晨读】神经电刺激治疗慢性头面部疼痛：综述（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。

Trigeminal Neuralgia
TN is a condition that causes unilateral, paroxysmal, facial pain. It is mediated by a branch of the trigeminal nerve. Although rare in the general population, TN incidence progresses with age, affecting 2 to 5 per 100,000 per year in the general population and increasing up to 25 per 100,000 per year in people aged > 70 years . Women are 1.5 to 1.75 times more likely to be affected. Trigeminal neuropathy has been seen in higher rates in those diagnosed with arterial hypertension, multiple sclerosis, Charcot-Marie-Tooth neuropathy, and glossopharyngeal neuralgia .The nature of pain is commonly severe electric shock, stabbing pain lasting from <1 second to 2 minutes. Pain can follow from an innocuous stimulus at the trigeminal nerve distribution.

三叉神经痛
TN是单侧、阵发性的面部疼痛性疾病。它由三叉神经的分支介导。尽管在人群中很少见，但TN的发病率随着年龄的增长而发展，在普通人群中为每年2-5人/100,000人，而在70岁以上的人群中为25人/100,000人。女性患病的可能性是男性的1.5至1.75倍。在患有高血压、多发性硬化、腓骨肌萎缩症和舌咽神经痛的患者中，三叉神经病的发生率更高。疼痛的性质通常为严重的电击痛和刺痛，持续时间从不到1秒到2分钟。三叉神经分布处的无害刺激可引起疼痛。

First-line treatment usually is carbamazepine with additional neuropathic pain agents added as needed. Carbamazepine and oxcarbazepine are first-line treatments and have great efficacy in patients with paroxysmal pain; however, these medications often lead to side effects that lead to a reduction in use by 27% and 18% of responding patients, respectively. Further invasive therapy can be undertaken with trigeminal nerve blocks, chemical or radiofrequency denervation, and even intracranial microvascular decompression.

一线治疗通常是卡马西平，并根据需要添加其他神经性止痛药。卡马西平和奥卡西平是一线药物，对阵发性疼痛患者有显著疗效；但是，这些药物通常会导致副作用，分别导致27％和18％有反应的患者减少使用量。进一步的有创治疗包括三叉神经阻滞、化学或射频神经毁损、甚至颅内微血管减压。

Another similar condition includes painful trigeminal neuropathy that is defined as pain in one or more branches of the trigeminal nerve caused by another disorder with likely neural damage. This pain is often nearcontinuous and described as burning or squeezing. In comparison to TN, there are less brief pain paroxysms. PHN is commonly seen in the trigeminal nerve distribution. It is more common in the elderly than younger individuals, and most commonly affects the ophthalmic division when causing facial pain. It can be treated with tricyclic antidepressants or anticonvulsants. Neurolytic treatments are not recommended because of the risk of deafferentation pain. Although the Neuromodulation Appropriateness Consensus Committee has not recommended the use of peripheral nerve stimulation(PNS) for trigeminal face pain, it may warrant consideration when intractable facial pain or headache can be localized to a specific nerve distribution.

另一种三叉神经的神经病理性疼痛是由另一种可能引起神经损伤的疾病引起的三叉神经的一个或多个分支的疼痛。这种疼痛通常是近乎连续的，被描述为灼痛或胀痛。与TN相比，短暂性疼痛发作少。PHN在三叉神经分布中很常见。它在老年人中比年轻人更常见，并且最常见影响眼支引起面部疼痛。三环类抗抑郁药或抗惊厥药可用于治疗。不推荐使用神经毁损疗法，因为它可能会导致去传入疼痛。尽管神经调节适当性共识委员会不建议使用周围神经刺激（PNS）来治疗三叉神经面部疼痛，但是当顽固性面部疼痛或头痛局限在特定的神经分布时，则可能需要考虑。

Glossopharyngeal Neuralgia
Glossopharyngeal neuralgia is a rare condition associated with paroxysmal pain in the distribution of the glossopharyngeal and vagus nerve. Studies have shown an incidence of 0.9 per 100,000 per year in men and 0.5 per 100,000 per year in women, with a mean age of onset of around age 64 years. Although rarer than TN, glossopharyngeal neuralgia has also been associated with multiple sclerosis. Based on International Headache Society classification, the condition involves stabbing pain in the ear, base of tongue, tonsillar region, or the angle of the jaw. Symptoms can also involve an autonomic component with bradycardia and syncopal episodes. Pain of a sharp, electrical nature commonly lasts from a few seconds to minutes. Swallowing, talking, coughing, or yawning often exacerbates this severe pain. Causes can be primary and idiopathic or secondary due to compressive lesions such as tumors, soft tissue and bone, or vascular structures. Neurovascular compression of the glossopharyngeal nerve may be diagnosed on imaging

