神经电刺激治疗慢性头面部疼痛：综述（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。

Cranial targeted neuromoduatation techniques

Transcranial Direct Current Stimulation

Transcranial direct current stimulation involves applying weak electrical currents over the scalp. By specifically placing one electrode over a target area, the cranial neuronal firing may be either increased or decreased. A recent review suggests there is low to moderate evidence for transcranial direct current stimulation to promote pain control and reduce pain medication intake in migraineurs.

颅靶向神经调控技术 

经颅直流电刺激

经颅直流电刺激是在头皮上给予微弱的电流。通过在目标区域上专门放置一个电极，可以增加或减少颅神经元放电。最近的综述表明，有低级别到中级别证据支持经颅直流电刺激治疗偏头痛可帮助控制疼痛并减少止痛药的使用。

Repetitive Transcranial Magnetic Stimulation

Repetitive transcranial magnetic stimulation is a form of noninvasive neurostimulation focusing changes in magnetic fields to deep brain targets in hopes of upregulating or downregulating certain neural activity. For pain, the primary targets investigated include the primary motor cortex and the dorsolateral prefrontal cortex. Some success with minimal risk has been reported in patients with migraine and TN, however, efficacy has not proven to be consistent.

重复经颅磁刺激

重复经颅磁刺激是一种非侵入性神经刺激，将磁场的变化集中到大脑深处的靶点，希望上调或下调某些神经活动。对于疼痛，所研究的主要靶点包括主要运动皮层和背外侧前额叶皮层。据报道，该技术在偏头痛和TN患者取得了一些成果且风险很小，但是，疗效尚未被证明是一致的。

Deep Brain Stimulation

Deep brain stimulation involves placing electrical devices intracranially and targeting subcortical regions. Several studies have displayed positive results in patients with chronic pain by targeting deep brain structures including the sensory thalamus, periaqueductal and periventricular gray, and the anterior cingulate cortex. Because of the severity of possible complications, deep brain stimulation is only recommended after exhausting other modalities.

脑深部电刺激

脑深部电刺激将电子设备放在颅内并靶向皮层下区域。通过针对深部大脑结构（包括感觉性丘脑、导水管周围和脑室周围的灰质以及前扣带回皮质）进行靶向治疗，一些研究已表明其对慢性疼痛患者的较好疗效。由于可能发生并发症的严重性，仅在用尽其他方式后才建议进行脑深部电刺激。

Levels of evidence

When reviewing the available literature, it is crucial to define the overall level of evidence a study provides before the research conclusions can be adopted to clinical practice. A concrete protocol is needed when analyzing studies to create evidence-based guidelines. Manchikanti et al has developed an interventional specific pain management instrument used in assessing the methodologic quality of trials (Table 1). Traditionally, randomized controlled trials (RCTs) are generally considered to be superior evidence than studies without randomization and without controls. The lowest levels of evidence are obtained from observational-based clinical experience or reports of expert committees. Using this qualified modified approach to grading of evidence, we are better able t put the totality of evidence into perspective .

证据分级

在查阅现有文献时，至关重要的是定义研究的总体证据等级，然后才能将研究结论用于临床实践。分析研究以建立基于证据的指南时，需要一个具体的方案。Manchikanti等人开发了一种干预性疼痛管理工具，用于评估试验的方法学质量（表1）。一般来说，与没有随机对照和没有对照的研究相比，通常认为随机对照试验（RCT）是更好的证据。最低水平的证据是从基于观察的临床经验或专家共识的报告中获得的。使用这种质量改进方法对证据进行分级，我们可以更好地分析整个证据并得出观点。