Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1533-x
ORIGINAL ARTICLE
Prevalence of neuropathic pain after radical sacral chordoma resection: an observational cohort study with 10-year follow-up Rapin Phimolsarnti • Saranatra Waikakul
Received: 10 April 2014 / Accepted: 8 August 2014 Ó Springer-Verlag France 2014
Abstract This study was carried out to discover the prevalence, characteristics and severity of neuropathic pain after wide resection of chordoma of the sacrum by the use of posterior approach. Patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990–2002, were followed up as a prospective cohort. Pain assessment was carried out in terms of onset, characteristics, intensity (numerical rating scale), response to pain medication and associated symptoms. The correlation between patients’ biographic data, preoperative neuropathic pain, type and levels of surgery and pain were analyzed. There were 21 patients; 14 male and 7 female patients. Their ages ranged between 29 and 75 years. Subtotal sacrectomy was carried out in 9 patients and total sacrectomy was carried out in 12 patients. All patients survived the operation. Neuropathic pain was found in 11 patients (52.4 %). Male patients and presentation of preoperative neuropathic pain were significantly related to postoperative neuropathic pain. The other factors were not related to the postoperative pain. Recurrent of severe pain with different characteristics after the operation might indicate tumor recurrent. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction. Keywords Sacrectomy Pain Neuropathic pain Amputation
R. Phimolsarnti S. Waikakul Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10110, Thailand S. Waikakul (&) 59/2 Soi Chareonjai Ekamai Road, Bangkok 10110, Thailand e-mail: [email protected]
Introduction Wide resection is still the treatment of choice in primary malignant tumors of the sacrum, especially chordoma [1– 4]. In order to provide a tumor-free margin during resection, a certain amount of soft tissue around the bone must be removed together with the tumor. Accordingly, all nerve roots that traverse the tumor mass have to be resected to prevent tumor contamination and recurrence [5, 6]. Concerning the surgical technique of sacrectomy, most of the authors reported good to acceptable results after posterior approach only [6–9]. On the other hand, some preferred anterior abdominal approach or combined approach for better internal organ protection and tumorfree margins [10]. To minimize postoperative neurological deficit and pain, preservation as many nerve roots as possible should be carried out [5–10]. Most of the authors tried to preserve S2 roots so that the patients might have a chance to walk independently [11]. Contralateral nerve roots should also be preserved when the tumor involves only one side of the sacrum [12]. Furthermore, various techniques have been used to monitor dissection intraoperatively to lessen chances of neural injury [13]. The procedure of tumor resection resulted in direct nerve damage which leads not only to loss of sensory and motor function but also chronic neuropathic pain [14]. When the nerve was cut, there would be several changes both peripherally at the operated site and centrally in the spinal cord and brain and might result in neuropathic pain. Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory system [15]. It manifests diverse clinical features which usually elicits suffering. Severity of pain also varies. Moreover, the course of pain is mostly long. When it exists for a certain period, it impairs patients’ overall health-related quality of life, including
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important aspects of physical and emotional functioning such as mobility and ability to work [14–16]. Consequently, it can cause the patients’ family a social burden. In an effort to prevent or reduce this catastrophic condition after the operation, surgeons try to detect and treat the neuropathic pain as early as possible. Currently, there is inadequate information about neuropathic pain characters, timing, severity and impact of the pain after sacrectomy. This study was performed to discover the prevalence and characteristics of the neuropathic pain after wide resection of sacral chordoma via posterior approach and the result of pain management.
Materials and methods The study was approved by Siriraj Institutional Review Board and the referent number was 428/2551(IEC3). Twenty-one patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990–2002 at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, were followed up as a prospective cohort. As the aim of operation is to provide a tumor-free margin while preserving nerves as many as possible, the patients were classified into two groups according to types of the operation; subtotal sacrectomy and total sacrectomy [6]. Subtotal sacrectomy was defined as when the S1 vertebra could be preserved and resulted in a stable pelvic ring. No bone reconstruction was needed in subtotal sacrectomy. Total sacrectomy was defined as the whole sacrum including S1 being removed with the tumor lesion and resulted in an unstable pelvic ring without any connecting between pelvis and spine. In particular patients, the vertebra of L5 or L4 needed to be removed as the tumor extended up to those vertebras and resulted in marked instability of the axial skeleton of the patients. Bone reconstruction with massive grafting and instrumentation were needed in total sacrectomy. Before the operation, patients’ biographic data and history of the tumor were recorded. Presentation, onset, duration, characteristics, intensity of neuropathic pain in term of numerical rating scale (NRS), pain medication and results of pain management just before the operation were recorded. Criteria of the neuropathic pain diagnosis were as follows: (1) moderate-to-severe pain numerical rating scale (0–10), NRS [ 3 within the involved nerve distribution from physical examination, imaging and intraoperative findings and (2) pain with abnormal sensory that was characterized by burning, electrical shock-like, pins, needles and tingling, hypoesthesia, dysesthesia with negative or positive signs, such as sensory loss, weakness,
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hyperalgesia and allodynia on physical exam at the previously innervated area or in its vicinity [17]. In the postoperative period, opioids and NSAIDs were used to control postoperative pain in all patients. Opioids could be discontinued within the first 2 weeks after the operations. Multidisciplinary approach was carried out for postoperative management. Pain was controlled according to mechanistic approach, either nociceptive or neuropathic pain by our group. The patients had follow-up visits to our tumor clinic every month for 1 year, every 3 months for the following 4 years and, thereafter, every 6 months for the last 5 years. After the operation, details of surgical intervention, ability of the patients to mobilize, postoperative complications, tumor recurrence, presentation of neuropathic pain, onset of pain, characteristics, presentation of phantom sensation and pain intensity at the last follow-up were recorded and analyzed. Factors influencing postoperative neuropathic pain, including patients’ biographic data, preoperative pain, level of neural resection, postoperative complication, tumor recurrence and pain medication were analyzed by the use of SPSS version 16. The continuous data were analyzed by Student’s t test, and the discrete data were analyzed by the use of chi-square test and Fisher’s exact test.
