面部疼痛的鉴别诊断和治疗指南（六）

 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Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111(1):95-104.本次学习由杨聪娴副主任医师主讲。

Trigeminal neuralgia and its variants

Trigeminal neuralgia is defifined by the IASP as 'a sudden usually unilateral severe brief stabbing recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve’; it has a profound effect on quality of life. Although rare, is it the most frequent diagnosis proposed for unilateral episodic pain. Its clinical features are given inTable 2. In rare cases, trigeminal neuralgia is symptomaticof other conditions (e.g. tumours, mostly benign), multiple sclerosis. There is an increasing literature describing variants of trigeminal neuralgia termed type 2, and/or trigeminalneuralgia with concomitant pain. In these cases, there is more prolonged pain in between the sharp shooting attacks. In the classical types, the most common cause is neurovascular compression of the trigeminal nerve in or around the route entry zone whereas Type 2 may be of more central origin.

三叉神经痛及其变异类型

三叉神经痛被IASP定义为“在三叉神经的一个或多个分支的分布区域，突然的通常为单侧的严重短暂刺痛，疼痛反复发作”;严重影响生活质量。虽然罕见，是最常见的单侧发作性疼痛。其临床特征在表2。在少数情况下，三叉神经痛继发于其他疾病(例如肿瘤，大部分是良性的，多发性硬化)。越来越多的文献描述变异的三叉神经痛，被称为2型，和/或三叉神经痛伴有其他疼痛。在这些情况下，严重疼痛的发作间期存在持久的疼痛。在经典类型中，最常见的原因是三叉神经入颅的途径上或周围存在血管神经压迫，而2型可能来源于更接近中枢的位置。

International guidelines and Cochrane reviews suggest that carbamazepine remains the primary drug of choice but oxcarbazepine is equally effective with fewer sideeffects.Other drugs for which there is some evidence include lamotrigine and baclofen. Also, there has been a RCT of gabapentin combined with ropivicaine and a longterm cohort study of pregablin suggesting effificacy.However, in many patients, side-effects become intolerable or pain control becomes sub-optimal; in these cases, surgical interventions are considered. It is important that a neurosurgical opinion is obtained at an early stage. There are very few randomized control trials of surgery. The only non-ablative (destructive) procedure is that of microvascular decompression; however, this is a major neurosurgical procedure in which access is gained to the posterior fossa in order to identify and remove a vascular compression of the trigeminal nerve. The nerve remains intact and so it is rare to get complications related to the trigeminal nerve, although 2–4% may suffer from hearing loss and, as with any major procedure, there is a 0.4% mortality. The chance of being pain free at 10 yr is 70%. Other peripheral ablative procedures are available [e.g. neurectomy, cryotherapy, Gasserian ganglion (e.g. radiofrequency thermocoagulation, glycerol rhizotomy,balloon compression), and posterior fossa level (e.g. rhizotomy, Gamma Knife)]. All destroy to a greater or lesser extent the sensory fifibres of the trigeminal nerve and hence result in varying degrees of sensory loss. These procedures result in an ~50% chance of being pain free at 4 yr. Quality of life can be markedly improved provided there are no complications.

国际指南和Cochrane的综述表明，卡马西平仍然是首选药物，但奥卡西平同样有效，副作用更少。其他有文献证明有效的药物包括拉莫三嗪和巴氯芬。此外，还有一个加巴喷丁联合罗哌卡因的随机对照试验提示有效，一项普瑞巴林的队列研究提示有效。许多患者，药物副作用变得难以忍受或者疼痛控制变差;在这些情况下，应考虑手术干预措施。早期诊断很重要。没有关于手术的随机对照试验。唯一未消融(破坏)是指微血管减压;然而，这是一个大的神经外科手术，到达后颅窝来识别和去除压迫三叉神经的血管。神经保持完整，所以很少出现与三叉神经有关的并发症，有2-4%的患者可能会遭受听力损失，和其他大手术一样，死亡率是0.4%。随访10年的有效率为70%。其他周围神经治疗(如神经切断，冷冻疗法)，半月神经节治疗(如射频热凝、丙三醇破坏、球囊压迫)和后颅窝水平治疗(如神经根切断术、伽玛刀)。都不同程度的破坏了三叉神经的感觉纤维，将导致不同程度的感觉丧失。随访4年的无痛率为50%。只要没有并发症，术后生活质量立即改善。

