Total Diz Artroplastisi Sonrası Kronik Ağrıda Mekanizmaya Göre Ağrı Tiplerinin Ağrı Şiddeti ve Yaşam Kalitesi Üzerine Etkileri

Öz

AMAÇ: Total diz artroplastisi (TDA) sonrası kronik ağrı gelişen hastalarda, nosiplastik ağrı da dahil olmak üzere farklı ağrı mekanizmalarının prevalansını (yaygınlığını) belirlemek ve bu mekanizmaların ağrı şiddeti, engellilik, ağrı felaketleştirme ve yaşam kalitesi ile olan ilişkilerini
değerlendirmektir.
GEREÇ ve YÖNTEM: Bu tek merkezli, kesitsel ve gözlemsel çalışma; Kasım 2022 ile Ocak 2023 tarihleri arasında, TDA sonrası kronik ağrısı olan ardışık 200 hastayı dahil etmiştir. TDA sonrası kronik ağrı; primer TDA'dan sonra ameliyat edilen dizde üç aydan fazla süren veya tekrarlayan, çalışma vizitindeki görsel analog skala (VAS) skoru 0'dan büyük olan ve hasta tarafından bildirilen ağrı olarak tanımlanmıştır. Nöropatik ağrı, 'painDETECT' anketi kullanılarak belirlenmiştir. Olası veya muhtemel nöropatik ağrı olarak sınıflandırılmayan hastalarda, kas-iskelet sistemini etkileyen nosiplastik ağrı; Kosek ve ark. tarafından önerilen, klinik öykü ile statik mekanik allodini, dinamik mekanik allodini, termal allodini
ve hiperaljeziye yönelik yatak başı duyusal muayeneyi içeren klinik kriterler ve derecelendirme sistemi kullanılarak tanımlanmıştır. Hastalar, önsel (a priori) bir analitik hiyerarşiye göre baskın bir ağrı fenotipine atanmıştır: nöropatik, nosiplastik ve nosiseptif ağrı. Ağrı şiddeti VAS ile, ağrı felaketleştirme 'Ağrı Felaketleştirme Ölçeği' ile, engellilik 'Western Ontario ve McMaster Üniversiteleri Osteoartrit İndeksi' (WOMAC) ile ve yaşam kalitesi ise '36 Maddelik Kısa Form Sağlık Taraması' (SF-36) ile değerlendirilmiştir.
BULGULAR: Sınıflandırma hiyerarşisine göre; 29 hastada (%14,5) olası nöropatik ağrı, 22 hastada (%11,0) nöropatik ağrı, 35 hastada (%17,5) olası nosiplastik ağrı, 61 hastada (%30,5) muhtemel nosiplastik ağrı ve 53 hastada (%26,5) nosiseptif ağrı saptanmıştır. VAS, WOMAC ve Ağrı Felaketleştirme Ölçeği skorları, ağrı fenotip grupları arasında anlamlı farklılık göstermiştir (tümü için p<0,001). Olası nöropatik, nöropatik ve muhtemel nosiplastik ağrısı olan hastalar; nosiseptif ağrısı olanlara kıyasla genel olarak daha yüksek ağrı şiddeti, engellilik ve ağrı felaketleştirme düzeyleri sergilemiştir. SF-36 fiziksel ve zihinsel bileşen skorları da gruplar arasında anlamlı derecede farklılık göstermiş olup, en düşük skorlar genellikle muhtemel nosiplastik ve olası nöropatik gruplarında gözlemlenmiştir.
SONUÇ: TDA sonrası kronik ağrı mekanistik olarak heterojendir ve mevcut kohortun yaklaşık dörtte üçü olası veya muhtemel nöropatik veya nosiplastik özellikler sergilemiştir. Bu bulgular, TDA öncesi ve sonrasında yapılandırılmış mekanizma temelli değerlendirmeyi desteklemekle birlikte, ameliyat öncesi ağrı fenotiplemesini ve standartlaştırılmış duyusal testleri içeren prospektif çalışmaların gerekliliğini vurgulamaktadır.

Anahtar Kelimeler

• Total diz artroplastisi kronik cerrahi sonrası ağrı
• nosiplastik ağrı
• nöropatik ağrı
• nosiseptif ağrı
• painDETECT
• WOMAC
• yaşam kalitesi

Types of Chronic Pain After Total Knee Arthroplasty and Their Relationship with Pain Intensity, Disability, and Quality of Life

Öz

OBJECTIVE: To determine the prevalence of different pain mechanisms, including nociplastic pain, and to evaluate the associations of these mechanisms with pain intensity, disability, pain catastrophizing, and quality of life in patients with chronic pain after total knee arthroplasty (TKA).

MATERIALS and METHODS: This single-center cross-sectional observational study included 200 consecutive patients with chronic post-TKA pain between November 2022 and January 2023. Chronic post-TKA pain was defined as patient-reported pain in the operated knee persisting or recurring for more than three months after primary TKA, with a visual analog scale (VAS) score greater than 0 at the study visit. Neuropathic pain was identified using the painDETECT questionnaire. In patients not classified as possible or likely neuropathic pain, nociplastic pain affecting the musculoskeletal system was identified using the clinical criteria and grading system proposed by Kosek et al., including clinical history and bedside sensory examination for static mechanical allodynia, dynamic mechanical allodynia, thermal allodynia, and hyperalgesia. Patients were assigned to one dominant pain phenotype according to an a priori analytic hierarchy: neuropathic, nociplastic, and nociceptive pain. Pain intensity was assessed using the VAS, pain catastrophizing by the Pain Catastrophizing Scale, disability by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and quality of life by the 36-item Short Form Health Survey (SF-36).

RESULTS: According to the classification hierarchy, 29 patients (14.5%) had possible neuropathic pain, 22 (11.0%) had neuropathic pain, 35 (17.5%) had possible nociplastic pain, 61 (30.5%) had probable nociplastic pain, and 53 (26.5%) had nociceptive pain. VAS, WOMAC, and Pain Catastrophizing Scale scores differed significantly across pain phenotype groups (all p<0.001). Patients with possible neuropathic, neuropathic, and probable nociplastic pain generally showed greater pain intensity, disability, and pain catastrophizing than those with nociceptive pain. SF-36 physical and mental component scores also differed significantly between groups, with the lowest scores generally observed in the probable nociplastic and possible neuropathic groups.

CONCLUSION: Chronic pain after TKA is mechanistically heterogeneous, and approximately three quarters of the present cohort showed possible or likely neuropathic or nociplastic features. These findings support structured mechanism-based evaluation before and after TKA, while also emphasizing the need for prospective studies including preoperative pain phenotyping and standardized sensory testing.

Anahtar Kelimeler

• Total knee arthroplasty
• chronic post-surgical pain
• nociplastic pain
• neuropathic pain
• nociceptive pain
• painDETECT
• WOMAC
• quality of life

Kaynakça

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