Results There were 21 patients who had chordoma of their sacrums and underwent wide resection via the posterior approach. Table 1 showed patients’ biographic data and pain characteristic of them before the operations. Fourteen patients were male and 7 were female. Their ages ranged between 29 and 75 years. All patients presented with tumor mass ranging from 4 to 20 cm in width, 3 to 20 cm in length and 3 to 20 cm in depth. Most of the patients presented with pain, neurological deficit and tumor mass. Only one patient had only mass at the first visit. Neuropathic pain was observed in eight patients or 38 %, with NRS between 9 and 10 and all had neurological deficit. Their neuropathic pain related to the areas of the neurological deficit. All patients had dysesthesia with both negative and positive signs. One patient usually had more than one type of neuropathic pain. Concerning types of pain, burning was found in seven, electrical shock-like pain was found in four, tingling was found in two and itching was found in only one patient. The patients concerned mostly about electrical shock-like pain as it disturbed their daily activities more than the other types of pain. All patients had on and off pain at the early period. However, during the last 3 months before surgery, they had continuous pain.
Eur J Orthop Surg Traumatol Table 1 Biographic data and pain characteristic of the patients before sacrectomy Group
Subtotal sacrectomy
No.
1
Sex
Age (years)
Level
Pain duration (months)
Presentation
Pain severity at the 1st visit, VAS
M
62
S2.1
12
Neuropathic pain, neurological deficit and mass
10
Types of pain
Pain severity just before the operation (VAS)
Burning
6
Tingling
2
M
66
S2.3
24
Pain and mass
7
–
3
M
56
S2.5
12
Pain and mass
8
–
2
4
M
75
S3.2
12
Pain, neurological deficit and mass
8
–
3
5
M
52
S2.6
24
Neuropathic pain, neurological deficit and mass
9
Burning
3
Neuropathic pain, neurological deficit and mass
9
2 5
Pain and mass Pain, neurological deficit and mass
7 7
– –
Pain and mass
7
–
6
F
41
S2.2
24
2
Itching Burning
3
Electrical shooting Tingling
Total sacrectomy
7 8
F F
69 69
S4.1 S2.4
9
F
29
S3.1
3
1
M
72
S1.7
12
Neuropathic pain, neurological deficit and mass
10
Burning
3 3
6
Pin and needle
2
M
52
S1.3
12
Pain and mass
7
–
2
3
M
46
L5.1
24
Neuropathic pain, neurological deficit and mass
9
Burning
4
Electrical shooting
4
M
72
S1.4
12
Neuropathic pain, neurological deficit and mass
9
Electrical shooting
5
5
M
75
S1.5
6
Neuropathic pain, neurological deficit and mass
9
Burning
6
Neuropathic pain, neurological deficit and mass
10
6
M
75
S1.6
6
7
M
62
L5.2
8
8
M
47
L5.3
2
9
M
52
L5.4
10
F
67
11
F
12
F
Electrical shooting Burning
6
Electrical shooting
Pain, neurological deficit and mass Pain and mass
7
–
3
7
–
3
12
Pain and mass
8
–
2
S1.1
24
Pain, neurological deficit and mass
9
–
3
58
S1.8
20
Pain and mass
7
–
3
58
S1.2
12
Mass
0
–
0
Pain management, including pharmacologic and nonpharmacologic approaches, was given to the patients before the surgery. However, most of the patients responded only moderately to pain management and 5/8 patients still had moderate-to-severe pain. Maximum pain intensity in NRS ranged from 3 to 6 was observed during preoperative period. Amitriptyline was the first drug to be used in these
eight patients; but only two patients could tolerate side effects of the drug. Gabapentin was used in six patients who had poor compliance to amitriptyline and all patients responded rather well to the drug. The doses of antineuropathic drugs were adjusted according to the patients’ requirements, ranging between 45 and 120 mg/day of amitriptyline and 400 and 1,200 mg/day of gabapentin.
