神经电刺激治疗慢性头面部疼痛：综述（十七）

 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。

Halo 360° Cranial Stimulation

The halo 360° cranial stimulation with the unique placement of a novel device aims to provide a wide array of coverage across the bilateral head to treat headaches, primarily migraines. This technique used 4 leads each with 8 electrode contacts and all powered by one single implantable pulse generator, thus allowing for a greater number of contacts over previous devices. Bilateral leads are placed superior to the ear and anteriorly to stimulate the supraorbital, supratrochlear, zygomaticotemporal, and auriculotemporal nerves. In addition, bilateral leads are placed posteriorly to stimulate the greater and lesser occipital, greater auricular, and branches of the third occipital nerve, and the posterior rami of C2 and C3 nerve roots. This comprehensive method requires further investigation for efficacy.

Halo 360°颅面部刺激

Halo 360°颅面部刺激是一种新的设备，旨在为头部两侧提供广泛的覆盖范围，用来治疗以偏头痛为主的头痛。该技术使用了4根电极，每根电极具有8个触点，并且全部由一个可植入的脉冲发生器供电，因此与以前的设备相比，可以使用更多的触点。将两根电极放置在两侧耳朵上方和前方，以刺激眶上神经、滑车上神经、颧颞神经和耳颞神经。此外，将两根电极置于后方两侧，以刺激枕大神经、枕小神经、耳大神经、第三枕神经的分支，以及C2和C3神经根的后支。这种综合方法需要进一步研究疗效。

Occipital Nerve Stimulation

ONS has been used to treat occipital neuralgia refractory to conventional medical management. Because of its mechanism and efficacy, the occipital nerve is one of the most studied targets for head and neck pain. With the greater and LONs being distal branches of C2 and C3, the mechanism of action is thought to involve modulation of peripheral and central nociceptive inputs (Fig. 5). Regional cerebral blood flow has also been shown to increase after ONS in migraineurs, an encouraging finding in the treatment of neurovascular headache.

枕神经刺激

ONS已被用于治疗常规药物难以控制的枕神经痛。由于其机制和疗效，枕神经是头颈部疼痛研究最多的靶点之一。枕大神经和枕小神经是C2和C3的远端分支，作用机制被认为涉及对周围和中央伤害感受输入的调节（图5）。偏头痛患者接受ONS治疗后，还显示出局部脑血流量增加，这在神经血管性头痛的治疗中是一个令人鼓舞的发现。

A study looked at 10 patients being treated for drug refractory chronic CH with ONS. Cranial positron emission tomography scans of 4 chronic stimulator patients and 6 patients scanned prestimulator implantation and postimplantation demonstrated that ONS has a neuromodulator effect in the central pain matrix, suggesting that the ONS works to reduce the ipsilateral hypothalamic hyperactivity that can be found in acute episodic CH attacks.

一项研究调查了10例接受ONS治疗的难治性慢性CH患者。对4例慢性电刺激患者和6例患者在植入前和植入后进行的颅正电子发射断层扫描显示，ONS在中央疼痛基质中具有神经调节作用，这表明ONS可以减轻急性发作性CH发作时发现的同侧下丘脑机能亢进。

One case series focusing on occipital neuralgia followed 13 patients who underwent a total of 17 peripheral suboccipital stimulation implants (Fig. 6) for intractable occipital neuralgia. To differentiate from migraines, each patient was required to demonstrate some response to local occipital nerve or selective C2 root block. The target for stimulation was the occipital nerve trunk at the level of C1. In this series of cases, over an average of 2-year follow-up, 66% of patients had excellent responses reported at > 75% pain relief. The remaining 33% demonstrated good responses with at least 50% pain relief. Similarly, Kapural et al described 6 patients with severe refractory occipital neuralgia who were treated with ONS at C1 through a midline approach. At 3-month follow-up, there was a significant change in pain and disability.

一个针对枕神经痛的病例系列随访了13例患者，这些患者总共放置了17个周围性枕下神经刺激植入物以治疗难治性枕神经痛（图6）。为了与偏头痛区分开来，要求每位患者对枕神经或选择性C2根阻滞有反应。刺激的靶点是在C1水平的枕神经干。在这一系列病例中，平均随访2年后，有66％的患者效果很好，疼痛缓解> 75％。其余33％的人效果良好，疼痛缓解至少50％。类似地，Kapural等人报道了6例重度难治性枕神经痛患者，他们通过中线入路在C1水平放置ONS治疗。在3个月的随访中，疼痛和失能发生了显着变化。