Prospective study of neuropathic pain after definitive surgery for extremity osteosarcoma in a pediatric population

Abstract

Background Neuropathic pain (NP) after definitive surgery for extremity osteosarcoma (OS) has not been previously characterized. This study prospectively investigates the incidence, duration, and treatment of NP in limb sparing surgery and amputation groups. Procedure In patients treated for OS on a chemotherapy and definitive surgery (limb sparing vs. amputation) protocol (OS08), we prospectively collected the following data: (i) demographical data (age, sex, race); (ii) NP time of onset and duration; and (iii) dose (starting, maximum) and duration of gabapentin, amitriptyline, and methadone treatment. Results Thirty-seven patients underwent 38 definitive surgeries: limb sparing (26, 68.4%) or amputations (12, 31.6%). Localization included lower extremity (30, 81%), upper extremity (6, 16%), or pelvis (1, 3%). Thirty patients (81%) developed NP and 26 of them required NP-specific medications (87.7%). The mean [standard deviation (SD)] duration of NP was 6.5 weeks (7.2) (median 4.4, range 0.3–29.9). All 26 patients (27 surgeries) treated with NP medications received gabapentin, either as single therapy (65.4%) (17 patients, 18 surgeries), dual therapy with gabapentin and amitriptyline (five patients), or triple therapy with gabapentin, amitriptyline, and methadone (four patients). The mean starting (maximum) doses of gabapentin, amitriptyline, and methadone (mg/kg/day) were 20.2 (43.8), 0.5 (0.7), and 0.3 (0.3), respectively. The incidence and duration of NP, duration of treatment, and NP-specific dose regimens were similar in the limb sparing and the amputation groups. Conclusions NP after definitive surgery for OS is frequently encountered, can persist for a significant time, and NP outcomes are similar in limb sparing and amputation groups.

Role of Amputation in Improving Mobility, Pain Outcomes, and Emotional and Psychological Well-Being in Children With Metastatic Osteosarcoma

“…Anghelescu et al found that the mean duration of postoperative neuropathic pain was 6.5 weeks after surgery for patients with extremity osteosarcoma, which could explain continued opioid use over time in our patients. 14 Our study did not investigate phantom limb pain; nevertheless, a previous study showed great improvement in outcomes of amputees with phantom limb pain, with little recurrence after 1 year of surgery. 15 The role of amputation in pediatric patients with metastatic osteosarcoma in our study correlates well with positive findings from several studies on adults with osteosarcoma and/or other bone tumors.…”

Prospective randomized trial of interventions for vincristine‐related neuropathic pain

“…Although this somewhat‐conservative strategy reflected the most common clinical practice, there are reports of substantially higher doses of gabapentin, at 45 mg/kg per day in a case report (n = 2) and 43.8 mg/kg per day in a prospective study of postsurgical neuropathic pain after surgery for osteosarcoma treatment (n = 30) (Table 3). 24,25 Although our study design indicated a gabapentin regimen of 20 mg/kg per day, the actual doses taken were lower (mean 18 mg/kg per day), most likely due to missed doses secondary to some combination of lack of adherence, concurrent nausea/vomiting related to other chemotherapy, or nil per os status related to anticipated anesthetics for oncological or surgical procedures. Comparisons of regimens for NP treatment with gabapentin in adults and children 23 support the concept that underdosing strategies are common in pediatric populations, whereas the standard recommendation for adults is to escalate doses up to 300 mg/day or 50‐70 mg/kg per day.…”

Neuropathic pain in children: Steps towards improved recognition and management

“…burning or hot, electric shocks or shooting, pricking or pins and needles) suggest possible neuropathic pain [4]. Similar sensations have been reported by children 6 years and older, including burning, tingling, numbness, itching, pins and needles [20][21][22], but the reporting and validity of different descriptors is also dependent on each individual's verbal repertoire [23]. The McGill Short-Form questionnaire, which includes sensory and affective adjectives, has identified group differences in adults with neuropathic and non-neuropathic pain [9], and tender, sharp, burning, stabbing and shooting were frequently reported by 10À17 year old adolescents with neuropathic pain (Fig.…”