Eur J Anaesthesiol 2019; 36:342–350

ORIGINAL ARTICLE

Genetics and postsurgical neuropathic pain

An ancillary study of a multicentre survey
nin, Be
Pierre Blanc, Emmanuelle Ge line Jesson, Claude Dubray, the EDONIS-gene Investigating

group, Christian Duale

BACKGROUND Neuropathic pain following surgery could
be a useful model for the study of the genetic mechanisms of
peripheral neuropathic pain.
OBJECTIVE The aim of this study was to identify genetic
predictors of persistent postsurgical neuropathic pain.
DESIGN An ancillary study from a prospective cohort.
SETTING Eighteen French university hospitals.
PATIENTS Five hundred and sixty-one patients at risk of
persistent postoperative pain who underwent scheduled
surgery were classified as 159 cases and 402 controls.
INTERVENTION Pre-operative blood sampling for DNA
analysis and questionnaires sent at the third and sixth month
after surgery.
MAIN OUTCOME MEASURES The phenotype was the
report of pain at the site of surgery with a positive response
in the DN4 questionnaire within 6 months after surgery. Out
of a list of 126 candidate genes involved in the initial
processes of peripheral neuropathic pain, a set of 4599
single nucleotide polymorphisms was tested on an Illumina
chip. We carried out the association tests, based on an
additive model, on 4422 single nucleotide polymorphisms.
RESULTS After correcting for type-I error inflation, only one
suggestive association was reached for one single nucleo-
tide polymorphism, the rs2286614, which we had selected
to tag KCNK4. This gene encodes for TRAAK, a two-pore
domain background Kþ channel involved in the modulation of
the primary thermoreceptors of the transient receptor poten-
tial channels family.
CONCLUSION This is the first genetic association study
specifically investigating the occurrence of persistent post-
surgical neuropathic pain. Its results help target future
research to better understand the mechanisms of peripheral
neuropathic pain.
TRIAL REGISTRATION ClinicalTrials.gov (ref. NCT00812734).
Published online 11 March 2019

Introduction
Due to its high prevalence,1 its negative effects on the
quality of life2 and the poor efficacy of the available
medication,3 neuropathic pain needs to be better under-
stood. In particular, studies into its mechanism need to
clarify the nature of the primary lesion of the nervous
system for secondary central sensitisation (spinal or
supraspinal), and supraspinal integration of the nocicep-
tive information.4,5 We are particularly interested in
persistent postsurgical neuropathic pain (nPSPP) as a
model in which individuals are exposed to a standardised
peripheral nerve lesion, but only a few express
neuropathic pain.6 In a previous cohort that underwent
thoracotomy, postsurgical investigation showed that,
although a nerve lesion was frequent (65% with sensory
deficit 2 weeks after surgery), nPSPP was much less
frequent at the same time (11% of mechanical allodynia),
and the report of spontaneous pain 4 months after surgery
(36% of the cohort) was associated with persistence of a
sensory deficit.7 This suggested that in patients under-
going the same surgery for the same disease, the devel-
opment of nPSPP seemed to be influenced by factors
other than the initial nerve aggression, for instance

From the AP-HP, Genetique m

edicale, Hôpital Necker-Enfants Malades (PB), INSERM, UMR1163, Paris (PB), INSERM, UMR1078 (EG), CHU Brest, EFS (EG), Universit
e
de Brest, Brest (EG), HELIXIO, Groupe Hybrigenics, Saint-Beauzire (BJ), CHU Clermont-Ferrand, Centre de Pharmacologie Clinique (C. Dubray, C. Dual
e), INSERM,
CIC1405 & UMR1107 (C. Dubray, C. Dual e), Universit
e Clermont Auvergne, Clermont-Ferrand, France (C. Dubray)
Correspondence to Christian Dual
e, Centre de Pharmacologie Clinique – CIC, CHU de Clermont-Ferrand, 58 rue Montalembert, Clermont-Ferrand 63000, France
Tel: +33 4 73 17 84 18; fax: +33 4 73 17 84 12; e-mail: cduale@chu-clermontferrand.fr

0265-0215 Copyright ß 2019 European Society of Anaesthesiology. All rights reserved. DOI:10.1097/EJA.0000000000000986

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.


