神经电刺激治疗慢性头面部疼痛：综述（二十）
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。
Another study examined tVNS in patients with migraines to target the auricular nerve (a branch of the vagus) at the concha of the outer ear. This parallelgroup randomized trial analyzed 22 patients who received 25 Hz stimulation and 17 patients who received 1 Hz stimulation for a total of 12 weeks. A total of 29.4% of the 1 Hz group had at least a 50% reduction in headache days. Contrary to the authors’ hypothesis, the 1 Hz group outperformed the 25 Hz (which is the routine frequency commonly used in VNS implants for other conditions). Overall these studies suggest that both VNS and tVNS may be safe alternatives to trial, however, more studies are needed specifically to define ideal stimulation parameters.
另一项研究利用tVNS使其靶向外耳道的耳神经（迷走神经的一个分支）治疗偏头痛。该平行随机试验分析了22位接受25 Hz刺激的患者和17位接受1 Hz刺激的患者，共12周。 1 Hz组中总共29.4％的头痛天数减少了至少50％。与作者的假设相反，1 Hz组的性能优于25 Hz（这是VNS电极在其他情况下通常使用的常规频率）。总的来说，这些研究表明，VNS和tVNS都是可尝试的安全的选择，但是，还需要进行更多的研究来确定理想的刺激参数。
Spinal cord stimulation
High Cervical Spinal Cord Stimulation
The use of dorsal column stimulation in the high cervical region has been used to treat headache and facial pain. Neurons projecting from the trigeminocervical complex to the trigeminal nucleus caudalis can be stimulated at C2-C3 (Fig. 7), potentially covering both facial and occipital pain. For refractory migraine headaches, one retrospective survey showed high cervical lead placement led to a decrease in pain intensity (with 71% of patients reporting a decrease of 50% or more), headache days, and medication usage at a follow-up period with a median of 15 months. However, the study size was small (n = 17), and further evidence is needed in this area. Cases have been reported of successful use of high cervical spinal cord stimulation (HCSCS) to treat CHs and posttraumatic headaches as well.
脊髓电刺激
高颈椎脊髓刺激
在高颈椎区域使用背柱刺激目前已用于治疗头面部疼痛。从三叉神经颈复合体投射到三叉神经尾状核的神经元可以在C2-C3处受到刺激（图7），可能覆盖面部和枕部疼痛。对于难治性偏头痛，一项回顾性调查显示，高位颈椎电极放置可降低疼痛强度（71％的患者减少50％或更多）、头痛天数以及随访期间的药物使用情况，随访中位数为15个月。但是，研究规模很小（n = 17），在这一领域还需要进一步的证据。已有报道成功使用高颈椎脊髓刺激（HCSCS）治疗CHs和创伤后头痛的案例。
After success with one patient with medically intractable chronic CH, Wolter et al reported on a case series of 7 patients. In all patients, an initial lead was placed slightly paramedian ipsilateral to the pain location. The electrode was directed cranially until movement was halted by the occipital bone or the posterior arch of the atlas. Paresthesias covered root C2 and ophthalmic nerve with some maxillary branches. In 2 patients, contralateral leads were placed one at 6 months and one at 7 years both secondary to shift of CH pain location. This study concluded that all patients had statistical differences in attack frequency, duration, and intensity, and half of the patients stopped all medication postimplantation. These results are promising with an attack frequency reduction of 40%, and effects lasting for 3 to 78 months with a median follow-up of 12 months. In 2016, Arcioni et al reported on a prospective, open-label, exploratory study in which 17 patients diagnosed with refractory CM underwent a trial of paresthesia-free cervical high frequency 10 kHz (HF10) SCS. The target for stimulation was the dorsal columns in the area corresponding to C2-C3 vertebral level. There was one trial failure, one trial infection, and one implant infection. The other 14 patients had successful implants that remained at the 6-month follow-up. A total of 7 out of the 14 were reported to have > 30% reduction in headache days, and 5 out of 14 had > 50% reduction in headache days. Overall, 8 subjects reverted to an episodic pattern experiencing headaches < 15 days a month. One patient required surgical revision secondary to lead migration.
在成功治愈了一名患有药物难治型慢性CH的患者后，Wolter等人报告了一个共7例患者的病例系列。在所有患者中，最初的电极放置在疼痛部位的同侧偏中线。将电极向颅侧放置，直到枕骨或寰椎后弓停止运动为止。感觉异常覆盖了C2和眼神经，并带有一些上颌支的支配范围。2例患者因继发CH疼痛部位转移在6个月和7年后在对侧放置了电极。这项研究得出的结论是，所有患者在发作频率、持续时间和强度方面都有统计学差异，并且一半患者在植入后停止了所有药物治疗。这些结果令人鼓舞，发作频率降低40％，疗效持续3到78个月，中位随访12个月。 2016年，Arcioni等人报道了一项前瞻性、开放性、探索性研究，其中17名被诊断为难治性CM的患者接受了无感觉异常的颈段高频10 kHz（HF10）SCS测试。刺激的靶点是与C2-C3水平对应区域的背柱。测试失败1例，测试感染1例，植入物感染1例。其他14例患者成功植入，并在6个月的随访中得以保留。据报道，在14例中，共有7例头痛天数减少了30％以上，而14例中有5例头痛天数减少了50％以上。总体而言，有8位受试者恢复为发作性模式，每月头痛少于15天。一名患者因发生电极移位再次手术。