un año después del RTR, lo que subraya la importancia de comprender los fenotipos del dolor en la osteoartritis para seleccionar estrategias adecuadas de tratamiento del dolor. La normalización de la hiperalgesia después de la cirugía se correlaciona con mejores resultados a largo plazo, lo que subraya aún más el potencial terapéutico de abordar los mecanismos anormales de procesamiento del dolor antes y después del RTR.



ABSTRACT

Background: Total knee replacement (TKR) is the gold standard treatment for endstage chronic osteoarthritis pain, yet many patients report chronic postoperative pain after TKR. The search for preoperative predictors for chronic postoperative pain following TKR has been studied with inconsistent findings.
Methods: This study investigates the predictive value of quantitative sensory testing (QST) and PainDETECT for postoperative pain 3, 6 and 12 months post-TKR. We assessed preoperative and postoperative (3 and 6 months) QST measures in 77 patients with knee OA (KOA) and 41 healthy controls, along with neuropathic pain scores in patients (PainDETECT). QST parameters included pressure pain pressure threshold (PPT), pain tolerance threshold (PTT), conditioned pain modulation (CPM) and temporal summation (TS) using cuff algometry, alongside mechanical hyperalgesia and temporal summation to repeated pinprick stimulation.
Results: Compared to healthy controls, KOA patients at baseline demonstrated hyperalgesia to pinprick stimulation at the medial knee undergoing TKR, and cuff pressure at the calf. Lower cuff algometry PTT and mechanical pinprick hyperalgesia were associated with preoperative KOA pain intensity. Moreover, preoperative pinprick pain hyperalgesia explained 25 % of variance in pain intensity 12 months post-TKR and preoperative neuropathic pain scores also captured 30 % and 20 % of the variance in postoperative pain at 6 and 12 months respectively. A decrease in mechanical pinprick hyperalgesia from before surgery to 3 months after TKR was associated with lower postoperative pain at the 12 months post-TKR follow-up.
Conclusion: Our findings suggest that preoperative pinprick hyperalgesia and neuropathic-like pain symptoms show predictive value for the development of chronic post-TKR pain.
Significance Statement: This study’s findings hold significant implications for chronic pain management in knee osteoarthritis patients, particularly those undergoing total knee replacement surgery (TKR). Mechanical hyperalgesia and neuropathic pain-like characteristics predict postoperative pain 1 year after TKR, emphasizing the importance of understanding pain phenotypes in OA for selecting appropriate pain management strategies. The normalization of hyperalgesia after surgery correlates with better long-term outcomes, further highlighting the therapeutic potential of addressing abnormal pain processing mechanisms pre- and post-TKR.





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Vigotsky A, Cong O, Pinto C, Barroso J, Perez J, Kjaer Petersen K, et all. Valor pronóstico de la hiperalgesia mecánica preoperatoria y cualidades del dolor neuropático en dolor postoperatorio tras artroplastia total de rodilla . Rev Soc Esp Dolor 2024; 31(1): 47-62 / DOI: 101002/ejp2295


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