differences in the way the nervous system reacts
to aggression.
Among these factors, genetics needs to be explored, as
has already been done in many fields of chronic pain.8–10
Given the relatively small size of the available cohorts,
single nucleotide polymorphism (SNP) arrays provide a
scalable tool to investigate hundreds of candidate genes.
However, although a few human association studies of
posttraumatic peripheral neuropathic pain have been
published,11–13 several association studies of persistent
postsurgical pain (PSPP) have been conducted, without
consideration of the neuropathic aspect. They have so far
failed to provide convergent results.14,15 In a prospective
study of 2009–2010,16 we reported a 20%-rate of occur-
rence of nPSPP within the 6-month period following one
of a range of procedures at risk, and we identified risk
factors such as a history of peripheral neuropathy prior to
surgery, a younger age or psychological factors. We there-
fore conducted an ancillary genetic study from this
cohort. By including a broad panel of procedures favour-
ing persistent pain, we anticipated a reduction in homo-
geneity, but an increase in the ability to detect any
genetic factor of nPSPP, while the precision of the
phenotype was unaffected. Due to the short follow-up
after surgery, we hypothesised that the observed cases of
nPSPP represented an individual susceptibility to
express a phenotype for pain following a nerve lesion,
regardless of later evolution to cure or permanence, thus
minimising the impact of environmental factors on the
pain phenotype. We then selected genes involved in the
function of the peripheral nerve fibre, or in the first spinal
relay of the nociceptive pathway.
Materials and methods
This manuscript adheres to the applicable STREGA
guidelines. The details of the methods of the main
epidemiological study are already published.16 Briefly,
this multicentre French study was approved by the
appropriate Institutional Review Board (CCPPRB
d’Auvergne/CPP Sud-Est VI; Clermont-Ferrand, France
ref. AU657) on 03 July 2006, and written informed
consent was obtained from all participants. The study
was declared to the French General Direction for Health
on 25 July 2006, and was registered at ClinicalTrials.gov
(NCT00812734). In each centre, an anaesthetist coordi-
nated and the anaesthesiology department conducted
data collection. This ancillary genetic study was con-
ducted only in those centres wishing to participate,
and for which the shipment of blood samples was easily
possible. A specific written consent was asked for each
individual genetic study, in addition to the consent for
the main one. All the participants in the genetic substudy
provided signed consent for blood sampling, DNA stor-
age and research-based genetic testing. Those enrolled
were patients over 18 years of age scheduled for one of
nine selected procedures. Breast cancer surgery,
Eur J Anaesthesiol 2019; 36:342–350
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Genetics and postsurgical neuropathic pain 343
thoracotomy and inguinal herniorraphy were already
known to induce nPSPP.6 The ability of other procedures
(sternotomy, caesarean section, laparoscopic cholecystec-
tomy, saphenectomy and knee arthroscopy) to cause
nPSPP was only suspected on the basis of published
data. The general noninclusion criteria were an antici-
pated difficulty in understanding or completing the ques-
tionnaires and being potentially unreachable during the
planned follow-up.
A questionnaire was mailed to participants on the third
and sixth month after surgery, in which he/she was asked
if pain was felt in the operated area. If yes, a set of
questions about the characteristics of the pain were
asked, including the items on the DN4 questionnaire,
a tool validated to screen the neuropathic origin of
chronic pain.17 nPSPP was defined as self-reported pain
in the operated area with at least four out of the 10 items
on the DN4 being positive. A ’case’ was a participant
reporting nPPSP in either the third or sixth month after
surgery and a ’control’ did not report nPPSP at any of the
two measurement points. Patients for whom there was no
complete information about persistent pain at both times
of assessment were not considered further. We assumed
that the proportion of controls likely to develop nPSPP
beyond the fixed period of 6 months was negligible. We
also considered that this 6-month period was the initial
phase of neuropathic pain as a chronic disease, and
therefore was unlikely to be influenced by environmental
factors. Details of patients included in the genetic study
are given in Table 1.
The final sample size was determined by the willingness
of both the centres and the patients to participate. Blood
withdrawal was performed during the hospital stay for the
scheduled surgery, pre-, intra- or postoperatively,
depending on the centre’s preference. The 2  5-ml
EDTA samples were identified by a label with the
individual code for the study and the sampling date.
They could be stored at ambient temperature until
shipment to the Clinical Investigation Centre (Cler-
mont-Ferrand, France). Within 48 h of sampling, the
tubes were placed in a freezer at –808C with continuous
monitoring of the temperature.
The candidate genes setting was designed to address the
early time-window of the neuropathic pain process, spe-
cifically the damage-induced peripheral fibres response
and spinal adaptation.5,18 We ruled out most of the
supraspinal processes, such as integration of chronic pain,
descending controls or mediation for psychological stress,
mood and affective states. These selection criteria led us
to target 126 candidate genes (Table 2 and Supplemental
Digital Content 1, http://links.lww.com/EJA/A196).
For some of these genes, variants were previously associ-
ated with phenotypes related to pain in humans (noci-
ceptive sensitivity or pain expression in normally painful
conditions), either from candidate-gene or genome-wide
 344 Blanc et al.

