神经电刺激治疗慢性头面部疼痛：综述（十一）
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。
Nerve Block
Local anesthetic and steroid injections are often used to target specific nerves. These treatments often have short-lasting responses and require frequent repeat injections. At times, relief may last from weeks to months because of a response in central pain modulation. Common targets include the GON, LON, and trigeminal nerve including its supratrochlear, supraorbital, and auriculotemporal branches. These procedures can be performed using anatomic landmarks or image guidance including fluoroscopy or ultrasound. Although there are few well-controlled trials, the greatest evidence is for greater occipital blocks in patients with CH. Furthermore, temporary nerve blocks can aid in establishing the diagnosis.
神经阻滞
局麻药和类固醇注射通常用于特定神经的治疗。这些治疗通常反应持续时间短，需要频繁重复注射。有时，由于中枢性疼痛调节的反应，缓解可能持续数周至数月。常见的靶点包括GON，LON和三叉神经（包括其滑车上、眶上和耳颞分支）。可以使用解剖标志物或包括X线或超声在内的影像引导来进行治疗。尽管缺少经过良好对照的试验，但最大的证据利用枕大神经阻滞治疗CH患者。此外，临时性神经阻滞有助于诊断。
SPG Block
The SPG has been specifically targeted as it contributes to the autonomic response displayed by many craniofacial pain syndromes. There is moderate evidence for the use of SPG blockage to treat CHs with cocaine or the preferred lidocaine. The addition of steroids may extend relief, however, evidence is weak. For migraines, one study demonstrated significant relief lasting 24 hours with bupivacaine application. Similarly, lidocaine nasal spray has been effective to treat TN. Although SPG block has efficacy acutely, there remains a lack of evidence for chronic pain management.
SPG阻滞
SPG作为一个特定的靶点，因为它有助于许多颅面痛综合征表现出的自主神经反应。有中度证据表明使用可卡因或首选利多卡因进行SPG阻滞可治疗CH。类固醇的添加可能会延长缓解期，但是证据不足。对于偏头痛，一项研究表明，应用布比卡因可持续缓解24小时。同样，利多卡因鼻喷雾剂在治疗TN有效。尽管SPG阻滞可以快速起效，但仍缺乏用于慢性疼痛治疗的证据。
Radiofrequency Ablation
Radiofrequency ablation (RFA) uses heat energy to create tissue destruction and loss of myelinated fibers, thus creating the ability to provide longer pain relief when compared with local anesthetic and steroid blocks. RFA has strong evidence when targeting the SPG when treating intractable CHs. Observational cohort studies report short to intermediate pain relief in occipital neuralgia. Similarly, in patients with TN, RFA of the Gasserian ganglion has displayed positive outcomes. Of note, longer pain relief was observed in patients with mandibular division pathology compared with those with maxillary branch or multiple distributions of pain. PRF works by induction of a low-intensity electrical field around sensory nerves that causes an overall decrease in conduction and an inhibition of long-term activation without associated thermal coagulation seen with standard RFA at higher temperatures. Recently, PRF of the Gasserian ganglion was shown to be an effective, safe and nondestructive method for those patients with intractable TN.
射频消融
射频消融（RFA）利用热能破坏组织并破坏髓鞘纤维，因此与局麻药和类固醇阻滞相比，能够提供更长的止痛效果。RFA在靶向SPG治疗顽固性CHs时有强有力的证据。观察性队列研究报告了枕神经痛的短期至中期缓解。同样，在TN患者中，半月节RFA预后较好。值得注意的是，与涉及上颌支或多分支疼痛分布的患者相比，单纯下颌支病变的患者疼痛缓解时间更长。PRF通过在感觉神经周围传导低强度电场来起作用，这会导致疼痛传导减少和长期激活的抑制，并且不会像标准RFA一样产生热凝。最近，对于那些难治性TN患者，半月节PRF被证明是一种有效、安全且无损的方法。
Chemical Neurolysis and Chemodenervation
Neurolysis of any nerve can be achieved through conventional radiofrequency, electromagnetic field PRF, or chemical neurolysis with phenol and alcohol, or more commonly glycerol. Neurolysis of the Gasserian ganglion has been used for TN and CHs. The most common complication includes facial hypoesthesia for > 2 weeks. Rare complications, from 0% to 2%, are cranial neuropathies and bacterial meningitis. Another option is percutaneous microcompression using a balloon catheter to compress the Gasserian ganglion. Neurolysis of the SPG has shown promise in treating patients with sphenopalatine neuralgia, TN, CH, migraine, and other atypical facial pain. The SPG is targeted through an infrazygomatic approach.
化学性神经毁损
任何神经的神经毁损都可以通过常规的射频，电磁场PRF以及苯酚、酒精或更常见的甘油化学神经毁损来实现。半月节的神经毁损已被用于TN和CHs。最常见的并发症包括面部超过 2周的感觉迟钝。罕见的并发症是颅神经病变和细菌性脑膜炎，发病率约为0％至2％。另一种选择是使用经皮球囊压迫来破坏半月节。SPG的神经毁损可用于治疗蝶颚神经痛、TN、CH、偏头痛和其他非典型性面部疼痛。通过颧牙槽通道达到SPG。