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All patients survived the operation; however, all patients had a certain degree of permanent bowel and bladder dysfunction and paralysis of the lower limbs that correlated to the level of scarified nerves. From pathological studies, all had definitive diagnosis as chordoma. Tumor-free margin was found in 14 patients. Inadequate margin was demonstrated in seven patients, 33.3 %, therefore radiotherapy was implemented as an adjuvant therapy in these patients. Table 2 showed results of the operations and pain characteristics after the operations. Subtotal sacrectomy was carried out in nine patients, five male and four female. In five of the nine patients, S2 nerve roots could be preserved. Of the rest 4 patients, S2 nerve roots were sacrificed. However, all patients could walk with the use of orthotics and walking aids. One patient had seroma at the surgical wound and responded well to the second operation to remove the collection. Neuropathic pain was found in 4 patients. Three patients with preoperative neuropathic pain, patient number 1, 5 and 6, continued to have similar pain after the operation. The patient number 3, who had no neuropathic pain before developed electrical shock-like pain at the tenth day after the operation. Pain medication was started immediately. Titrated dose amitriptyline was given to the patient and the patient could tolerate the drug well. The drug was continued to the last visit. NSAIDs and paracetamol were used on and off at particular periods in all patients for pain control. Patient number 2 had phantom sensation without pain at the surgical area. This sensation was not reported after the third year follow-up. All patients had minimal pain at the tenth year follow-up with NRS between 1 and 2. The patient number seven had tumor recurrence at the third year follow-up. Reoperation was carried out successfully, and no tumor recurrent was found at the tenth year follow-up. Total sacrectomy was done in 12 patients. All sacral nerve roots of these patients were sacrificed, and the patients have marked neurological deficit. However, L4 nerve roots could be preserved in these 12 patients. Nevertheless, L5 nerve roots could be preserved only in ten patients. Table 2 showed the results after total sacrectomy. Five patients needed wheelchair for their ambulation and the rest (seven patients) could walk with the use of orthotic and walking aids. Four patients had postoperative complications; one patient had seroma and three patients had local infection and all patients were treated surgically right after the detection. All patients responded well to postoperative treatment, and they had no significant complication during the follow-up. Neuropathic pain was found in seven patients. Five patients, patient number 1, 3, 4, 5 and 6, who had neuropathic pain before the operation continued to have similar pain after the operation. Meanwhile, two patients, patient number 2 and 9 who had no neuropathic pain before the operation developed the pain at the fifth and
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twelfth postoperative days. Both patients had electrical shock-like pain which was their main concern. Pain management was carried out immediately and all patients had improved with lower pain. Gabapentin with titrated dosing was needed in all patients until the tenth year follow-up. NSAIDs and paracetamol were used on and off at particular periods in all patients for pain control. Two patients, patient number 1 and 9, had mechanical pain due to screw fixation at the iliac crests and this pain disappeared after screw revision. All patients had NRS between 1 and 2 during the follow-up. Three patients, patient number 1, 2 and 3, had phantom sensation and pain, Table 2. One patient, patient number 10 had only phantom sensation of her sacrum without pain. This sensation disappeared after the fourth year follow-up. Two patients, patient number 1 and 9 had tumor recurrent at the seventh year follow-up and patient number 1 expired with generalized tumor metastasis. Reoperation was carried out successfully for the patient number 9. In summary, neuropathic pain was found in 11 patients, or 52.4 %, after the surgery, 4 patients in the subtotal sacrectomy group and 7 in the total sacrectomy group, Table 2. The risk factors of postoperative neuropathic were male and presentation of preoperative neuropathic pain, Table 3. On the other hand, duration of preoperative pain, sites and extent of the tumor, levels of tumor resection, preservation of L2 nerve root, postoperative complication, adjunctive radiotherapy and disability of the patients had no significant relationship to neuropathic pain. Regarding patients’ satisfaction, 14 patients felt that they had good results while 5 patients felt that they had fair results. Two patients, one with neuropathic pain and one without neuropathic pain, were not satisfied with the results because of neurological deficit of their lower limbs and their bowel and bladder dysfunction. Three patients who had tumor recurrence experienced relapsing of severe pain. The characteristics of new pain were different from the previous ones. All patients had dull aching and crushing pain.
Discussion Neuropathic pain can be found in patients who have malignancy that involves the nervous system [14]. This type of neuropathic pain is rather severe and usually does not respond well to any modality of treatment. Eight of the patients, or 38 %, had neuropathic pain before the definitive surgical treatment. Despite all kinds of treatment, including non-pharmacologic treatment such as walking aids, posture correction, supports, bed and chair adaptation, and pharmacologic treatment such as opioids, NSAIDs and antineuropathic drugs, 6 of the 8 patients who had
Eur J Orthop Surg Traumatol Table 2 Result of the operation and pain characteristic after sacrectomy Group
Subtotal sacrectomy
No.