Table 1 Description of patients from whom DNA was extracted for genetic analysis.

Controls (n U 409) Cases (n U 163) Whole sample (n U 572)

Age (years) 57.7  14.4 53.5  13.0 56.5  14.2
Female sex 181 (44.3) 105 (64.4) 286 (50.0)
Body mass index (kg m2) 25.7  4.6 25.0  4.6 25.5  4.6
Surgery
Breast cancer 50 (12.2) 53 (32.5) 103 (18.0)
Caesarean section 21 (5.1) 14 (8.6) 35 (6.1)
Cholecystectomy 48 (11.7) 3 (1.8) 51 (8.9)
Inguinal herniorraphy (laparoscopic) 32 (7.8) 3 (1.8) 35 (6.1)
Inguinal herniorraphy (open mesh) 56 (13.7) 14 (8.6) 70 (12.2)
Knee arthroscopy 7 (1.7) 6 (3.7) 13 (2.3)
Saphenectomy 38 (9.3) 8 (4.9) 46 (8.0)
Sternotomy 46 (11.2) 5 (3.1) 51 (8.9)
Thoracotomy 111 (27.1) 57 (35) 168 (29.4)

Results are given as mean  SD or number (%).

(GWAS) association studies. For some other genes, subtle
changes in their quantitative expression and function
were linked to multifactorial phenotypes for pain.8,9,19
Also, even though no association has been reported in
humans, a third set of genes potentially involved in the
pathophysiology of neuropathic pain was selected, based
on functional studies in animal models. Other genes,
although not referenced in the literature, were also
considered (GFRA1, GFRA3, CACNA1C) due to their
functional proximity with well-referenced genes.
Finally, we added the gene encoding of the fibroblast
growth factor receptor 1 (FGFR1), as fibrosis entrapments
were reported around peripheral fibres in an nPSPP
context.20–24
Within each gene, the SNPs were targeted either because
they were reported to be functional or because they were
known to capture the genotype of the surrounding SNPs
(tagSNPs). The functional SNPs were prioritised from
the literature based on phenotype association or tran-
scriptional effect. The tagSNPs were representative mar-
kers of a genomic region, having high linkage
disequilibrium with nongenotyped neighbouring SNPs.
Genotyping was conducted with the Illumina Inc. tech-
nologies (San Diego, California, USA) and data analysis
with PLINK v.1.9 software (Broad Institute, Cambridge,
Massachusetts, USA). The procedure to identify and
select the tagSNPs is detailed in the Supplemental
Digital Content 2, http://links.lww.com/EJA/A196. In
total, 4599 tagSNPs were selected, and a custom-array
was designed using Illumina GoldenGate Assay that also
included a selection of 57 ancestry-informative markers
(AIMs) in order to correct for population stratification.25
The final array design included 5329 SNPs; in the output
files, calling results were listed for 4646 SNPs (4599
functional or tag, and 47 AIMS). The complete list is
given in Supplemental Digital Contents 3 and 4, http://
links.lww.com/EJA/A196. The procedure for quality con-
trol is detailed in the Supplemental Digital Content 2,
http://links.lww.com/EJA/A196, as well as the selection of
data (SNPs or individuals) before statistical analysis.
Statistical analysis
Association was tested by using the PLINK association
function or the PLINK logistic when sex was included as
a covariate. An additive model and the odds ratio (OR)
were assumed and a 95% confidence interval was com-
puted by PLINK. The inflation of type-I error was
corrected with Bonferroni’s correction in the first inten-
tion. However, as this correction might have been too
conservative because of linkage disequilibrium and the
resultant non-independence of SNPs, we also used a
more liberal correction, using the effective number of
independent markers (Me) for the adjustment of multiple
testing, as described by Li et al.26; in this model, the limits
for P-values are 3.320.10 –4, 1.660.10 –5 and 3.320.10 –7,
respectively, for ‘suggestive’, ‘significant’ and ‘highly
significant’ associations.
Results
The final analysis involved 561 individuals (159 cases and
402 controls), for which European ancestry had previ-
ously been checked (Supplemental Digital Content 2,
http://links.lww.com/EJA/A196). The genotyping rate in
the remaining samples was 99.94% with no individual
showing genotype missing rate greater than 1.2%. The
results of the association test with the occurrence of
nPSPP, with and without adjustment for sex, are given
in Supplemental Digital Content 5, http://links.lww.com/
EJA/A196 (full results for the remaining 4422 SNPs, for
unadjusted and sex-adjusted analyses). They are also
illustrated by a Quantile to Quantile plot (Fig. 1), which
suggests a high outlier, the rs2286614 SNP, which lies on
chromosome 11 (GRCh37: g.64068310).
On the forward strand, the ancestral allele is C and the
alternative allele is T. The association test showed a
frequency of the alternative allele of 11.0 and 21.9% for
the cases and controls, respectively. The unadjusted OR
was 0.4413 (95% CI: 0.2991 to 0.6511) and the P-value for
the x2 association test was 2.614.10 –5. The sex-adjusted
OR was 0.4354 (95% CI 0.2921 to 0.6491) and the P-value
for the x2 association test was 4.463.10 –5. The association

