神经电刺激治疗慢性头面部疼痛：综述（十四）

 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。

Neuromodulation for headaches and facial pain: evidence and rationale

Peripheral Nerve Stimulation

Although intractable pain of the trunk and/or limbs has been the traditional indication for neuromodulation via spinal cord stimulation (SCS), refractory facial and headache pain has been shown to respond to neurostimulation in some cases. When conservative medical management fails and surgery is not appropriate, has failed, or is contraindicated, neurostimulation can be a viable alternative. Various targets and techniques have been employed using neuromodulation for facial and headache pain (Table 2). However, PNS for facial pain and headache is not without risk as stimulation of extracranial nerves may be more technically challenging than stimulation of peripheral nerves in the torso or extremities. Common complications include infection, skin erosion, seroma, allodynia over the lead site, as well as technical complications such as lead migration, lead fracture, and battery malfunction. Although there are not enough data to reliably compare complication rates of extracranial PNS targets, mitigation of adverse events to improve patient safety and outcomes should be of upmost priority. The same principles of appropriate patient selection that apply for traditional SCS apply for this modality. Consensus recommendations also support the consideration of neurostimulation prior to initiation of long-term, long-acting opioid therapy.

头面痛的神经调节：证据和原理

周围神经刺激

躯干和/或四肢的顽固性疼痛已成为通过脊髓刺激（SCS）进行神经调节的传统指征，在某些情况下顽固性头面痛已显示出对神经刺激的反应。当保守疗法失败并且手术不合适、失败或禁忌时，神经刺激可以作为一种可行的选择。目前已采用了多种靶点和技术来利用神经调节治疗头面痛（表2）。然而，用于头面痛的PNS并非没有风险，颅外神经刺激比躯干或四肢的周围神经刺激更具技术挑战性。常见的并发症包括感染、皮肤糜烂、血肿、电极部位的异常性疼痛，以及技术并发症，例如电极移位、断裂和电池故障。尽管没有足够的数据可靠地比较颅外PNS的并发症发生率，但减轻不良事件以提高患者的安全性和预后应该是重中之重。适用于传统SCS的适应证也适用于此模式。共识建议还支持在开始长期、长效阿片类药物治疗之前考虑神经刺激。

Trigeminal Nerve Stimulation

Although central and peripheral techniques of trigeminal nerve stimulation have been well described in literature, PNS has proved to be the safer, more reliable option (4,80,81). Ophthalmic, maxillary, and mandibular branches of the trigeminal nerve, as well as more distal branches such as the supraorbital, infraorbital, and auriculotemporal nerves anatomically lend themselves as good targets for PNS for facial pain (4). In 2004, Johnson et al (82) reported on 10 patients treated with implanted subcutaneous pulse generators and quadripolar electrodes to stimulate the supraorbital or infraorbital branches of the trigeminal nerve. This retrospective analysis showed promising results, as 70% of patients experienced at least a 50% degree of pain relief and 70% reported a decrease in medication use up to 4 years postimplantation. Of note, all 5 patients who were originally diagnosed with posttraumatic neuropathic pain had at least a 50% pain reduction posttreatment, whereas 2 out of 4 of those diagnosed with postherpetic neuropathy had a therapeutic outcome. The overall complication rate was high at 30%, with 2 patients developing wound breakdown over the connector and another patient with discomfort associated with the tension of the extension lead during head movements, each of these 3 were later successfully managed through repeat surgical intervention.

三叉神经刺激

尽管在文献中已经很好地介绍了三叉神经刺激的中枢和外周技术，但事实证明，PNS是更安全可靠的方法。三叉神经的眼支、上颌支和下颌支以及更远端的眶上、眶下和耳颞神经等远端分支在解剖学上很容易成为PNS治疗面部疼痛的靶点。 2004年，Johnson等报告了10例患者，他们接受了植入皮下脉冲发生器和四触点电极刺激三叉神经的眶上或眶下分支的治疗。这项回顾性分析显示了较好的结果，70％的患者获得至少50％的疼痛缓解，而70％的患者在最长4年的随访中植入后用药减少。值得注意的是，最初被诊断为创伤后神经病理性疼痛的所有5名患者在治疗后至少减轻了50％的疼痛，而在诊断为带状疱疹后神经痛的4名患者中，2位有治疗效果。总体并发症发生率高达30％，其中2例患者在连接器位置发生伤口裂开，另一例患者在头部运动时因牵拉线的张力而感到不适，这3例患者中的每一个均通过再次手术得以成功治疗。