【晨读】神经电刺激治疗慢性头面部疼痛：综述（一）

 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。

Abstract

Background: Head and facial pain is a common and often difficult to treat disorder. Routine treatments sometimes fail to provide acceptable relief, leaving the patient searching for something else, including narcotics and surgery. Recently, neuromodulation has been expanding to provide another option. Secondary to its potentially temporary nature and relatively manageable risk profile, several reviews have suggested trialing neuromodulation prior to starting narcotics or invasive permanent surgeries. There is evidence that neuromodulation can make a difference in those patients with intractable severe craniofacial pain.

Objectives: To provide a basic overview of the anatomy, epidemiology, pathophysiology and common treatments of several common head and facial disorders. Furthermore, to demonstrate the suggested mechanisms of neuromodulation and the evidence currently existing for the use of neuromodulation.

Methods: A comprehensive review was performed regarding the available literature through targeting articles reporting on the use of neuromodulation to treat pain of the head and face.

Results: We compiled and discuss the current evidence available in treating head and facial pain. The strongest evidence currently for neuromodulation is for occipital nerve stimulation for migraine, transcutaneous vagal nerve stimulation for migraine and cluster headache, sphenopalatine ganglion microstimulation for cluster headache, and transcutaneous supraorbital and supratrochlear nerve stimulation for migraine. In addition, there is moderate evidence for occipital nerve stimulation in treating occipital neuralgia.

Limitations: Neuromodulation has been trialed and is promising in several craniofacial pain disorders; however, there remains a need for large-scale, randomized, placebo-controlled clinical trials to further evaluate the efficacy and safety of most treatments. Much of the current data relies on case reports without randomization or placebo controls.

Conclusions: With advancing techniques and technology, neuromodulation can be promising in treating intractable pain of the head and face. Although more randomized controlled trials are warranted, the current literature supports the use of neuromodulation in intractable craniofacial pain.

Key words: Neuromodulation, headache, facial pain, craniofacial pain, migraine, cluster headache, trigeminal neuralgia, occipital neuralgia, peripheral nerve stimulator, high cervical spinal cord stimulator, peripheral nerve field stimulator.

摘要
背景：头面部疼痛是常见且通常难以治疗的疾病。常规治疗有时无法提供令人满意的效果，患者不得不寻找其他止痛方式，包括毒麻药品和外科手术。最近，神经调节为患者提了供另一种选择。考虑到其潜在的暂时性特征和相对可控的风险，一些综述建议在开始选择毒麻药品或侵入性永久性手术之前先试着进行神经调节。有证据表明，在顽固性重度颅面部疼痛的患者中，神经调节可能会有所作为。
目的：对一些常见的头部和面部疾病的解剖学、流行病学、病理生理学和常用治疗方法进行基本概述。此外，对相关的神经调节机制和目前存在的使用神经调节的证据进行展示。
方法：通过针对报道使用神经调节治疗头部和面部疼痛的文章对现有文献进行了全面审查。
结果：我们汇总并讨论了目前可用于治疗头部和面部疼痛的证据。目前关于神经调节的最有力证据是偏头痛的枕神经刺激、偏头痛和丛集性头痛的经皮迷走神经刺激、丛集性头痛的蝶颚神经节微刺激以及偏头痛的经皮眶上和滑车上神经刺激。另外，枕神经刺激治疗枕神经痛有中等程度的证据。
局限性：神经调节已经在临床中试用，并有望在几种颅面痛性疾病中发挥作用。然而，仍然需要进行大规模，随机，安慰剂对照的临床试验，以进一步评估大多数治疗的疗效和安全性。当前的许多数据都依赖于病例报告，而没有随机分组或安慰剂对照。
结论：随着先进技术的发展，神经调节在治疗头部和面部顽固性疼痛方面很有前途。尽管有必要进行更多的随机对照试验，但目前的文献支持在顽固性颅面痛中使用神经调节。
关键词：神经调节，头痛，面部疼痛，颅面疼痛，偏头痛，丛集性头痛，三叉神经痛，枕神经痛，周围神经刺激器，高颈脊髓刺激器，周围神经区域刺激器。

Neuromodulation is an ever-expanding field that has been used for the treatment of chronic pain disorders for the last 50 years. Although the predominant use of neurostimulation has been for the treatment of conditions such as failed back surgery syndrome, complex regional pain syndrome and the like, it has expanded over time to include pelvic pain ,traumatic neuropathies, diabetic neuropathies, and postherpetic neuralgia (PHN) . Recent developments in waveform technology have brought promising potential advancements to the field. In addition to targeting dorsal column fibers via leads placed in the epidural space, tonic stimulation of both peripheral nerves and subcutaneous unnamed small fibers of peripheral nerves has been employed for pain control. As the understanding, technology, and proven efficacy of peripheral neurostimulation has improved, newer extracranial and intracranial modalities have shown promise in treating headache and facial pain. There is growing consensus among the pain community that extracranial and intracranial modalities be considered prior to starting chronic, longterm opioid therapies in certain conditions refractory to conservative medical management.

神经调节是一个不断扩展的领域，在过去的50年中一直用于治疗慢性疼痛疾病。尽管主要使用神经刺激来治疗诸如失败的背部手术综合征，复杂的局部疼痛综合征等病症，但随着时间的流逝，神经刺激已扩大到包括盆腔痛、外伤性神经病、糖尿病性神经病和带状疱疹后神经痛的治疗。波形技术的最新发展为该领域带来了令人鼓舞的潜在进步。除了将电极放置在硬膜外腔靶向刺激背柱纤维外，还可以采用刺激周围神经和皮下不知名的周围神经小纤维来控制疼痛。随着对周围神经刺激的认识、技术和行之有效的治疗方法的改进，新的颅外和颅内治疗方法已显示出治疗头痛和面部疼痛的可能。疼痛界越来越多的共识是，在某些保守治疗效果欠佳的情况下，在开始长期的阿片类药物治疗之前，应考虑颅外和颅内治疗方法。