神经电刺激治疗慢性头面部疼痛：综述（二十二）

 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。

Peripheral Nerve Field Stimulation

Peripheral nerve field stimulation (PNfS) targets the subcutaneous small fiber nerve endings of peripheral nerves, not necessarily correlating with the distribution of a single “named” nerve. A recent cohort in 2016 of 10 patients with intractable facial pain in the trigeminal distribution who were trialed with PNfS: 8 of the 10 proceeded to implant and reported significant pain relief, and 2 of these patients reported an absence of pain after implant. Similar results were seen in another case series of 6 total drug-resistant patients: 2 with classical TN, 2 with concomitant persistent facial pain, and 2 with postherpetic trigeminal neuropathy. Average pain intensity decreased by 83% and number of attacks decreased by 73% with a mean follow-up of 15.2 months. A total of 5 out of the 6 patients reduced their pain medication intake. One patient developed a device infection at 4 months, and after a relapse of pain underwent a second implantation that was successful. Overall, this case series shows effective treatment with PNfS for classic TN and facial pain.

周围神经区域刺激

周围神经区域刺激（PNfS）针对周围神经的皮下小纤维神经末梢，不一定与单个“有名称”神经的分布有关。2016年的一项最新队列研究收集了10名三叉神经分布区难治性面部疼痛患者，并进行了PNfS试验：10名患者中有8名植入并疼痛缓解，其中2名患者植入后疼痛消失 。在另一纳入6例耐药患者的病例系列中观察到相似的结果：2例为经典TN，2例伴发持续性面部疼痛，2例为带状疱疹后三叉神经病。平均疼痛强度降低了83％，发作次数降低了73％，平均随访时间为15.2个月。6例患者中有5例减少了止痛药的摄入量。一名患者在四个月时出现了设备感染，在疼痛复发后进行了第二次成功的植入。总体而言，该病例系列显示了用PNfS治疗经典TN和面部疼痛是有效的。

Additional case reports have demonstrated effectiveness using PNfS for atypical facial pain. One patient with axial neck pain had 100% relief and reduction in opioids postplacement of PNfS to the paraspinal and trapezius muscles. Two PHN patients displayed successful pain relief postimplantation in the lateral thoracic region with PNfS. A second case report looked at combining ONS with bilateral subcutaneous electrical stimulation over the temporal region to treat a patient diagnosed with complicated migraine and occipital neuralgia. At 2-year follow-up, the headache onset was reduced by > 50%, and there was a cessation of neurologic deficits that had been seen with previous attacks. In 2014, Verrills et al reported on 60 patients with either chronic daily headache, occipital neuralgia, or CM who underwent successful trial and later PNfS implantation with 50 targeting the occipital, 3 the supraorbital and infraorbital, and the remaining 7 were a combination of these 3 nerves (Fig. 8). Outcomes were successful with average reduction in pain scores of 4.8, and overall 41 out of the 60 patients demonstrated at least 50% reduction in pain. Although prospective trials are lacking, PNfS has shown promise as a treatment for debilitating refractory facial pain.

其他病例报告表明使用PNfS治疗不典型面痛有效。一名患有轴向颈痛的患者将PNfS放置在椎旁和斜方肌后疼痛完全缓解，且阿片类药物的使用降低。两名PHN患者在胸部外侧区域植入PNfS后成功止痛。另一篇病例报告探讨了将ONS与颞区双侧皮下电刺激相结合，以治疗被诊断患有复杂性偏头痛和枕部神经痛的患者。在2年的随访中，头痛发作减少了50％以上，并且以前发作时神经功能缺损也停止了。2014年，Verrills等人收集了60例慢性每日头痛、枕神经痛或CM患者，这些患者均在测试成功后进行PNfS植入，其中50例针对枕神经、3例眶上和眶下神经，其余7例为这三对神经的组合（图8）。结果是成功的，疼痛评分平均降低了4.8，这60例患者中有41例疼痛减轻了至少50％。尽管尚缺乏前瞻性试验，但PNfS已显示出有望使弱化难治性面部疼痛的治疗方法。

SPG Stimulation

Neurostimulation of the SPG is a relatively novel and promising treatment modality for refractory craniofacial pain. A 7-patient monocentric case series examined SPG and Gasserian ganglion stimulation for facial pain with most patients diagnosed with persistent idiopathic facial pain. A total of 5 of the 7 patients proceeded to permanent implantation: one patient had stimulation of the SPG; 3 patients had stimulation of SPG combined with peripheral nerve branches either the supraorbital, auriculotemporal, and occipital; and one patient had a Gasserian ganglion only implant for trigeminal neuropathic pain. A total of 4 out of 5, including several of the SPG implanted patients and the one Gasserian ganglion only implant, experienced sustained pain relief, which was reported out to 24 months, with a mean of 9.6 months. Of note, paresthesia-free stimulation was reported in several of the SPG stimulation cases. Due to multiple implant targets in most patients, the efficacy obtained from the SPG alone is difficult to deduce. Another case report describes successful SPG stimulation for intractable facial pain, after failure of SPG block with local anesthetic, which resulted in cessation of opioids and significant pain relief.

SPG电刺激

SPG的神经刺激是一种难治性颅面痛的相对新颖和有前途的治疗方式。一个收集了7位患者的单中心病例系列报道了SPG和半月节刺激对面部疼痛的影响，大多数患者被诊断为持续性特发性面部疼痛。7例患者中共有5例进行了永久植入：1例患者接受了SPG的刺激；3例患者接受了SPG的刺激以及眶上、耳颞和枕神经周围神经分支的刺激；一名患者因三叉神经性疼痛而仅植入了半月节。5名患者中的4名，包括几名接受SPG植入的患者和1名仅半月节植入的患者，获得长期的疼痛缓解，随访截止到24个月，平均9.6个月。值得注意的是，在一些SPG刺激病例报告描述了无感觉异常的刺激。由于大多数患者中有多个植入靶点，因此仅凭SPG难以获得疗效。另一例病例报告描述了在SPG阻滞失败后，SPG刺激可有效治疗难治的面部疼痛，患者随后阿片停药且疼痛明显缓解。