L2 root preserved
Ambulation
Postoperative complications
Presentation of pain
1
No
Walkable
Seroma
Neuropathic pain
2
No
Walkable
No
3
No
Walkable
4
No
5
Yes
6
Yes
Walkable
Pain severity postoperation
Types of pain
Phantom sensation
Pain severity during follow-up
6
Burning
No
1
No
7
–
Yes
2
No
Neuropathic pain
6
Electrical shooting
No
1
Walkable
No
No
4
–
No
1
Walkable
No
Neuropathic pain
7
Burning
No
1
No
Neuropathic pain
6
Burning
No
2
Tumor recurrent
Tingling
Itching Electrical shooting Tingling
Total sacrectomy
7
Yes
Walkable
No
No
3
–
No
1
8
Yes
Walkable
No
No
5
–
No
1
9 1
Yes No
Walkable Wheel chair
No Infection
No Neuropathic pain
– Burning
No Yes
1 1
Yes
1
Yes
2
No
1
Burning Electrical shooting
No
1
Burning
No
1
2 10
Pin and needle
Mechanical pain 2
3
4
No
No
No
Walkable
Seroma
Wheel chair
No
Walkable
No
Neuropathic pain
7
Neuropathic pain
6
Neuropathic pain
7
Burning
Yes at third year
Yes at seventh year
Electrical shooting Burning Electrical shooting Burning Electrical shooting Tingling
5
No
Walkable
No
Neuropathic pain
6
6
No
Walkable
No
Neuropathic pain
7
Electrical shooting
7
No
Wheel chair
Infection
No
5
–
No
1
8
No
Wheel chair
Infection
No
2
–
No
2
9
No
Wheel chair
No
Neuropathic pain
Electrical shooting
No
2
10
Mechanical pain
Pin and needle
10
No
Walkable
No
No
8
–
Yes
2
11
No
Walkable
No
No
8
–
No
2
12
No
Walkable
No
No
8
–
No
2
Yes at seventh year
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Eur J Orthop Surg Traumatol Table 3 Factors which have significant relationship to postoperative neuropathic pain Factors
With postoperative neuropathic pain
Without postoperative neuropathic pain
p value
Sex Male
10
4
1
6
Presentation of preoperative neuropathic pain
8
0
No presentation of preoperative neuropathic pain
3
10
Female
0.024
Preoperative condition 0.001
neuropathic pain still had moderate-to-severe pain with a NRS above 3, Table 1. The management of pain could reduce pain intensity of the patients only down to a certain level. As long as the tumor was not removed, the patients still had significant pain. Concerning the frequency of pain, all of the patients had frequency of intermittent pain of 1–10 times a day at preoperative period. Interestingly, when the patients had learned that they had malignancy at their sacrum, all experienced continuous pain. Both rapid growth of the tumor and psychological factors might influence the change of pain frequency. Presentation of neuropathic pain at preoperative period significantly related to postoperative neuropathic pain. Furthermore, neuropathic pain after the surgery was found more in male patients, Table 3. Neuropathic pain has been reported in 15–30 % of the patients whose particular organs such as breast, uterus and colon were resected out because of malignancy [18–21]. This chronic pain was usually confined to the surgical area or nearby. Chronic phantom pain after tooth extraction has also been reported [22]. En block resection of the sacral tumor can be compared with radical resection of breast, uterus and colon. The prevalence of neuropathic pain after the surgery in our patients was 52.4 % or 11 of 21 patients which was higher than the pain after radical resection of the other organs. There were two patients, 9 %; one with subtotal sacrectomy and another one with total sacrectomy who had phantom sensation of their sacrums, Table 2. The sensation subsided during the 3- to 4-year follow-up. Furthermore, phantom pain was reported in 3 patients, patient number 1, 2 and 3, in the total sacrectomy group, Table 2. These findings have not been mentioned from our literature review. Phantom sensation and phantom pain have been reported after tooth extraction, radical resection of breast,
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hysterectomy and colectomy which could be comparable with sacrectomy in our study [19–23]. Extensive damage to sacral plexus during tumor resection could be the main cause of the phantom sensation and pain after the operation [21, 23]. Onset of pain after the surgery in our patients was within the first 2 weeks which was similar to those who have had breast resection, hysterectomy and colectomy [18–21]. All patients, who had neuropathic pain before the surgery, had continuous pain during the postoperative period with similar characteristics, Table 3. These findings were also similar to the reports about neuropathic pain after breast resection, hysterectomy and colectomy [18–21]. Sacrum is innervated by both a visceral nerve and a somatic nerve that are different from the extremities. This pattern of nerve supply might influence pain characteristics and abnormal sensations after the surgery. However, there was no significant difference in pain characteristics of neuropathic pain after sacrectomy when compared with neuropathic pain after the amputation of extremities [21]. Burning pain and electrical shock-like pain were the most common pain characteristics to be reported. Pin and needle pain, itching pain and tingling pain were also found in our patients after the surgery. Electrical shock-like pain was still the worst pain about which our patients concerned, just as it was in the time before the operation. This finding was similar to that of most neuropathic pain, especially phantom limb pain [21]. Levels of tumor resection have no significant effect on presentation of neuropathic pain, even though 7/12 patients, 58.3 %, in the total sacrectomy group had neuropathic pain, while only 4/9 patients, 44.4 %, who underwent subtotal sacrectomy had neuropathic pain. The numbers of our patients might be too small to reveal the relationship between the extent of nerve root resection and the presentation of neuropathic pain. However, phantom pain was found more often in the total sacrectomy group. After the surgery, pain management resulted in better outcomes. Most of the patients had mild pain, NRS \ 3. Bracing and the use of a lumbar corset could help the patients in terms of stability of the lumbosacral mechanism and lessen the chance of having mechanical induced pain [24]. Recurrence of severe pain with differences in pain characteristics might indicate tumor recurrence. Concerning medication for pain control after the surgery, opioids, NSAIDs and antineuropathic drugs were used in all patients to minimize any postoperative pain which might lessen the chance of chronic neuropathic pain. Opioids could be discontinued shortly within the first 2 weeks after the operation. Amitriptyline was the first drug to be used in these patients who had neuropathic pain because of the limitation of the budget of treatment; however, only one patient could tolerate the side effects of
Eur J Orthop Surg Traumatol
the drug. In the remaining 10 patients, gabapentin was used with good results. No significant side effects of the drug were observed in long-term use. All of our patients were rather old and they might thus be prone to have side effects of amitriptyline.
9.
10.
Conclusion
11.
Neuropathic pain was found in 11 patients or 52.4 % of the patients who underwent sacrectomy via the posterior approach. The pain usually happened within 2 week after the operation. Phantom sensation was found in two patients or 9 % and phantom pain was reported in three patients or 14 %. The factors that related to the presentation of postoperative neuropathic pain were male and the presentation of preoperative neuropathic pain. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction. Recurrent severe pain with different pain characteristics after the operation might indicate tumor recurrence. Conflict of interest
None.
