The added value of bedside examination and screening QST to improve neuropathic pain identification in patients with chronic pain

Hans Timmerman,1 Oliver HG Wilder-Smith,1,2 Monique AH Steegers,3 Kris CP Vissers,3 André P Wolff4 1Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; 2Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark; 3Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; 4Department of Anesthesiology, Pain Center, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands Background: The assessment of a neuropathic pain component (NePC) to establish the neurological criteria required to comply with the clinical description is based on history taking, clinical examination, and quantitative sensory testing (QST) and includes bedside examination (BSE). The objective of this study was to assess the potential association between the clinically diagnosed presence or absence of an NePC, BSE, and the Nijmegen–Aalborg screening QST (NASQ) paradigm in patients with chronic (≥3 months) low back and leg pain or with neck shoulder arm pain or in patients with chronic pain due to suspected peripheral nerve damage.Methods: A total of 291 patients participated in the study. Pain (absence or presence of neuropathic pain) was assessed independently by two physicians and compared with BSE (measurements of touch [finger, brush], heat, cold, pricking [safety pin, von Frey hair], and vibration). The NASQ paradigm (pressure algometry, electrical pain thresholds, and conditioned pain modulation) was assessed in 58 patients to generate new insights.Results: BSE revealed a low association of differences between patients with either absent or present NePC: heat, cold, and pricking sensations with a von Frey hair were statistically significantly less common in patients with present NePC. NASQ did not reveal any differences between patients with and without an NePC.Conclusion: Currently, a standardized BSE appears to be more useful than the NASQ paradigm when distinguishing between patients with and without an NePC. Keywords: quantitative sensory testing, NASQ, Nijmegen–Aalborg screening QST, clinical assessment, diagnostic accurac

Sublingual sufentanil for postoperative pain relief: first clinical experiences

Fleur Meijer,1 Petra Cornelissen,2 Corina Sie,3 Michel Wagemans,4 Anja Mars,5 Tiny Hobma,1,6 Marieke Niesters,1 Albert Dahan,1 J Seppe Koopman,6 Monique AH Steegers2 1Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands; 2Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; 3Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands; 4Department of Anesthesiology and Pain Medicine, Reinier de Graaf Hospital, Delft, the Netherlands; 5Department of Anesthesiology and Acute Pain Service, Alrijne Hospital, Leiderdorp, the Netherlands; 6Department of Anesthesiology, Maasstad Hospital, Rotterdam, the Netherlands Background: The sublingual sufentanil tablet system (SSTS) is a novel hand-held patient-controlled analgesia device developed for treatment of moderate-to-severe postoperative pain. Here we present the first results of its clinical use. Methods: Adult patients undergoing major surgery in five hospitals in the Netherlands received the SSTS for postoperative pain relief as part of multimodal pain management that further included paracetamol and a nonsteroidal anti-inflammatory drug (NSAID). The following variables were collected: postoperative pain scores using the 11-point numerical rating score (NRS) at rest, number of tablets used, occurrence of nausea, and patient satisfaction scores. Results: We included 280 patients in the study; the majority underwent laparoscopic abdominal (49%) or orthopedic (knee replacement) surgery (34%). The median NRS was 3.5 (interquartile range 2.3–4.0) on the day of surgery, 3.3 (2.3–4.0) on the first postoperative day, and 2.8 (2.0–4.0) on the second postoperative day; pain scores did not differ between surgery types. Mean number of tablets used was 19 (range 0–86). Nausea occurred in 34% of patients, more often in women (45% vs 19%). Overall satisfaction was high in 73% of patients. Satisfaction was correlated with pain relief (p<0.001) and inversely correlated with occurrence of nausea (p=0.01). Discussion: In this data set obtained under real-life conditions we show that the SSTS effectively managed postoperative pain in abdominal and orthopedic surgeries. Future studies should determine patient populations that benefit most from the SSTS, assess the added values versus intravenous patient-controlled analgesia, and determine the pharmacoeconomics of the system. Keywords: acute pain, opioid, postoperative pain, sufentanil, sublingual formulatio