神经电刺激治疗慢性头面部疼痛：综述（十五）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Antony AB,  Mazzola AJ,  Dhaliwal GS, et al. Neurostimulation for the Treatment of Chronic Head and Facial Pain: A Literature Review[J]. Pain Physician, 2019, 22(5):447-477. 本次学习由陈阳住院医师主讲。

In 2006, Slavin et al reviewed prospectively collected data of 30 patients who were trialed with PNS of which 22 had permanent stimulation implant surgery for their neuropathic craniofacial pain. The targets included 4 supraorbital, 3 infraorbital, and 13 occipital nerves, with 2 patients having a combination of either infraorbital and occipital or supraorbital and occipital. Twelve patients (10 occipital and 2 supraorbital) had bilateral stimulation. A total of 16 of the 22 patients reported > 50% pain relief. Specifically, 9 patients underwent implantation for trigeminal neuropathic pain,and 3 of these patients had their stimulators removed each secondary to either improvement of pain, loss of efficacy, or generator site infection. Of the remaining patients, 5 out of the 6 had > 50% pain improvement over a mean 44-month follow-up period. In 2012, Stidd et al presented 3 cases of patients with trigeminal neuropathic pain. The first 2 cases developed chronic facial pain in the ophthalmic and maxillary distribution posttraumatic fractures. After 7- to 10-day successful trials targeting the supraorbital and infraorbital nerves (Fig. 3), both patients underwent implantation with promising results. The third patient suffered from herpes zoster in the ophthalmic distribution. After a successful 7-day trial, the patient was implanted with supraorbital nerve stimulator. Although initial pain relief was substantial, the pain returned secondary to lead migration. After reimplantation, patient continued to report 60% pain decrease. Interestingly, one case report demonstrates optimal stimulation for facial pain using “cross talk” between one peripherally placed lead at the maxillary nerve and one cervical epidural lead. To be further discussed, the branches of the trigeminal nerve remain integral in targeting craniofacial pain. Although evidence for efficacy are limited case series, case reports, and expert consensus guidelines, results have been promising for intractable craniofacial pain.

2006年，Slavin等人回顾性收集了30例接受PNS治疗的患者的数据，其中22例因颅面部神经病理性疼痛而进行了永久电刺激植入手术。靶点包括眶上神经4例，眶下神经3例和枕神经13例，其中2例患者合并眶下和枕神经或眶上和枕神经。12例患者（枕神经10例，眶上2例）进行了双侧刺激。22例患者中有16例疼痛缓解>50％。具体而言，有9位患者因三叉神经性神经病理性疼痛而进行了植入，其中3位患者因疼痛改善、疗效下降或发生IPG部位感染而移除了刺激器。在其余的患者中，6例中有5例在平均44个月的随访期内疼痛改善> 50％。 2012年，Stidd等报道了3例三叉神经病理性疼痛患者。前2例因眶周及下颌区域创伤后骨折出现了慢性面部疼痛。在针对眶上神经和眶下神经成功进行7至10天的测试后（图3），这两名患者均接受了植入手术，并获得了可喜的结果。第三位患者是眼支带状疱疹。经过成功的7天试验后，该患者植入了眶上神经刺激器。尽管最初的疼痛缓解明显，但因电极移位后疼痛复发。再次植入后，患者疼痛减轻了60％。有趣的是，一例病例报道表明，通过在上颌神经周围放置的一根电极与一根颈硬膜外电极之间的“串扰”，可以最佳刺激治疗面部疼痛。虽然需要进一步研究，针对三叉神经分支来治疗颅面痛仍是必须的。尽管有关疗效的证据都是等级有限的病例系列、病例报告和专家共识指南，但对于顽固的颅面部疼痛而言，其结果令人鼓舞。

Supraorbital and Supratrochlear Stimulation

Similarly, supraorbital nerve stimulation has been shown to be effective for treatment of supraorbital neuralgias, as well as other headache disorders such as CMs and CHs. Amin et al published a case series of supraorbital PNS in 2008. The study showed marked reduction in pain scores and opioid consumption after 10 of 16 trialed patients were permanently implanted for supraorbital neuralgias. A small case series by Reed et al found that concordant combined occipital and supraorbital neurostimulation may provide effective therapy for both the pain and motor aura in some patients with hemiplegic migraine. Hann et al had similar promising results in a case series involving 14 patients who underwent dual supraorbital and ONS for CMs. A majority of patients reported marked improvement in headache severity and frequency (71%), resolution of associated neurologic symptoms (50%), and resumption of a normal functional lifestyle (50%). However, 9 of the 14 experienced a postoperative complication that included lead migration (42.8%), lead site allodynia (21.4%), and infection secondary to exposed hardware (14.2%). Five patients (35.7%) needed one or more reoperations due to infection, incomplete coverage from stimulation, or near electrode exposure.

眶上和滑车上神经刺激

同样，眶上神经刺激已被证明可以有效治疗眶上神经痛以及其他头痛疾病，例如CM和CHs。Amin等人于2008年发表了1篇眶上神经痛病例系列。该研究表明，在16名接受测试的眶上神经痛患者中，有10例进行了永久植入，疼痛评分和阿片类药物消耗明显减少。Reed等人的1篇小型病例系列发现，枕神经和眶上神经的联合刺激在某些偏瘫性偏头痛患者中可为疼痛和运动先兆提供有效的治疗方法。 Hann等人在1篇病例系列中获得了类似的结果，该文章收集了14位接受了眶上和枕神经刺激的CM患者。大多数患者头痛的严重程度和频率（71％），相关神经系统症状（50％）和正常的功能生活方式（50％）均有明显改善。然而，这14例中有9例发生了术后并发症，包括电极移位（42.8％），电极处异常性疼痛（21.4％）和继发于暴露的硬件的感染（14.2％）。5名患者（35.7％）由于感染、刺激覆盖不完全或临近电极暴露而需要进行一次或多次手术。