神经电刺激治疗慢性头面部疼痛：综述（十六）

 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 2013, Schoenen et al reported on a randomized control sham trial on 59 patients with migraine: 30 in treatment group and 29 in sham. They used transcutaneous neurostimulation with self-adhesive electrodes placed over the skin targeting the supraorbital and supratrochlear nerves bilaterally for 20 minutes a day for 90 days (compliance was approximately 60% for daily stimulation). Interestingly, both groups reported a decrease in migraine days on average by 20% in the first month. However, at month 3, the decrease in monthly migraine days in the treatment group continued to improve to 29.7%, whereas the initial positive response in the sham group was no longer exhibited. Of note, this trial excluded patients who were using antimigraine treatments in the past 3 months and those who had failed at least 3 preventative drug treatments; these refractory patients are the seemingly helpless patients who surgical implantable stimulation regularly attempts to treat.

2013年，Schoenen等报道了一项针对59例偏头痛患者的随机对照假手术试验：治疗组30例，假手术29例。他们使用自粘式电极经皮神经刺激，将其置于皮肤上，刺激双侧眶上及滑车上神经，每天20分钟，共90天（每天刺激的依从性约为60％）。有趣的是，两组均报告第一个月的偏头痛天数平均减少20％。然而，在第3个月，治疗组每月偏头痛天数的减少继续改善至29.7％，而假手术组不再表现出最初的阳性反应。值得注意的是，该试验排除了过去3个月内使用抗偏头痛治疗的患者以及至少3种预防性药物治疗失败的患者。这些难治性患者是看似无助的患者，他们经常尝试通过外科植入式刺激进行治疗。

In 2012, Vaisman et al reported on a retrospective case series of 5 patients presenting with intractable trigeminal autonomic cephalgia, 4 diagnosed with CH. After implantation of neurostimulation device targeting the supraorbital and supratrochlear nerves, patients on average reduced pain from a mean of 8.9 to 1.6 with an average follow-up period of 25 months. Of note, 2 patients required reimplantations (at 1 and 3 years) due to skin erosion with repeat success and 3 patients were completely weaned off of opioids, whereas the other 2 decreased their opioid usage. Supraorbital nerve stimulation, which can cover the supratrochlear region as well with a single lead placement, has positive outcomes in multiple retrospective case series; further research is indicated.

在2012年，Vaisman等人回顾性报道了5例顽固性三叉神经自主性头痛的患者，其中4例被诊断为CH。植入针对眶上神经和滑车上神经的神经刺激装置后，患者疼痛情况从平均8.9减轻到1.6，平均随访期为25个月。值得注意的是，有2例患者因皮肤糜烂而需要重新植入（分别为1年和3年），并获得了成功，另外3例患者完全戒断了阿片类药物，而其他2例减少了阿片类药物的使用。眶上神经刺激可以覆盖上睑上皮区域，而且只需放置1根电极即可，在多个回顾性病例系列中均取得了积极的成果。有待进一步研究。

Auriculotemporal Stimulation

The auriculotemporal nerve is another terminal branch of the trigeminal nerve that has been targeted with PNS. Rodriguez-Lopez et al conducted a small prospective case series in 2015 for 6 patients with TMJ syndrome that did not respond to intraarticular local anesthetic or corticoid steroid injections. With PNS of the auriculotemporal nerve (Fig. 4), the group reported an average of 72% pain relief with the majority of patients discontinuing analgesic medications. One case report followed a patient treated with bilateral auriculotemporal nerve stimulators for CM. Pain intensity decreased from 8-9 to 5 at the 16-month follow-up. In addition, migraine disability assessment went from total disability to mild disability as photophobia and pain were better controlled. The auriculotemporal nerve has been used for targeted PNS to treat migraine headache and jaw pain with promising efficacy.

耳颞刺激

耳颞神经作为三叉神经的另一个末端分支也是PNS的靶点。 Rodriguez-Lopez等人在2015年对6例对关节内局麻药或皮质类固醇激素注射无反应的TMJ综合征患者进行了1项前瞻性病例系列研究。通过对耳颞神经的PNS，该组的平均疼痛缓解率为72％，大多数患者停止使用止痛药。一位接受双侧耳颞神经刺激器治疗CM的患者在16个月的随访中疼痛强度从8-9降至5。此外，由于可以更好地控制畏光和疼痛，偏头痛的失能评估从完全失能变为轻度失能。耳颞神经已作为PNS的靶点有效的治疗偏头痛和下颌痛。