Eur J Anaesthesiol 2019; 36:342–350

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 Table 2 Gene selection

Encoded protein: definition and function References

Secondary function
Phenotype if mutation report (syndrome) Monogenic /
No. of tested Phenotype in gene-association studies Pain-related Mendelian
Gene SNPs Name Type (MAF) SNP heredity Other
Signal transduction
ACCN1 634 ASIC 1 Acid-sensing ion ch. Fibre: modulation X
ACCN2 7 ASIC 2
ACCN3 1 ASIC 3
ACCN4 9 ASIC 4
KCNC4 11 Kv 3.4; a s/u A-type Kþ ch. X
KCND3 192 Kv 4.3; a s/u
KCNK18 7 TRIK (TRESK) Two-pore-domain background Kþ ch. X
KCNK2 57 TREK 1 X
KCNK4 2 TRAAK
TRPA1 27 TRPA1 Transient rec. potential ch. Fibre: modulation? X X
Enhanced sensitivity to pain
TRPM8 95 TRPM8 Fibre: modulation? X X
TRPV1 35 TRPV1 Fibre: modulation? X X
Altered sensitivity to pain
TRPV2 10 TRPV2 Fibre: modulation? X
TRPV3 39 TRPV3
TRPV4 12 TRPV4
P2RX2 1 P2RX2 Purinergic rec. (ion.) Spinal: synaptic transmission X
P2RX4 14 P2RX4 Spinal: microglial regulation X
P2RX7 34 P2RX7 X X
Conduction
þ
KCNQ5 148 Kv 7.5; a s/u Delayed rectifier K ch. (voltage- Fibre: modulation? X
dependent)
SCN1B 1 Nav; b s/u (IF 1) Naþ ch. (V-dep.) Regulation of a s/u X
SCN2B 10 Nav; b s/u (IF 2) X
SCN3A 30 Nav 1.3; a s/u Supraspinal
SCN3B 19 Nav; b s/u (IF 3) Regulation of a s/u X
SCN4B 14 Nav; b s/u (IF 4)
SCN8A 30 Nav 1.6; a s/u Supraspinal X
SCN9A 37 Nav 1.7; a s/u Complete insensitivity to acute pain X X X
SCN10A 44 Nav 1.8; a s/u X
SCN11A 23 Nav 1.9; a s/u X
Conduction/modulation?
KCNK3 7 TASK 1 Two-pore-domain background Kþ ch. X
KCNA1 3 Kv 1.1; a s/u Delayed rectifier Kþ ch. (V-dep.) X
KCNA2 2 Kv 1.2; a s/u
KCNA3 1 Kv 1.3; a s/u
KCNA5 6 Kv 1.5; a s/u
KCNQ2 19 Kv 7.2; a s/u X
KCNQ3 136 Kv 7.3; a s/u
þ
KCND2 84 Kv 4.2; a s/u A-type K ch. X
KCNJ10 13 KIR 4.1 Inward rectifier-type Kþ ch. Spinal: microglial regulation X
KCNJ3 93 KIR 3.1 Morphine-induced analgesia X
KCNJ6 112 KIR 3.2 X
KCNN1 19 KCa 2.1 Kþ intermediate/small conductance X
Ca2þ-activated ch.
KCNN2 44 KCa 2.2
KCNN3 139 KCa 2.3
TRPC1 9 TRPC1 Transient rec. potential ch. X
Modulation
CNR2 4 CB2 Cannabinoid rec. X
HCN1 28 HCN1 Kþ/Naþ hyperpolarisation-activated X
cyclic nucleotide-gated ch.
MAPK14 14 p38 MAP-kinase MAP-kinase Spinal: microglial regulation X
P2RY12 21 P2RY12 Purinergic rec. (metab.) X

