基于中医证型的人工全膝关节置换术后慢性疼痛的危险因素探究及风险预测模型构建

Investigation of Risk Factors for Chronic Post-surgical Pain After Total Knee Arthroplasty and Construction of A Model for Risk Prediction Based on Traditional Chinese Medicine Syndrome Differentiation

【目的】基于中医证型探索人工全膝关节置换(TKA)术后慢性疼痛(CPSP)的危险因素并构建风险预测模型。【方法】以2020年4月30日至2020年10月30日在广州中医药大学第一附属医院行TKA手术治疗的膝骨性关节炎(KOA)患者为研究对象,结合文献资料自制《人工膝关节置换术后慢性疼痛危险因素探究调查表》,通过查询电子病例系统结合电话随访的方式获取患者的基本资料、既往史、个人史、中医证型、CPSP情况、疼痛数字评价量表(NRS)评分等相关信息并进行相关性分析,根据是否发生CPSP分为CPSP组和非CPSP组,采用多因素COX回归分析患者发生CPSP的危险因素,并建立预测模型。【结果】(1)共纳入137例患者,在随访过程中剔除12例,最后纳入125例患者。其中,发生CPSP的患者(CPSP组)44例,占35.20%;未发生CPSP的患者(非CPSP组)81例,占65.80%。(2)单因素COX回归分析显示:饮酒史、体质量指数(BMI)、气滞血瘀证、寒湿痹阻证、肝肾亏虚证、术后当天及次日平均静息疼痛NRS评分、手术当天及次日平均运动疼痛NRS评分、中西医关节康复训练等均是TKA术后发生CPSP的独立影响因素(P<0.05)。(3)进一步进行多因素COX回归分析,结果发现,饮酒史(OR=5.425,95%CI:1.436-20.489)、BMI(OR=3.480,95%CI:1.236-9.795)、气滞血瘀证(OR=4.711,95%CI:1.381-16.070)、寒湿痹阻证(OR=5.197,95%CI:1.192-22.645)、肝肾亏虚证(OR=4.358,95%CI:1.120-16.950)、术后当天及次日平均静息疼痛NRS评分(OR=5.579,95%CI:1.179-26.398)、手术当天及次日平均运动疼痛NRS评分(OR=3.800,95%CI:0.683-21.157)与CPSP呈正相关(P<0.05),中西医关节康复训练(OR=0.146,95%CI:0.046-0.459)与CPSP呈负相关(P<0.05)。【结论】行TKA手术治疗患者的饮酒史、BMI、气滞血瘀证、寒湿痹阻证、肝肾亏虚证、术后当天及次日平均静息疼痛NRS评分、手术当天及次日平均运动疼痛NRS评分是术后发生CPSP的危险因素,中西医关节康复训练是保护性因素。

Objective To investigate the risk factors for chronic post-surgical pain(CPSP) after total knee arthroplasty(TKA)and to construct a model for risk prediction based on traditional Chinese medicine(TCM)syndrome differentiation. Methods Patients with knee osteoarthritis(KOA)treated with TKA surgery at the First Affiliated Hospital of Guangzhou University of Chinese Medicine from April 30,2020 to October 30,2020 were included into the investigation. A self-made Questionnaire for Investigation of Risk Factors for Chronic PostSurgical Pain after Total Knee Arthroplasty was developed after review of the literature data. The patients’ basic information,medical history,personal history,TCM syndrome type,CPSP status,pain numerical rating scale(NRS)score and other relevant information were obtained by retrieving the electronic case system and by telephone follow-up,and the correlation among the above factors was analyzed. The patients were divided into CPSP and non-CPSP groups for the investigation of the risk factors for the occurrence of CPSP using multi-factor COX regression,and then a model for risk prediction was established. Results(1)A total of 137 patients were enrolled into the study, and then 12 cases were excluded during the follow-up. Finally, a total of 125 patients were included. Among them,44(35.20%)patients having CPSP served as the CPSP group,and 81(65.80%)patients having no CPSP served as non-CPSP group.(2)One-way COX regression analysis showed that the independent influencing factors for the occurrence of CPSP after TKA covered the history of alcohol consumption,body mass index(BMI), qi stagnation and blood stasis syndrome, cold-damp obstruction syndrome, liver and kidney insufficiency syndrome,mean resting pain NRS score on the day of surgery and in the next day,mean motion pain NRS score on the day of surgery and in the next day,and joint rehabilitation training by Chinese and western medical methods(P<0.05).(3)Further multi-factor COX regression analysis revealed that CPSP was positively correlated with the history of alcohol consumption(OR = 5.425,95% CI:1.436-20.489),BMI(OR = 3.480,95% CI:1.236-9.795),qi stagnation and blood stasis syndrome(OR = 4.711,95% CI:1.381-16.070),colddamp obstruction syndrome(OR = 5.197,95% CI:1.192-22.645),liver and kidney insufficiency syndrome(OR = 4.358,95% CI:1.120-16.950),mean resting pain NRS score on the day of surgery and in the next day(OR = 5.579,95% CI:1.179-26.398),mean motor pain NRS score on the day of surgery and in the next day(OR = 3.800,95% CI:0.683-21.157),while CPSP was negatively correlated with joint rehabilitation training by Chinese and western medical methods(OR = 0.146,95% CI:0.046-0.459),the differences being significant(P<0.05). Conclusion History of alcohol consumption,BMI,qi stagnation and blood stasis syndrome,colddamp obstruction syndrome,liver and kidney insufficiency syndrome,mean resting pain NRS score on the day of surgery and in the next day,and mean motion pain NRS score on the day of surgery and in the next day contribute to the risk factors,while joint rehabilitation training by Chinese and western medical methods is the protective factor for the development of CPSP after TKA.