舌咽神经痛
舌咽神经痛是一种罕见的疾病，与舌咽和迷走神经的分布有关。研究表明，男性的发病率是每年每十万人中有0.9例，女性每年的发病率是每十万人中有0.5例，平均发病年龄为64岁左右。舌咽神经痛虽然比TN少见，但也与多发性硬化症有关。根据国际头痛协会的分类，该病涉及耳朵、舌根、扁桃体区域或下颌角的刺痛。还可能涉及心动过缓和晕厥发作的自主神经症状。尖锐的、触电样的疼痛通常持续几秒钟到几分钟。吞咽、说话、咳嗽或打哈欠通常会加剧这种严重的疼痛感。病因可能是原发的、特发的或者继发的，比如由于诸如肿瘤、软组织和骨骼或血管结构等的压迫。影像学检查可诊断舌咽神经的神经血管受压。

Medical treatment involves anticonvulsants, membrane stabilizers, and antidepressants for neuropathic pain. Nerve blocks can be performed at various branches of glossopharyngeal nerve or vagus nerve, however, their efficacy has been questioned. A randomized, prospective, active-controlled, parallel group study showed similar efficacy in treatment between 15 patients with glossopharyngeal neuralgia treated with standard oral therapy of gabapentin, tramadol, and methylcobalamin and the intervention group that received the same oral therapy with additional extraoral glossopharyngeal nerve blocks. Each patient received a diagnostic block with lidocaine followed by alternating day steroid plus bupivacaine for 3 injections and followed by 2 more blocks of only bupivacaine. This study lacked image guidance to confirm ideal target of injectate. Although nerve blocks did not appear to add benefit, there were no adverse events, and in refractory cases nerve blocks should still be considered.

药物治疗包括抗惊厥药、膜稳定剂和神经性疼痛的抗抑郁药。神经阻滞可以在舌咽神经或迷走神经的各个分支处进行，但是，其功效受到质疑。一项随机、前瞻性、主动控制、平行分组的研究显示，在15例舌咽神经痛患者接受加巴喷丁、曲马多和甲钴胺的标准口服治疗组以及接受相同药物治疗外加舌咽舌神经阻滞治疗的干预组之间的疗效相似。每位患者均进行利多卡因诊断性阻滞，然后每隔1天注射类固醇和布比卡因3次，然后单纯注射布比卡因2次。该研究缺乏影像引导来确定理想的注射靶点。尽管神经阻滞似乎没有增加收益，但也没有不良事件，在难治性病例中仍应考虑神经阻滞

Surgical treatment involves rhizotomy or nerve section, or microvascular decompression of the glossopharyngeal or vagus nerve. A meta-analysis by Lu et al  of 792 patients with glossopharyngeal neuralgia treated surgically either by nerve section(36%), microvascular decompression (56%), or stereotactic radiosurgery (8%) concluded a complete long-term (median 33, 56, and 45 months, respectively) pain relief in 91% overall (96%, 90%, and 82%,respectively). Other studies show surgical treatment has great efficacy; however, temporary nerve deficits can be seen in 20 to 34% of patients with permanent damage in up to 17%. Recently, Gamma Knife radiosurgery has been proposed as a less invasive option.In one case series, 8 of 9 patients underwent a total of 10 Gamma Knife radiosurgeries targeting the glossopharyngeal meatus of the jugular foramen. A total of 8 patients reported pain relief, with 6 patients pain-free at 3 months and at 46 months on average long-term follow-up. Currently, there is no literature to support management of this condition with neurostimulation.

手术治疗包括神经根离断或神经切除术，或舌咽或迷走神经的微血管减压。Lu等人对792例接受外科手术的舌咽神经痛患者进行了荟萃分析：他们分别接受了神经离断术（36％）、微血管减压术（56％）或立体定向放射外科手术（8％），并获得了完整的长期疼痛缓解（中位数分别有33、56和45个月），总体缓解率为91％（分别为96％、90％和82％）。其他研究表明手术治疗具有很好的疗效。但是，20％到34％的患者会出现暂时性神经功能缺损，而永久损害的患者最高可达17％。最近，伽马刀放射外科手术已被提出作为一种创伤较小的选择。在一个病例系列中，9例患者中有8例接受了总共10次针对颈静脉孔的舌咽神经管的伽玛刀放射外科手术。共有8例患者疼痛缓解，其中6例患者在3个月和平均长期随访时长46个月时无疼痛。目前，没有文献支持通过神经刺激来治疗该疾病。