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ORIGINAL ARTICLE
Prevalence of neuropathic pain after radical sacral chordoma resection: an observational cohort study with 10-year follow-up Rapin Phimolsarnti • Saranatra Waikakul
Received: 10 April 2014 / Accepted: 8 August 2014 Ó Springer-Verlag France 2014
Abstract This study was carried out to discover the prevalence, characteristics and severity of neuropathic pain after wide resection of chordoma of the sacrum by the use of posterior approach. Patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990–2002, were followed up as a prospective cohort. Pain assessment was carried out in terms of onset, characteristics, intensity (numerical rating scale), response to pain medication and associated symptoms. The correlation between patients’ biographic data, preoperative neuropathic pain, type and levels of surgery and pain were analyzed. There were 21 patients; 14 male and 7 female patients. Their ages ranged between 29 and 75 years. Subtotal sacrectomy was carried out in 9 patients and total sacrectomy was carried out in 12 patients. All patients survived the operation. Neuropathic pain was found in 11 patients (52.4 %). Male patients and presentation of preoperative neuropathic pain were significantly related to postoperative neuropathic pain. The other factors were not related to the postoperative pain. Recurrent of severe pain with different characteristics after the operation might indicate tumor recurrent. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction. Keywords Sacrectomy Pain Neuropathic pain Amputation
R. Phimolsarnti S. Waikakul Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10110, Thailand S. Waikakul (&) 59/2 Soi Chareonjai Ekamai Road, Bangkok 10110, Thailand e-mail: [email protected]
Introduction Wide resection is still the treatment of choice in primary malignant tumors of the sacrum, especially chordoma [1– 4]. In order to provide a tumor-free margin during resection, a certain amount of soft tissue around the bone must be removed together with the tumor. Accordingly, all nerve roots that traverse the tumor mass have to be resected to prevent tumor contamination and recurrence [5, 6]. Concerning the surgical technique of sacrectomy, most of the authors reported good to acceptable results after posterior approach only [6–9]. On the other hand, some preferred anterior abdominal approach or combined approach for better internal organ protection and tumorfree margins [10]. To minimize postoperative neurological deficit and pain, preservation as many nerve roots as possible should be carried out [5–10]. Most of the authors tried to preserve S2 roots so that the patients might have a chance to walk independently [11]. Contralateral nerve roots should also be preserved when the tumor involves only one side of the sacrum [12]. Furthermore, various techniques have been used to monitor dissection intraoperatively to lessen chances of neural injury [13]. The procedure of tumor resection resulted in direct nerve damage which leads not only to loss of sensory and motor function but also chronic neuropathic pain [14]. When the nerve was cut, there would be several changes both peripherally at the operated site and centrally in the spinal cord and brain and might result in neuropathic pain. Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory system [15]. It manifests diverse clinical features which usually elicits suffering. Severity of pain also varies. Moreover, the course of pain is mostly long. When it exists for a certain period, it impairs patients’ overall health-related quality of life, including
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important aspects of physical and emotional functioning such as mobility and ability to work [14–16]. Consequently, it can cause the patients’ family a social burden. In an effort to prevent or reduce this catastrophic condition after the operation, surgeons try to detect and treat the neuropathic pain as early as possible. Currently, there is inadequate information about neuropathic pain characters, timing, severity and impact of the pain after sacrectomy. This study was performed to discover the prevalence and characteristics of the neuropathic pain after wide resection of sacral chordoma via posterior approach and the result of pain management.
Materials and methods The study was approved by Siriraj Institutional Review Board and the referent number was 428/2551(IEC3). Twenty-one patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990–2002 at the Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, were followed up as a prospective cohort. As the aim of operation is to provide a tumor-free margin while preserving nerves as many as possible, the patients were classified into two groups according to types of the operation; subtotal sacrectomy and total sacrectomy [6]. Subtotal sacrectomy was defined as when the S1 vertebra could be preserved and resulted in a stable pelvic ring. No bone reconstruction was needed in subtotal sacrectomy. Total sacrectomy was defined as the whole sacrum including S1 being removed with the tumor lesion and resulted in an unstable pelvic ring without any connecting between pelvis and spine. In particular patients, the vertebra of L5 or L4 needed to be removed as the tumor extended up to those vertebras and resulted in marked instability of the axial skeleton of the patients. Bone reconstruction with massive grafting and instrumentation were needed in total sacrectomy. Before the operation, patients’ biographic data and history of the tumor were recorded. Presentation, onset, duration, characteristics, intensity of neuropathic pain in term of numerical rating scale (NRS), pain medication and results of pain management just before the operation were recorded. Criteria of the neuropathic pain diagnosis were as follows: (1) moderate-to-severe pain numerical rating scale (0–10), NRS [ 3 within the involved nerve distribution from physical examination, imaging and intraoperative findings and (2) pain with abnormal sensory that was characterized by burning, electrical shock-like, pins, needles and tingling, hypoesthesia, dysesthesia with negative or positive signs, such as sensory loss, weakness,
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hyperalgesia and allodynia on physical exam at the previously innervated area or in its vicinity [17]. In the postoperative period, opioids and NSAIDs were used to control postoperative pain in all patients. Opioids could be discontinued within the first 2 weeks after the operations. Multidisciplinary approach was carried out for postoperative management. Pain was controlled according to mechanistic approach, either nociceptive or neuropathic pain by our group. The patients had follow-up visits to our tumor clinic every month for 1 year, every 3 months for the following 4 years and, thereafter, every 6 months for the last 5 years. After the operation, details of surgical intervention, ability of the patients to mobilize, postoperative complications, tumor recurrence, presentation of neuropathic pain, onset of pain, characteristics, presentation of phantom sensation and pain intensity at the last follow-up were recorded and analyzed. Factors influencing postoperative neuropathic pain, including patients’ biographic data, preoperative pain, level of neural resection, postoperative complication, tumor recurrence and pain medication were analyzed by the use of SPSS version 16. The continuous data were analyzed by Student’s t test, and the discrete data were analyzed by the use of chi-square test and Fisher’s exact test.