Glossopharyngeal neuralgia

Glossopharyngeal neuralgia has the same characteristics as trigeminal neuralgia except for location (Table 2). Pain can be experienced in the ear only and therefore confused with TMD; it may also be confifined to the posterior part of the tongue. In rare cases, it can be associated with syncope because of anatomical proximity to the vagus. Management is the same as for trigeminal neuralgia. Microvascular decompression can be performed but is more diffificult technically; there are very few reports of this.

舌咽神经痛

除部位外，舌咽神经痛具有与三叉神经痛相同的特征(表2)。部分患者有耳内疼痛，容易与TMD混淆;部分患者可能局限于舌后部。在极少数情况下，因为解剖上靠近迷走神经，可能伴晕厥。治疗和三叉神经痛是一样的。可以行微血管减压术，但在技术上比较困难;关于这一点的报道很少。

Trigeminal autonomic cephalgias

Trigeminal autonomic cephalgias are a group of unilateral episodic pains, some of which can easily be mistaken for trigeminal neuralgia. These include: short unilateral neuralgiform pain with conjunctival injection, tearing, and redness (SUNCT); and short unilateral neuralgiform pain with crania lautonomic features (SUNA) (e.g. unilateral tearing, meiois, sweating, nasal blockage or rhinorrhea, and ear fullness).The aetiology may be different from trigeminal neuralgia which may account for poorer outcomes after surgery.There are currently no RCTs or even large cohort data on the management of SUNA/SUNCT but treatments with anticonvulsants such as lamotrigine can be effective.

三叉神经自主神经性头痛

三叉神经自主神经性头痛是一组单侧的阵发性疼痛，有些很容易被误诊为三叉神经痛。这些包括:短的单侧神经痛伴结膜充血、流泪、发红(SUNCT);以及伴有颅神经自主神经症状的单侧神经痛(SUNA)(如单侧流泪、瞳孔缩小、出汗、鼻塞或流涕、耳内胀感)。病因可能与三叉神经痛不同，因此手术效果差。目前没有关于SUNA/SUNC的治疗的随机对照试验，甚至没有大型队列数据。抗惊厥药物的治疗如拉莫三嗪可以有效。

Vascular causes

It is essential to consider giant cell arteritis in any patient over the age of 50 who presents with pain in the temporal region which may mimic TMD as this can result in blindness if not rapidly treated. ESR and C reactive protein are typically raised and referral for biopsy should be requested urgently so that treatment with systemic steroids can be commenced. Post-stroke pain can affect part or the whole of the face and its characteristics are described in Table 2. Management is along the same principles as neuropathic pain.

血管原因

50岁以上出现颞部类似TMD疼痛的患者，需要排除巨细胞动脉炎，因为如果不迅速治疗，会导致失明。ESR和C反应蛋白是典型的升高，应尽快进行活检，尽早全身使用类固醇治疗。中风后疼痛可影响部分或整个面部，其特征见表2。治疗是和神经性疼痛的原理是一样的。

Persistent idiopathic facial pain PIFP (atypical facialpain)

When patients present with symptoms that do not fulfifil any criteria currently available, then a diagnosis of persistent idiopathic facial pain (atypical facial pain) is made; the symptoms are described in Table 2. There is often a history of other chronic pain, poor coping skills, and mood disturbance. Management includes use of antidepressants often combined with cognitive behaviour therapy. It is important for the patient’s pain to be acknowledged as real.

持续的特发性面部疼痛PIFP(非典型面痛)

当病人症状不符合目前所有的诊断标准，可以诊断为持久的特发性面部疼痛(非典型性面部疼痛);症状在表2中描述。往往有其他慢性疼痛病史，应对能力差，情绪障碍。管理包括经常联合使用抗抑郁药通过认知行为疗法。承认病人的疼痛是真实的，这非常重要。