Eur J Anaesthesiol 2019; 36:342–350

Genetics and postsurgical neuropathic pain 345

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 Table 2 (continued )

Encoded protein: definition and function References

Secondary function
Phenotype if mutation report (syndrome) Monogenic /
No. of tested Phenotype in gene-association studies Pain-related Mendelian
Gene SNPs Name Type (MAF) SNP heredity Other
346 Blanc et al.

Sensitisation
BDKRB1 8 B1 Bradykinin rec. X
BDKRB2 39 B2
IL1B 7 IL1B Pro-inflammatory cytokine X
IL1RB 17 IL1RB Cytokine rec. X
IL6 9 IL6 Pro-inflammatory cytokine X
ILR6 15 ILR6 Cytokine rec.
LIF 4 LIF Pro-inflammatory cytokine
TNF 7 TNF a X X
Regeneration
BDNF 9 BDNF Neurotrophin X
CCL2 4 Chemokine ligand 2 Chemokine Spinal: microglial regulation X
CCR2 3 CCR2 CCL2 rec. X
GDNF 20 GDNF Neurotrophin X
GFRA1 111 GFRA1 GDNF (neurotrophin) rec.
GFRA2 2 GFRA2
GFRA3 6 GFRA3
NGF 50 NGF Neurotrophin Congenital insensitivity to pain (HSAN-5) X X X
NGFR 14 p75 (LNGFR) NGF/BDNF (neurotrophins) rec. Spinal: microglial regulation X

Eur J Anaesthesiol 2019; 36:342–350

NTF3 48 NT3 Neurotrophin X
NTRK1 28 Trk A NGF (neurotrophin) rec. Congenital insensitivity to pain (HSAN-4) X X
NTRK2 93 Trk B BDNF (neurotrophin) rec. Spinal: microglial regulation
Peripheral fibrogenesis
FGFR1 14 FGFR1 FGF rec. X
Primary function: at the spinal level
Synaptic transmission
CACNA1A 140 Cav 2.1; a1 s/u X
CACNA1B 39 Cav 2.2; a1 s/u Ca2þ ch. (V-dep.) X
CACNA1C 1 Cav 1.2; a1 s/u
CACNA1E 124 Cav 2.3; a1 s/u X
CACNA1G 23 Cav 3.1; a1 s/u X
CACNA1H 20 Cav 3.2; a1 s/u X
CACNA1I 36 Cav 3.3; a1 s/u X
CACNA2D1 225 Cav a2d s/u (IF 1) X
CACNA2D3 432 Cav a2d s/u (IF 3) Action site of gabapentinoids X X
CACNG2 60 Cav g s/u (IF 2) X X
Antinociception
OPRD1 21 d Opioid rec. Spinal action site of opioid analgesics X X
Modified sensitivity to pain
OPRK1 14 k Spinal action site of opioid analgesics X
OPRM1 82 m Spinal and supraspinal action site of opioid X X
analgesics
Enhanced sensitivity to pain (0.172)
Transduction
PRKCG 14 PKC g Protein kinase Allodynia X X
Impaired sensibility for touch and pain
PRKCZ 16 PKC z Supraspinal X
Sensitisation
GRIN1 4 NR1 EAA rec., NMDA (ion.) X
GRIN2A 183 NR2A X
GRIN2B 262 NR2B X
GRIN2C 2 NR2C X
GRM1 62 mGluR1 EAA rec. (metab.) X
GRM2 0 mGluR2 X
GRM3 58 mGluR3
GRM4 43 mGluR4
GRM5 148 mGluR5 Descending controls X

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 Table 2 (continued )