Results There were 21 patients who had chordoma of their sacrums and underwent wide resection via the posterior approach. Table 1 showed patients’ biographic data and pain characteristic of them before the operations. Fourteen patients were male and 7 were female. Their ages ranged between 29 and 75 years. All patients presented with tumor mass ranging from 4 to 20 cm in width, 3 to 20 cm in length and 3 to 20 cm in depth. Most of the patients presented with pain, neurological deficit and tumor mass. Only one patient had only mass at the first visit. Neuropathic pain was observed in eight patients or 38 %, with NRS between 9 and 10 and all had neurological deficit. Their neuropathic pain related to the areas of the neurological deficit. All patients had dysesthesia with both negative and positive signs. One patient usually had more than one type of neuropathic pain. Concerning types of pain, burning was found in seven, electrical shock-like pain was found in four, tingling was found in two and itching was found in only one patient. The patients concerned mostly about electrical shock-like pain as it disturbed their daily activities more than the other types of pain. All patients had on and off pain at the early period. However, during the last 3 months before surgery, they had continuous pain.
Eur J Orthop Surg Traumatol Table 1 Biographic data and pain characteristic of the patients before sacrectomy Group
Subtotal sacrectomy
No.
1
Sex
Age (years)
Level
Pain duration (months)
Presentation
Pain severity at the 1st visit, VAS
M
62
S2.1
12
Neuropathic pain, neurological deficit and mass
10
Types of pain
Pain severity just before the operation (VAS)
Burning
6
Tingling
2
M
66
S2.3
24
Pain and mass
7
–
3
M
56
S2.5
12
Pain and mass
8
–
2
4
M
75
S3.2
12
Pain, neurological deficit and mass
8
–
3
5
M
52
S2.6
24
Neuropathic pain, neurological deficit and mass
9
Burning
3
Neuropathic pain, neurological deficit and mass
9
2 5
Pain and mass Pain, neurological deficit and mass
7 7
– –
Pain and mass
7
–
6
F
41
S2.2
24
2
Itching Burning
3
Electrical shooting Tingling
Total sacrectomy
7 8
F F
69 69
S4.1 S2.4
9
F
29
S3.1
3
1
M
72
S1.7
12
Neuropathic pain, neurological deficit and mass
10
Burning
3 3
6
Pin and needle
2
M
52
S1.3
12
Pain and mass
7
–
2
3
M
46
L5.1
24
Neuropathic pain, neurological deficit and mass
9
Burning
4
Electrical shooting
4
M
72
S1.4
12
Neuropathic pain, neurological deficit and mass
9
Electrical shooting
5
5
M
75
S1.5
6
Neuropathic pain, neurological deficit and mass
9
Burning
6
Neuropathic pain, neurological deficit and mass
10
6
M
75
S1.6
6
7
M
62
L5.2
8
8
M
47
L5.3
2
9
M
52
L5.4
10
F
67
11
F
12
F
Electrical shooting Burning
6
Electrical shooting
Pain, neurological deficit and mass Pain and mass
7
–
3
7
–
3
12
Pain and mass
8
–
2
S1.1
24
Pain, neurological deficit and mass
9
–
3
58
S1.8
20
Pain and mass
7
–
3
58
S1.2
12
Mass
0
–
0
Pain management, including pharmacologic and nonpharmacologic approaches, was given to the patients before the surgery. However, most of the patients responded only moderately to pain management and 5/8 patients still had moderate-to-severe pain. Maximum pain intensity in NRS ranged from 3 to 6 was observed during preoperative period. Amitriptyline was the first drug to be used in these
eight patients; but only two patients could tolerate side effects of the drug. Gabapentin was used in six patients who had poor compliance to amitriptyline and all patients responded rather well to the drug. The doses of antineuropathic drugs were adjusted according to the patients’ requirements, ranging between 45 and 120 mg/day of amitriptyline and 400 and 1,200 mg/day of gabapentin.
