Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes
Kevin M. Klifto, PharmD1, Pooja S. Yesantharao, MS1, A. Lee Dellon, M.D., Ph.D.2, Charles Scott Hultman, MD, MBA1 and Scott D. Lifchez, MD, FACS3, (1)Johns Hopkins University School of Medicine, Baltimore, MD, (2)Dellon Institute for Peripheral Nerve Surgery, Towson, MD, (3)Hand Surgery Service, Johns Hopkins Bayview Medical Center, Baltimore, MD
Introduction: Chronic, neuropathic pain after burn injury to hand/upper-extremity is common. However, a paucity of information exists on etiology, management, and outcomes of this pain. This study characterizes patients with neuropathic pain after burn injury to the hand/upper-extremities, to guide risk stratification and treatment strategies.
Materials & Methods: This is an IRB-approved, retrospective investigation at a single institution, from January 1, 2014 through January 1, 2019. Patients 15 years and older admitted to the Burn Unit after hand/upper extremity burns were included in our study. Chronic pain was defined as self-described pain longer than 6 months after burn injury, not including pain due to pre-existing illness/medication. Two subgroups were defined: 1) patients with chronic pain responsive to treatment (response group), and 2) patients with chronic pain unresponsive to treatment (non-response group). Mann-Whitney-U and Fischer's Exact tests were used to compare patient cohorts, and multivariate linear/logistic regression were used to analyze pain outcomes.
Results: Of the patients who met inclusion criteria in the study period, 55 had chronic pain. Of these chronic pain patients, 29 (53%) were in the non-response group and 26 (47%) were in the response group. Overall, 84% of chronic pain patients had surgery. Positive Tinel signs were located at the carpal tunnel (n=9, 16.3%), cubital tunnel (n=6, 10.9%), Guyon's canal (n=2, 4%), and radial tunnel (n=1, 1.8%). Compared to the response group, the non-response group had higher rates of comorbid psychiatric disease (21% versus 12%, p=0.04) and suffered greater mean percentages of total body surface area (%TBSA) burned (30.7% versus 18.5%; p=0.04). The non-response group was also more likely to have had surgery (27% versus 19%; p=0.04), be intubated (18% versus 9%; p=0.02) and be admitted to the ICU for burn management (18% versus 7%; p=0.009). In all chronic pain patients, a greater %TBSA burned conferred significantly greater odds of having non-responsive pain (OR=1.04, p=0.007). Furthermore, having a nerve release procedure during burn management significantly decreased odds of a positive Tinel sign at time of discharge (OR=0.8, p=0.009). Longer hospital lengths of stay (OR=1.02, p=0.04) and need for surgical treatment conferred greater odds of complications (OR=13.52, p=0.004). Finally, in all chronic pain patients, gabapentin (p=0.04) and ascorbic acid (p=0.03) were associated with significant decreases in pain scores on follow-up.
Conclusions: This study characterizes chronic, neuropathic pain after hand/upper-extremity burns. In doing so, this study hopes to help optimize outcomes for chronic, neuropathic pain after hand/upper extremity burns.
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