Encoded protein: definition and function References

Secondary function
Phenotype if mutation report (syndrome) Monogenic /
No. of tested Phenotype in gene-association studies Pain-related Mendelian
Gene SNPs Name Type (MAF) SNP heredity Other
NKCC1 0 NKCC1 Naþ/Kþ/Ca2þ cotransporter X
NKCC2 0 NKCC2
TACR1 74 NK1 Neurokinin rec. X
Microglial regulation
CX3CR1 16 r CX3CL1 Fractalkin rec. X
P2RY6 13 P2RY6 Purinergic rec. (metab.) X
TLR2 8 TLR2 Toll-like rec. X
TLR4 15 TLR4
Primary function: at both peripheral and spinal level
Neuroprotection
GPX1 2 GPX1 Glutathione-peroxydase X
GPX4 2 GPX4
Synaptogenesis
GJA1 5 Connexin 43 Neurotrophin X
GJA4 2 Connexin 37 X
Primary function: other/unknown site
ADRB2 6 b2 Beta-2 adrenergic rec. X X
ANKRD13A 1 ANKRD13A Ankyrin repeat domain Analgesic onset X X
COMT 19 COMT Catechol-O-methyltransferase Catecholamine catabolism / Descending X X
controls
Modified sensitivity to pain (0.25 to 0.5)
FAAH 12 FAAH Fatty acid amide hydrolase Enhanced sensitivity to pain X X
FAM134B 81 FAM134B Family with sequence similarity 134, Progressive loss of all sensations (HSAN-2b) X X
member B
GCH1 21 GCH1 GTP cyclohydrolase Partial analgesia (0.154) X X
IKBKAP 40 IKBKAP Inhibitor of kappa light polypeptide gene Absence of pain (HSAN-3) X X
enhancer in B-cells
MAOA 4 MAO-A Monoamine oxidases Catecholamine catabolism/Descending X
controls
MAOB 2 MAO-B X
MC1R 4 MC1R Melanocortin 1 rec. Partial analgesia (0.02 to 0.045) X X
MPZL2/CD3E 1 MPZL2 or CD3E Myelin protein zero-like / Postoperative pain rating X X
T-cell surface glycoprotein
SHANK2 1 SHANK2 SH3 and multiple ankyrin repeat domains Adapter protein in the postsynaptic density of X X
protein 2 excitatory synapses
SLC6A2 1 SLC6A2 Solute carrier for noradrenaline Postoperative analgesic onset X X
SLC6A4 1 SLC6A4 Solute carrier for serotonin Postoperative pain onset X X
SLC12A1 15 SLC12A1 Na-K-2Cl cotransporters X X
SLC12A2 17 SLC12A2 X X
SPOCK3/ANXA10 1 SPOCK3 or ANXA10 Osteonectin/Annexin Analgesic onset X X
SPTLC1 15 SPTLC1 Serine palmitoyltransferase (long chain s/ Loss of heat and cold pain sensation (HSAN- X X
u) 1a)
WDFY4 1 WDFY4 WD repeat- & Analgesic onset X X
FYVE domain-containing
WNK1 29 WNK1 With-no-lysine kinase 1 Progressive loss of all sensations (HSAN-2a) X X
ZNF429 4 ZNF429 Zinc finger Analgesic onset X X
LOC100286918/ 1 Unknown Postoperative pain onset time X X
LOC729977
LOC400680 0 Analgesic onset X X

This table provides an overview of the preliminary selected 126 genes of interest, with their respective functions and supposed relationship with the phenotype of the study, neuropathic post-surgical persistent pain. The SNPs that
passed the quality control and were tested are listed in Supplementary Table 2, http://links.lww.com/EJA/A196. In the column ‘References/Other’, the underscored ‘X’ signals that the gene has been tested in clinical studies of
either postsurgical persistent pain or neuropathic pain (Supplemental Digital Content 1, http://links.lww.com/EJA/A196 for details). BDNF, brain-derived neurotrophic factor; Ca2þ, calcium; CCL2, chemokine ligand 2; ch., channel;
EAA, excitatory amino-acid; FGF, fibroblast growth factor; GDNF, glial cell-derived neurotrophic factor; GTP, guanosine triphosphate; HSAN, hereditary sensory and autonomic neuropathy; ion., ionotropic; Kþ, potassium; MAF,
þ
minor allele frequency; metab., metabotropic; Na , sodium; NGF, nerve growth factor; NMDA, n-methyl-d-aspartate; rec., receptor; rev., review(s); SNP, single nucleotide polymorphism; s/u, subunit; V-dep., voltage-dependent.