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All patients survived the operation; however, all patients had a certain degree of permanent bowel and bladder dysfunction and paralysis of the lower limbs that correlated to the level of scarified nerves. From pathological studies, all had definitive diagnosis as chordoma. Tumor-free margin was found in 14 patients. Inadequate margin was demonstrated in seven patients, 33.3 %, therefore radiotherapy was implemented as an adjuvant therapy in these patients. Table 2 showed results of the operations and pain characteristics after the operations. Subtotal sacrectomy was carried out in nine patients, five male and four female. In five of the nine patients, S2 nerve roots could be preserved. Of the rest 4 patients, S2 nerve roots were sacrificed. However, all patients could walk with the use of orthotics and walking aids. One patient had seroma at the surgical wound and responded well to the second operation to remove the collection. Neuropathic pain was found in 4 patients. Three patients with preoperative neuropathic pain, patient number 1, 5 and 6, continued to have similar pain after the operation. The patient number 3, who had no neuropathic pain before developed electrical shock-like pain at the tenth day after the operation. Pain medication was started immediately. Titrated dose amitriptyline was given to the patient and the patient could tolerate the drug well. The drug was continued to the last visit. NSAIDs and paracetamol were used on and off at particular periods in all patients for pain control. Patient number 2 had phantom sensation without pain at the surgical area. This sensation was not reported after the third year follow-up. All patients had minimal pain at the tenth year follow-up with NRS between 1 and 2. The patient number seven had tumor recurrence at the third year follow-up. Reoperation was carried out successfully, and no tumor recurrent was found at the tenth year follow-up. Total sacrectomy was done in 12 patients. All sacral nerve roots of these patients were sacrificed, and the patients have marked neurological deficit. However, L4 nerve roots could be preserved in these 12 patients. Nevertheless, L5 nerve roots could be preserved only in ten patients. Table 2 showed the results after total sacrectomy. Five patients needed wheelchair for their ambulation and the rest (seven patients) could walk with the use of orthotic and walking aids. Four patients had postoperative complications; one patient had seroma and three patients had local infection and all patients were treated surgically right after the detection. All patients responded well to postoperative treatment, and they had no significant complication during the follow-up. Neuropathic pain was found in seven patients. Five patients, patient number 1, 3, 4, 5 and 6, who had neuropathic pain before the operation continued to have similar pain after the operation. Meanwhile, two patients, patient number 2 and 9 who had no neuropathic pain before the operation developed the pain at the fifth and
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twelfth postoperative days. Both patients had electrical shock-like pain which was their main concern. Pain management was carried out immediately and all patients had improved with lower pain. Gabapentin with titrated dosing was needed in all patients until the tenth year follow-up. NSAIDs and paracetamol were used on and off at particular periods in all patients for pain control. Two patients, patient number 1 and 9, had mechanical pain due to screw fixation at the iliac crests and this pain disappeared after screw revision. All patients had NRS between 1 and 2 during the follow-up. Three patients, patient number 1, 2 and 3, had phantom sensation and pain, Table 2. One patient, patient number 10 had only phantom sensation of her sacrum without pain. This sensation disappeared after the fourth year follow-up. Two patients, patient number 1 and 9 had tumor recurrent at the seventh year follow-up and patient number 1 expired with generalized tumor metastasis. Reoperation was carried out successfully for the patient number 9. In summary, neuropathic pain was found in 11 patients, or 52.4 %, after the surgery, 4 patients in the subtotal sacrectomy group and 7 in the total sacrectomy group, Table 2. The risk factors of postoperative neuropathic were male and presentation of preoperative neuropathic pain, Table 3. On the other hand, duration of preoperative pain, sites and extent of the tumor, levels of tumor resection, preservation of L2 nerve root, postoperative complication, adjunctive radiotherapy and disability of the patients had no significant relationship to neuropathic pain. Regarding patients’ satisfaction, 14 patients felt that they had good results while 5 patients felt that they had fair results. Two patients, one with neuropathic pain and one without neuropathic pain, were not satisfied with the results because of neurological deficit of their lower limbs and their bowel and bladder dysfunction. Three patients who had tumor recurrence experienced relapsing of severe pain. The characteristics of new pain were different from the previous ones. All patients had dull aching and crushing pain.
Discussion Neuropathic pain can be found in patients who have malignancy that involves the nervous system [14]. This type of neuropathic pain is rather severe and usually does not respond well to any modality of treatment. Eight of the patients, or 38 %, had neuropathic pain before the definitive surgical treatment. Despite all kinds of treatment, including non-pharmacologic treatment such as walking aids, posture correction, supports, bed and chair adaptation, and pharmacologic treatment such as opioids, NSAIDs and antineuropathic drugs, 6 of the 8 patients who had
Eur J Orthop Surg Traumatol Table 2 Result of the operation and pain characteristic after sacrectomy Group
Subtotal sacrectomy
No.
