【晨读】脊髓电刺激（二）

 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ROCK AK , Truong H , Park YL, et al. Spinal Cord Stimulation[J]. Neurosurg Clin N Am, 2019, 30(2):169-194.本次学习由谢珺田副主任医师主讲。

INDICATIONS

Currently, the Food and Drug Administration has approved several SCS systems for the use in the management of chronic intractable pain of the trunk and limbs, including unilateral or bilateral pain associated with failed back surgery syndrome (FBSS), intractable low back and leg pain, com-plex regional pain syndrome (CRPS) type I and II, and neuropathic pain. Several governing bodies have published recommendations and guidelines pertaining to the use of SCS. These recom-mendations are summarized in Table 1. For a wide variety of indications, there remains a paucity of quality evidence to support or refute the utility of SCS as an adjunct or alternative to conventional medical management (CMM) strategies. Most ev-idence supports the use of SCS for the treatment of FBSS, CRPS, and refractory angina pectoris (RAP). Therefore, these indications are the primary focus for discussion in this review.

适应症

目前，美国食品药品监督管理局已经批准了几种SCS系统，用于治疗躯干和四肢的慢性顽固性疼痛，包括与背部手术综合征失败（FBSS）相关的单侧或双侧疼痛，顽固性腰背和小腿疼痛，I型和II型复杂性局部疼痛综合征（CRPS）以及神经性疼痛。几个理事机构已经发布了有关使用SCS的建议和指南。表1总结了这些建议。对于各种各样的适应症，仍然很少有证据支持或驳斥SCS作为传统医学管理（CMM）策略的辅助或替代方法。大多数证据支持使用SCS治疗FBSS，CRPS和难治性心绞痛（RAP）。因此，这些适应症是本综述中讨论的主要重点。

Failed Back Surgery Syndrome

Table 2 summarizes studies related to SCS treat-ment of FBSS. FBSS is a condition where patients experience recurring low back pain following prior spinal surgery. Approximately 10% to 30% of pa-tients experience postoperative low back pain, and SCS has been found to successfully treat this pain with a low morbidity rate compared with reoperation. In a case series with long-term follow-up, North and colleagues reported prom-ising results of SCS therapy for FBSS patients, with success rates of 53% to 60% at 2.2 years and 47% to 54% at 5 years. The results were later replicated by LeDoux and Langford within a se-ries of 32 patients with FBSS, in which 82% and 74% patients had good results at 6-month and 2-year time points, respectively. These results prompted more definitive studies. In a RCT, North and colleagues randomized 51 FBSS patients to SCS or reoperation. Clinical improvement and treatment satisfaction, indicated by the desire to crossover to the other randomized treatment, were reported and analyzed. The initial results at 6-month follow-up and later on with 3-year average follow-up both confirmed SCS to be more satisfactory than reoperation in terms of self-reported pain relief and the crossover rate. In a multicenter RCT for patients with FBSS (n 5 100), Kumar and colleagues demonstrated SCS to be more effective than conservative medi-cal management (CMM) at improving pain relief, quality of life (QoL), and functional capacity at 1-year follow-up. These benefits were sustained at 2-year follow-up. QoL also seemed to mark-edly improve when patients were randomized to SCS as compared with CMM.

腰椎手术失败综合征

表2总结了与SCS治疗FBSS有关的研究。FBSS是患者在先前的脊柱外科手术后反复出现下腰痛的情况。大约10％到30％的患者会出现术后下背部疼痛，并且与再手术相比，已经发现SCS能以较低的发病率成功治愈该疼痛。在长期随访的病例系列中，North及其同事报告了可喜的结果：FBSS患者接受SCS治疗在2.2年时成功率为53％至60％，在5年时成功率为47％至54％。LeDoux和Langford随后在一系列32例FBSS患者中印证了这些结果，其中分别有82％和74％的患者在6个月和2年时间点获得了良好的效果。这些结果促使进行更明确的研究。在一个RCT中，North及其同事将51名FBSS患者随机分配至SCS或再次手术。报告并分析了希望转用其他随机治疗方法所表明的临床改善和治疗满意度。在6个月的随访和随后的3年平均随访上的初步结果均证实，SCS在自我报告的疼痛缓解和交叉率方面比再手术更令人满意。在针对FBSS患者的多中心RCT中（n = 5 100），Kumar及其同事证明SCS能够缓解疼痛，生活质量（QoL）和1年随访时的功能能力方面比保守医学管理（CMM）更有效。向上。这些益处在随访2年后得以维持。与CMM相比，将患者随机分配至SCS时QoL似乎也明显改善。

In recent years, new waveforms, including burst and high-frequency stimulation, have been intro-duced. Burst stimulation, which delivers five spikes at 500 Hz 40 times per second, has been found to suppress pain and tonic stimulation, but without evoking paresthesia. Initial results in 48 patients who were on tonic stimulation and switched to burst stimulation showed improved pain relief with minimal to no paresthesias in 60% of patients. The SUNBURST trial compared burst stimulation and traditional tonic stimulation in a randomized crossover trial. Patients had greater improvement on Visual Analog Scale (VAS) for pain with burst SCS when compared to tonic SCS; with most patients preferring burst SCS (70.8%). This preference was maintained at 1-year follow-up. Similarly, 10-kHz high-frequency (HF10) therapy has shown promise. In the SENZA-RCT, 171 SCS-naive patients were randomized to tonic versus HF10 stimulation ther-apy. There were significantly more responders (defined as 50% pain relief) in the HF10 group as compared with tonic SCS.The benefit was main-tained at 2-year follow-up.

近年来，已经引入了新的波形，包括猝发和高频刺激。爆炸刺激可以每秒500次以500 Hz的频率提供五个峰值，已经发现它可以抑制疼痛和强直刺激，但不会引起感觉异常。在接受强直刺激并转为爆发性刺激的48位患者中，初步结果显示，60％的患者疼痛缓解得到改善，感觉异常降至最低甚至没有感觉异常。SUNBURST试验在一项随机交叉试验中比较了突发刺激和传统滋补刺激。与强直性SCS相比，患者在视觉模拟量表（VAS）上爆发性SCS疼痛的改善更大。大多数患者更喜欢爆发性SCS（70.8％）。这种偏好在1年的随访中得以维持。同样，10 kHz高频（HF10）治疗也显示出了希望。在SENZA-RCT中，将171名SCS初次接受治疗的患者随机分为补品和HF10刺激疗法。与强直性SCS相比，HF10组的应答者（定义为50％的疼痛缓解）显着增加。随访2年维持获益。