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。
Patient selection is critical for promoting positive outcomes following SCS. Other treatment modalities, such as medication, steroid injections, and/or PT, should be pursued before proposing the possibility of SCS. Then, several factors need to be considered before pursuing SCS, including: psychiatric comorbidities, MRI eligibility, preoperative surgical risk, and expected response to a trial of SCS. If patients are ineligible to receive MRI, they need to be followed with computed tomography or computed tomography myelography. From a surgical perspective, general contraindications include uncontrolled bleeding disorders, sepsis, cognitive impairments, unresolved psychological disorders, and/or substance use disorders. In particular, tobacco use has been associated with early SCS failure. The importance of tobacco use cessation should be emphasized with each patient and urine drug and ethanol screening should be performed to better optimize other comorbidities preoperatively.病例选择
病例选择对于SCS治疗效果至关重要。在考虑选择SCS治疗之前，首先应予以其他它治疗方式如药物治疗、类固醇注射和/或PT。然后，在采用SCS试验治疗之前，需要考虑几个因素，包括：合并精神疾病、完善MRI检查资料、充分做好手术风险评估和设定SCS试验的预期效果。如果患者不能接受核磁共振成像检查，可以进行计算机断层扫描或计算机断层扫描脊髓造影。从手术角度来说，禁忌证包括难以控制的出血障碍、败血症、认知障碍、不稳定的心理障碍和/或物质滥用。特别是吸烟与早期SCS失败有关。应强调每位患者戒烟的重要性，术前应进行尿检和酒精筛查，以进一步排查合并疾病。
Evaluation and treatment of comorbid mental health conditions is an important step before a trial of SCS, because chronic pain can severely affect each patients’ QoL, interpersonal relationships, and activities of daily living. Establishing effective coping skills helps improve outcomes following SCS surgery. For emphasis, patients should expect an upfront goal not to relieve all pain, but to decrease it by 50%. Thorough preoperative psychiatric evaluations can help identify underlying untreated depression, anxiety, personality, substance use, or post-traumatic stress disorders that may need further clinical management. Prior studies have demonstrated that 63% and 23% of patients may exhibit symptoms of depression or anxiety, respectively. These rates are higher than the general population, indicating the importance of preSCS psychological screening. Instruments that have demonstrated efficacy in the diagnosis and treatment of comorbid mental health conditions in SCS include the Beck Depression Inventory, Pain Catastrophizing Scale, and the Minnesota Multiphasic Personality Inventory.由于慢性疼痛会严重影响每个患者的生活质量、人际关系和日常生活活动，因此评估和治疗合并疾病以及充分进行心理健康状况评估是SCS试验治疗前的一个重要步骤。建立有效的应对技能有助于改善SCS手术治疗的效果。需要强调的是，患者应该期望预先设定的目标不是减轻所有疼痛，而是将其减少50%。充分的术前精神评估有助于确定潜在的抑郁、焦虑、人格障碍、物质滥用或创伤后应激障碍，这些可能需要进一步的临床治疗。前期研究表明，分别有63%和23%的患者可能表现出抑郁或焦虑症状。这些比率高于一般人群，表明SCS治疗之前心理筛查的重要性。在诊断和治疗SCS患者的心理健康疾病方面，有效的评估工具包括贝克抑郁量表、疼痛灾变量表和明尼苏达多相人格量表。
One of the benefits of SCS is the opportunity for patients to pursue a trial period with a temporary device before permanent implantation. This allows the clinician and patient to gauge the potential benefits that may be achieved on permanent implantation. Typically, a 5- to 7-day trial period is recommended for all patients, during which clinicians follow-up closely. If initial pain relief is limited, patients should follow-up in the outpatient setting for a radiographic evaluation and/or potential device reprogramming. At the end of the trial, patients decide whether their pain, QoL, and/or functionality improved by at least 50% and whether they want to pursue permanent implantation. Common instruments to assess the response to SCS trials include the VAS, McGill Pain Questionnaire, and Oswestry Disability Index. These subjective and objective instruments help patients in making a decisive decision about their long-term management with SCS. If they remain indecisive, the trial period is extended or programming parameters adjusted for more informed decision-making.试验治疗
在考虑永久SCS植入术之前，患者必须首先使用临时装置进行试验治疗。这使得临床医生和患者能够充分评估永久性植入可能带来的治疗效应。通常情况下，建议所有患者进行5-7天的试验治疗期，在此期间临床医生密切观察访视。如果初期疼痛缓解有限，患者应在门诊进行随访，以进行影像学评估和/或必要时设备重新编程。在试验结束时，患者决定他们的疼痛程度、生活质量和/或功能是否至少改善了50%，是否希望进行永久性植入手术。评估SCS试验治疗反应的常用工具包括VAS、McGill疼痛问卷和Oswestry功能障碍指数量表。这些主观和客观的工具有助于患者做出决定，是否接受永久SCS植入手术。如果他们仍然犹豫不决，可适当延长试验治疗期或调整治疗参数，以便做出更为明智的决策。
During a trial, it is important to obtain radiographic imaging of lead placement as a way to guide permanent implantation. Imaging should extend from the bottommost rib and have clear identification of each vertebral body and the laterality clearly designated. It is then necessary to obtain data on the location of stimulation on each lead in reference to these landmarks and areas of perceived clinical benefit. For instance, if the “sweet spot” of the lead is at the top of the lead, the lead is placed higher during permanent placement than in the trial so that the “sweet spot” is in the middle (Fig. 1). Optimal lead positioning plays a crucial role in postoperative pain relief. Lead location for back and leg coverage varies among devices and varying waveforms, thus trial periods are a good way to ascertain vital information on expected efficacy. In the case of HF10, the leads should always be placed for coverage over the T9-10 regions. For arm and neck pain, we typically place cervical leads either with a retrograde paddle from occiput to C3 or one/two leads depending on symptoms in a “blooming flower” configuration up to C1-2. Details on these procedures have been previously described by Haider and colleagues.52 Lastly, leads for managing RAP should typically cover the T4-6 region.在试验治疗阶段，获得清晰的透视图像非常关键，可作为指导永久植入手术的重要参考依据。透视图像应从最下位肋骨开始，清晰定位每节椎体，并结合正侧位图片准确判定电极位置。然后，参考这些标志和产生异感的区域，定位每根电极上刺激位点。例如，电极的“适宜刺激位点”在电极顶部，则电极在永久放置时的位置应比试验期间更高，才能使得“适宜刺激位点”在电极中部（图1）。电极准确定位对术后疼痛的缓解起着至关重要的作用。背部和下肢覆盖的导联位置因设备和不同波形而异，因此试验期是确定预期疗效的重要信息的好方法。对于HF10，电极应始终放置在T9-10区域的覆盖范围内。对于手臂和颈部疼痛，我们通常放置颈部电极，或者从枕骨到C3逆行放置电极板，或者根据症状放置一根或两根电极，呈“花瓣状”放置到C1-2。Haider及其同事之前已经描述了这些操作细节。最后，治疗RAP的电极刺激范围通常应覆盖T4-6节段皮区。