L2 root preserved
Ambulation
Postoperative complications
Presentation of pain
1
No
Walkable
Seroma
Neuropathic pain
2
No
Walkable
No
3
No
Walkable
4
No
5
Yes
6
Yes
Walkable
Pain severity postoperation
Types of pain
Phantom sensation
Pain severity during follow-up
6
Burning
No
1
No
7
–
Yes
2
No
Neuropathic pain
6
Electrical shooting
No
1
Walkable
No
No
4
–
No
1
Walkable
No
Neuropathic pain
7
Burning
No
1
No
Neuropathic pain
6
Burning
No
2
Tumor recurrent
Tingling
Itching Electrical shooting Tingling
Total sacrectomy
7
Yes
Walkable
No
No
3
–
No
1
8
Yes
Walkable
No
No
5
–
No
1
9 1
Yes No
Walkable Wheel chair
No Infection
No Neuropathic pain
– Burning
No Yes
1 1
Yes
1
Yes
2
No
1
Burning Electrical shooting
No
1
Burning
No
1
2 10
Pin and needle
Mechanical pain 2
3
4
No
No
No
Walkable
Seroma
Wheel chair
No
Walkable
No
Neuropathic pain
7
Neuropathic pain
6
Neuropathic pain
7
Burning
Yes at third year
Yes at seventh year
Electrical shooting Burning Electrical shooting Burning Electrical shooting Tingling
5
No
Walkable
No
Neuropathic pain
6
6
No
Walkable
No
Neuropathic pain
7
Electrical shooting
7
No
Wheel chair
Infection
No
5
–
No
1
8
No
Wheel chair
Infection
No
2
–
No
2
9
No
Wheel chair
No
Neuropathic pain
Electrical shooting
No
2
10
Mechanical pain
Pin and needle
10
No
Walkable
No
No
8
–
Yes
2
11
No
Walkable
No
No
8
–
No
2
12
No
Walkable
No
No
8
–
No
2
Yes at seventh year
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Eur J Orthop Surg Traumatol Table 3 Factors which have significant relationship to postoperative neuropathic pain Factors
With postoperative neuropathic pain
Without postoperative neuropathic pain
p value
Sex Male
10
4
1
6
Presentation of preoperative neuropathic pain
8
0
No presentation of preoperative neuropathic pain
3
10
Female
0.024
Preoperative condition 0.001
neuropathic pain still had moderate-to-severe pain with a NRS above 3, Table 1. The management of pain could reduce pain intensity of the patients only down to a certain level. As long as the tumor was not removed, the patients still had significant pain. Concerning the frequency of pain, all of the patients had frequency of intermittent pain of 1–10 times a day at preoperative period. Interestingly, when the patients had learned that they had malignancy at their sacrum, all experienced continuous pain. Both rapid growth of the tumor and psychological factors might influence the change of pain frequency. Presentation of neuropathic pain at preoperative period significantly related to postoperative neuropathic pain. Furthermore, neuropathic pain after the surgery was found more in male patients, Table 3. Neuropathic pain has been reported in 15–30 % of the patients whose particular organs such as breast, uterus and colon were resected out because of malignancy [18–21]. This chronic pain was usually confined to the surgical area or nearby. Chronic phantom pain after tooth extraction has also been reported [22]. En block resection of the sacral tumor can be compared with radical resection of breast, uterus and colon. The prevalence of neuropathic pain after the surgery in our patients was 52.4 % or 11 of 21 patients which was higher than the pain after radical resection of the other organs. There were two patients, 9 %; one with subtotal sacrectomy and another one with total sacrectomy who had phantom sensation of their sacrums, Table 2. The sensation subsided during the 3- to 4-year follow-up. Furthermore, phantom pain was reported in 3 patients, patient number 1, 2 and 3, in the total sacrectomy group, Table 2. These findings have not been mentioned from our literature review. Phantom sensation and phantom pain have been reported after tooth extraction, radical resection of breast,
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hysterectomy and colectomy which could be comparable with sacrectomy in our study [19–23]. Extensive damage to sacral plexus during tumor resection could be the main cause of the phantom sensation and pain after the operation [21, 23]. Onset of pain after the surgery in our patients was within the first 2 weeks which was similar to those who have had breast resection, hysterectomy and colectomy [18–21]. All patients, who had neuropathic pain before the surgery, had continuous pain during the postoperative period with similar characteristics, Table 3. These findings were also similar to the reports about neuropathic pain after breast resection, hysterectomy and colectomy [18–21]. Sacrum is innervated by both a visceral nerve and a somatic nerve that are different from the extremities. This pattern of nerve supply might influence pain characteristics and abnormal sensations after the surgery. However, there was no significant difference in pain characteristics of neuropathic pain after sacrectomy when compared with neuropathic pain after the amputation of extremities [21]. Burning pain and electrical shock-like pain were the most common pain characteristics to be reported. Pin and needle pain, itching pain and tingling pain were also found in our patients after the surgery. Electrical shock-like pain was still the worst pain about which our patients concerned, just as it was in the time before the operation. This finding was similar to that of most neuropathic pain, especially phantom limb pain [21]. Levels of tumor resection have no significant effect on presentation of neuropathic pain, even though 7/12 patients, 58.3 %, in the total sacrectomy group had neuropathic pain, while only 4/9 patients, 44.4 %, who underwent subtotal sacrectomy had neuropathic pain. The numbers of our patients might be too small to reveal the relationship between the extent of nerve root resection and the presentation of neuropathic pain. However, phantom pain was found more often in the total sacrectomy group. After the surgery, pain management resulted in better outcomes. Most of the patients had mild pain, NRS \ 3. Bracing and the use of a lumbar corset could help the patients in terms of stability of the lumbosacral mechanism and lessen the chance of having mechanical induced pain [24]. Recurrence of severe pain with differences in pain characteristics might indicate tumor recurrence. Concerning medication for pain control after the surgery, opioids, NSAIDs and antineuropathic drugs were used in all patients to minimize any postoperative pain which might lessen the chance of chronic neuropathic pain. Opioids could be discontinued shortly within the first 2 weeks after the operation. Amitriptyline was the first drug to be used in these patients who had neuropathic pain because of the limitation of the budget of treatment; however, only one patient could tolerate the side effects of
Eur J Orthop Surg Traumatol
the drug. In the remaining 10 patients, gabapentin was used with good results. No significant side effects of the drug were observed in long-term use. All of our patients were rather old and they might thus be prone to have side effects of amitriptyline.
9.
10.
Conclusion
11.
Neuropathic pain was found in 11 patients or 52.4 % of the patients who underwent sacrectomy via the posterior approach. The pain usually happened within 2 week after the operation. Phantom sensation was found in two patients or 9 % and phantom pain was reported in three patients or 14 %. The factors that related to the presentation of postoperative neuropathic pain were male and the presentation of preoperative neuropathic pain. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction. Recurrent severe pain with different pain characteristics after the operation might indicate tumor recurrence. Conflict of interest
None.
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