Eur J Anaesthesiol 2019; 36:342–350

Genetics and postsurgical neuropathic pain 347

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 348 Blanc et al.

Fig. 1

Unajusted Gender-adjusted

4
4
Observed (−log10P)

Observed (−log10P)
3
3

2 2

1 1

0 0
0 1 2 3 4 0 1 2 3 4

Expected (−log10P) Expected (−log10P)

Quantile–Quantile plots of the results from the case–control association test for all the 4422 single nucleotide polymorphisms (SNPs) that passed
the standard quality control filters. The two tests were conducted either without (left) or with adjustment for sex (right). The observed –log10(P-
values) on the y-axis are ranked and plotted against the expected –log10(P-values) under the null hypothesis on the x-axis. The diagonal line
represents the null distribution and the grey zone represents the 95% confidence interval of the expected distribution of the test statistics. The high
outlier is the rs2286614 SNP.

was not found significant with the Bonferroni’s correc-
tion. However, by using the Me for the adjustment of
multiple testing, the association was found suggestive
(ratio of effective number of tests over observed number
of tests: 3013/4449 ¼ 0.680).
Discussion
This is the first genetic study of nPSPP. Our results need
to be considered in the context of the available data from
previously published genetic studies of PSPP. Out of 15
studies, 10 reported significant associations, and eight of
these followed procedures likely to induce nPSPP.14,15
The published results were not consistent with those of
the current study, partly because they used a different
strategy of gene selection, and also because their phe-
notype was not selective for the neuropathic aspects of
PSPP. Depending on the study, associations were
reported with genes related to the major histocompati-
bility complex (DQB103:02 haplotype), cytokines
(IL1R2 and the IL10 haplotype A8), a nicotinic acetyl-
choline receptor (CHRNA6), various potassium and cal-
cium ion channels (KCNA1, KCND2, KCNJ3, KCNJ6,
KCNK9, CACNG2), a purinergic receptor (P2RX7), a
nerve growth factor (BDNF) and an opioid receptor
(OPRK1).
We report a suggestive association for a SNP tagging
KCNK4 that deserves some consideration. The encoded
protein, TRAAK, is a two-pore domain (K2P) background
Kþ channel, belonging to a family of mechano-gated and
temperature-gated channels involved in nociception,
including TREK-1. Both TRAAK and TREK-1 are
expressed in the dorsal root ganglion neurons,27,28 and
act as silencers of the primary thermoreceptors of the
TRP family, with which they colocalise. The implication
of TRAAK, interacting with TREK-1, has been demon-
strated in a rat model of neuropathic pain.29 Although
these data are all preclinical, it must be noted that in our
study following thoracotomy,7 surgery-induced neuropa-
thy was regularly characterised by an impairment of warm
and heat sensations, while pain was more linked to an
impairment of warm sensations. Furthermore, some
patients noted an ‘altered sensation of heat’, which was
often described as a burning pain but without a previous
sensation of warmth; this symptom was associated with
the report of nPSPP. However, there is still a large gap
between the currently observed genetic association, and a
clear role of TRAAK in the development of nPSPP; the
nature of the information captured by rs2286614 and the
functional impact of this information, in particular, need
to be clarified.
The main limitation of the current study is that it centres
on multicandidate genes using tagSNPs, as, contrary to a
GWAS, only a selected list of genes was tested, with a
resultant risk of missing relevant genes. Such bias can be
reduced however by a selection closely justified by sci-
entific hypotheses, which was our intention. Neverthe-
less, despite this approach being likely to preserve
statistical power, after correcting the type-I error

