神经电刺激治疗慢性头面部疼痛：综述（二十三）

 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 addition to craniofacial pain, stimulation of the SPG has been well described for CH. In 2013, Schoenen et al conducted a multicenter trial (Pathway CH-1) comparing on-demand ipsilateral Autonomic Technologies Inc. SPG microstimulation at HF (average 120 Hz) and subthreshold amplitudes versus sham stimulation for CH attacks. The 28 patients were implanted targeting the SPG (Fig. 9) and were instructed to use the handheld remote controller to activate stimulation for 15 minutes as needed when they experienced a moderate pain intensity headache. The devices were programmed to at different times randomly deliver each of 3 types of stimulation: full stimulation, subperception stimulation, or sham stimulation. Out of the 566 total CH attacks treated, 67.1% of those that received full stimulation achieved pain relief at 15 minutes compared to just 7.5% of those that received sham treatment. This study demonstrated statistically significant results in favor of SPG stimulation. In 2016, an open label follow-up study of the original Pathway CH-1 results showed 45% of 33 patients were acute responders as they demonstrated at least a 50% decrease of pain in at least half of their attacks through the 24-month review period. Some 35% of the 33 patients reported a 50% reduction in attack frequency, 61% were therapeutic responders as they had either an acute pain relief or frequency response, and 30% of the patients were found to have a remission period lasting at least one month. The authors conclude that self-administered SPG stimulation is effective in the acute period, reduces attack frequency, and may induce a state of remission thereafter. Similarly in 2018, Barloese et al reported on another open-label prospective study for 12 months in which 85 patients (78 with chronic CH and 7 with episodic CH) were implanted with a SPG microstimulator. A total of 32% of patients were acute responders meaning they had effective therapy in at least half of their attacks. These active responders were able to treat 86% of their attacks. Some 65% of all subjects were therapeutic responders in that they had 50% reduction in attack frequency or achieved effective therapy in at least half of all attacks. Quality of life scores were significantly improved at 12 months compared to baseline.

除颅面疼痛外SPG刺激用于CH。2013年，Schoenen等人进行了一项多中心试验（Pathway CH-1），比较了按需的同侧Autonomic Technologies Inc设备的作用。在CH发作时，比较SPG微刺激（HF（平均120 Hz）和亚阈值振幅）与假刺激。28位患者植入了靶向SPG的装置（图9），并嘱托他们在经历中度头痛时根据需要使用手持遥控器激活刺激15分钟。该设备被编程为在不同的时间随机传递三种刺激类型中的一种：完全刺激、知觉域下刺激或假刺激。在总共566次CH发作的治疗中，接受完全刺激的患者中有67.1％的患者在15分钟后达到了缓解疼痛的效果，而接受假治疗的患者中仅有7.5％的患者得到了缓解。这项研究表明SPG刺激非常有效。2016年，一项针对Pathway CH-1结果的开放标签随访研究表明，33名患者中有45％为急性反应者，在24个月的随访中至少一半发作中疼痛至少减轻了50％。33名患者中约35％的患者发作频率降低了50％，61％的患者为治疗反应者，因为他们既有急性疼痛缓解又有频率降低，并且30％的患者缓解期至少持续1个月。作者得出结论，自我管理的SPG刺激在急性期是有效的，减少了发作频率，并且此后可能诱发缓解状态。同样在2018年，Barloese等人报告了另一项开放标签的前瞻性研究，为期12个月，向85例患者（78例慢性CH和7例阵发性CH）植入了SPG微刺激器。共有32％的患者为急性反应者，这意味着他们至少有一半的发作得到了有效的治疗。这些有效反应者能够治疗其86％的发作。在所有受试者中，约有65％是治疗性反应者，他们的发作频率降低了50％，或者在至少一半的发作中获得了有效的治疗。与基线相比，在12个月时生活质量得分显着提高。

In 2013, Schytz et al reported on a double-blind cross-over study in which 6 patients with CH who were previously implanted with a SPG neurotransmitter were randomly allocated to receive HF (80-120 Hz) or low frequency (LF, 5 Hz) stimulation for 3 minutes on 2 separate days. Three patients reported cluster-like attacks during or within 30 minutes of LF SPG stimulation, and each of these attacks were successfully treated with HF stimulation. One patient reported a clusterlike attack within 3 minutes of HF SPG stimulation, which was also successfully treated with further HF stimulation. This suggests that efferent parasympathetic outflow from the SPG can trigger CHs that may be better controlled using HF stimulation. HF stimulation of the SPG for refractory CH is now recognized by expert consensus groups and guidelines have been published, becoming commercially available and approved in Europe. It appears that long-term powered prospective studies may be feasible considering that efficacy has been shown with this therapy. Studies are ongoing to evaluate the role in acute and preventive treatment of migraine headaches with SPG stimulation.

2013年，Shytz等人报道了一项双盲交叉研究，随机分配了6名先前植入SPG微刺激器的CH患者，分别在2天内持续3分钟接受高频（HF，80-120 Hz）或低频（LF，5 Hz）治疗。三名患者在LF SPG刺激期间或30分钟之内报告了簇状发作，并且这些发作均被HF刺激缓解。一名患者在HF SPG刺激后3分钟内报告了簇状发作，并且通过进一步的HF刺激缓解。这表明从SPG传出的副交感神经可以触发CH，使用HF刺激可以更好地控制CH。HF刺激SPG用于难治性CH现已取得专家共识，并且已经发布了指南，现已在欧洲上市并获得批准。考虑到这种疗法已经显示出疗效，长期的前瞻性研究似乎是可行的。目前有研究正在进行来评估SPG刺激在偏头痛的急性和预防性治疗中的作用。