Eur J Anaesthesiol 2019; 36:342–350

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

inflation, we found only one suggestive association, but
none reached significance. For this reason, our study
should be repeated. Also, we still have no direct informa-
tion about the gene itself, whether or not its variants are
functional, and whether such a function has a relationship
with the phenotype. More precise information would be
provided by direct DNA sequencing, probably restricted
to a smaller list of candidate genes. Lastly, an additional
bias is the poor match between cases and controls, due to
a liberal recruitment of sample donors in the main epi-
demiological study. As a result, interaction of factors
linked to the cause of surgery cannot be excluded.
Excluding unmatched individuals would have consider-
ably impaired the statistical power, but this could be
acceptable in a restricted repeat study. Finally, although
the report of pre-operative pain is currently known as a
risk factor for PSPP,30 we intentionally did not adjust our
analyses for this factor because it did not predict nPSPP
in our main cohort.16
To conclude, further research is still needed to confirm
the implication of the KCNK4/TRAAK system in the
development of nPSPP, firstly by a closer exploration
of the surrounding genomic region and by replicating the
study in other similar cohorts, and secondly by back-
translation research. Also, a more restricted panel of other
genes of interest, selected on the basis of our results as
well as those of similar studies, is necessary, with partic-
ular attention to gene–gene interactions.
Acknowledgements relating to this article
Assistance with the study: we would like to thank Didier Bouhassira
(AP-HP, Hôpital Ambroise Par e, Boulogne-Billancourt, INSERM
UMR987, Universit e Versailles-Saint-Quentin, France) and Rad-
houane Dallel (Universit e Clermont Auvergne, INSERM
UMR1107, Clermont-Ferrand, France), for supporting the work
on behalf of the INSERM; Frances van Wyk de Vries for correcting
the English manuscript, and the members of the EDONIS-gene
Investigating group
Financial support and sponsorship: this work was supported by
a grant from the French Ministry of Health (Programme Hospitalier
de Recherche Clinique, appel d’offre national 2005 & 2010, PHRCN-
2010-05-04), by the INSERM network of pain research, and by
Pfizer.
Conflicts of interest: CD, as the coordinating investigator, had
support from Pfizer through subsidies paid to the University Hos-
pital of Clermont-Ferrand.
Presentation: none.
EDONIS-gene Investigating group: Pierre Schoeffler, CHU
Clermont-Ferrand Universite Clermont Auvergne; Sylvie Soule-
Sonneville, Centre d’Investigation Clinique, Clermont-Ferrand,
France.
In-hospital investigation and coordination: Monique Belon, CHG
Aurillac (IHR-OM, Saph); Patrick Reynier, CHU Bordeaux (ThT);
Hammou Taheri, CHU Clermont-Ferrand (ThT); Aline Albi-Feld-
zer, Centre Ren e-Huguenin, Saint-Cloud (BKS); Didier Journois,
Hôpital Europeen Georges Pompidou, Paris (CcE, StT, ThT); Bilal
Eur J Anaesthesiol 2019; 36:342–350
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Genetics and postsurgical neuropathic pain 349
El Drayi, CHG Thiers (CcE, IHR-OM, Saph); Bertrand Nougar-
ède, Centre Jean-Perrin, Clermont-Ferrand (BKS); Martine Bon-
nin, CHU Clermont-Ferrand (Ces); Laurent Vallet, CHG Riom
(CCE, IHR-L); Vedat Eljezi, CHU Clermont-Ferrand (StT);
Franck Ruiz, CHG Vichy (CCE, IHR-OM); Emmanuelle Schaack,
Hôpital Ambroise-Par e, Boulogne-Billancourt (Saph); Bertrand
Guillot, CHU Saint-Etienne (ThT); Brigitte Sokolo, CHG Le
Puy en Velay (IHR-OM, Saph); Marie-Noëlle Falewee, Centre
Antoine-Lacassagne, Nice (BKS); Denis Baylot, Clinique Mutua-
liste Chirurgicale Saint-Etienne (KnA); Jean-Marc Vedrinne, Clin-
ique du Tonkin, Villeurbanne (IHR-L); Claudine Chirat, CHG
Montluçon (IHR-L); Lise Brisebrat, CHG Roanne (Ces); Virginie
Cognet, HC Lyon (Ces).
DNA extraction: Vincent Sapin & Isabelle Creveaux, CHU
Clermont-Ferrand, Biochimie M
edicale – Biologie Mol
eculaire,
Universit
e Clermont Auvergne, INSERM, Clermont-Ferrand,
France.
Gene selection: Fr
ed
eric Libert, CHU Clermont-Ferrand, Pharma-
cologie M
edicale, Universit
e Clermont Auvergne, INSERM, Cler-
mont-Ferrand, France.
Clinical data management: Lemlih Ouchchane, CHU Clermont-
Ferrand, Biostatistiques et Information M
edicale, Universit
e Cler-
mont Auvergne, CNRS, Clermont-Ferrand, France.
Institution to which the work must be attributed: CHU Clermont-
Ferrand, Centre de Pharmacologie Clinique (INSERM CIC1405),
63000 Clermont-Ferrand, France.
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