脊髓后根入髓区射频毁损术治疗臂丛神经撕脱伤后顽固性疼痛1例并文献复习

目的探讨脊髓背根入髓区(dorsal root entry zone DREZ)切开术在臂丛神经撕脱伤后慢性疼痛中的临床应用。方法1例臂丛神经撕脱伤后顽固性疼痛患者,用DREZ射频毁损术(C3～8)治疗。结果随访10月,止痛效果显著,疼痛减轻85%以上。结论DREZ区切开术对臂丛神经撕脱伤后顽固性疼痛疗效满意,可显著提高患者的生活质量。     

中枢性疼痛的神经外科治疗

目的 研究中枢性疼痛的神经外科治疗策略.方法 根据疼痛性质和部位的不同,行立体定向中脑毁损术1例、双侧扣带回前部毁损术2例、中脑加双侧扣带回联合毁损术9例、运动皮层电刺激术(MCS) 11例、脊髓电刺激术(SCS)3例和脊髓后根入髓区(DREZ)切开术79例次.结果 术后患者疼痛均不同程度减轻,1个月以内镇痛疗效满意,VAS评分较术前均显著降低(P＜0.01).随访12 -36个月,观察术后6个月以上的长期疗效,发现中脑加双侧扣带回联合毁损术好于单纯中脑或扣带回前部毁损术的效果;MCS和SCS治疗的多数患者疗效有波动;DREZ切开术的长期疗效满意,82.1％的臂丛神经撕脱后疼痛患者能够保持50％以上疼痛缓解率,88.9％的脊髓损伤后疼痛患者止痛疗效长期稳定.结论 神经外科止痛手术能够确实有效地治疗中枢性疼痛,脊髓损伤、脊神经根撕脱等脊髓水平的中枢性疼痛应该首选DREZ切开术治疗,对于脑梗死、脑出血等原因造成的中枢性疼痛,MCS是一种可供选择的治疗手段.     

应用脊神经后根入髓区毁损术治疗截瘫后顽固性疼痛

目的 探讨脊神经后根入髓区(DREZ)毁损术治疗截瘫后顽固性疼痛的手术方法和疗效.方法 对截瘫后伴有残肢痛和幻肢痛的8例患者实施相应节段DREZ毁损术,并进行术后3个月、6个月、12个月的随访,平均6.6个月.结果 8例患者疼痛都有不同程度的缓解,其中完全缓解6例.结论 脊神经后根DREZ毁损术治疗伴有脊髓损伤和脊神经根撕脱伤的截瘫患者疼痛疗效确切,掌握好手术适应证十分重要.     

脊髓背根入髓区切开术治疗慢性神经源性疼痛

在20世纪60年代,人们发现脊髓背根入髓区(Dorsal root entry zone,DREZ)与痛觉传导有关,并开始探讨将其作为疼痛手术治疗的靶点.1979年,Nashold和Ostdahl[1]首先报道了用DREZ切开术治疗臂丛神经撕脱伤后疼痛,取得了良好的疗效.此后,又有数例慢性神经源性疼痛患者接受了该手术,包括幻肢痛和脊髓损伤后疼痛.     

脊髓背根入髓区毁损术治疗臂丛神经撕脱伤后疼痛

目的 探讨脊髓背根入髓区毁损术治疗臂丛神经撕脱伤后疼痛的疗效及安全性.方法 15例臂丛神经撕脱伤后疼痛患者接受脊髓背根入髓区毁损术治疗.分别于术后2周、6个月和1年采用视觉模拟评分（VAS）、汉密尔顿抑郁（HAMD）和焦虑评分（HAMA）来评估手术疗效.结果 手术早期,100%的患者疗效满意,经过1年的随访,疗效满意率逐渐下降.但是比较术后2周和术后6个月,以及比较术后2周和术后1年的VAS评分,结果 显示无统计学差异.并发症主要包括同侧下肢的轻度无力（3例）和同侧下肢深感觉障碍（3例）,在术后6个月都有不同程度的恢复.结论 脊髓背根入髓区毁损术是治疗臂丛神经撕脱伤后疼痛的一种安全、有效的措施.     

神经电生理监测在脊髓背根入髓区毁损术中的应用

目的 探讨神经电生理监测在脊髓背根入髓区（DREZ）毁损术治疗慢性神经病理性疼痛 中的应用。方法 回顾性分析2018 年9 月至2019 年3 月，深圳大学总医院神经外科在术中神经电生理 监测下接受DREZ毁损术治疗慢性神经病理性疼痛的患者10 例，应用运动诱发电位（MEP）、体感诱发电 位（SEP）和肌电图（EMG）行术中神经电生理监测并收集临床资料。结果 10 例患者中，6 例为脊髓损伤 后疼痛，均监测双下肢SEP、MEP 及EMG，均经过神经根牵拉刺激确认神经根或马尾；其中2 例患肢SEP 未引出，2 例患肢MEP未引出。4 例为臂丛神经撕脱伤后疼痛患者，其中2 例患侧上肢截肢，监测双下 肢SEP、MEP；未截肢者监测四肢SEP、MEP，1 例患肢SEP 未引出。所有患者中，术中电生理监测一过性 MEP波幅下降＞ 50%者3 例，SEP波幅一过性下降＞ 50% 者2 例。10 例患者术后疼痛均得到显著改善， 缓解程度70%以上。术后4 例患者有轻微感觉减退、肢体肌力减退，2 例患者轻度排尿困难，均为一过 性改变，未见明显术后并发症。结论 行DREZ毁损术的患者病情复杂，术中神经电生理监测难度较大， 但MEP、SEP 及EMG 联合应用可有效提高手术成功率，降低手术并发症。     

脊髓背根入髓区毁损术治疗脊髓和马尾神经损伤后疼痛的长期疗效分析

目的探讨脊髓背根入髓区（dorsal not entry zone,DREZ）显微外科毁损术对脊髓和马尾神经损伤后神经病理性疼痛的长期疗效和安全性。方法脊髓和马尾神经损伤后神经病理性疼痛35例,均行DREZ显微外科毁损术。对所有病人进行术前和术后视觉模拟疼痛评分（VAS）,以术后疼痛缓解〉75％为疗效优秀,疼痛缓解50％～75％为良好,疼痛缓解〈50％为差。结果术后2周疗效优秀33例（94．3％）,疗效差2例（5．7％）。长期随访中,疗效优秀24例（68．6％）,疗效良好6例（17．1％）,疗效差5例（14．3％）。结论DREZ显微外科毁损术对脊髓和马尾神经损伤后神经病理性疼痛长期疗效满意,并发症少,可明显提高病人的生活质量。     

脊髓背根入髓区毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素分析(附105例报告)

目的探讨脊髓背根入髓区(DREZ)毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素。方法回顾性分析2005年8月至2018年1月首都医科大学宣武医院功能神经外科收治的105例臂丛神经损伤后神经病理性疼痛患者的临床资料。根据患者疼痛及感觉缺失区对应的皮节,采用颈髓DREZ毁损术治疗。术后对所有患者行电话或门诊随访,随访内容为疼痛数字评分(NRS),以疼痛改善率[(术前NRS-术后NRS)/术前NRS×100%]评估患者疗效;其中改善率>75%为优秀,50%~75%为良好,≤50%为差。进一步采用单因素和多因素logistic回归分析法判断影响患者疗效的临床因素。结果105例患者的手术均成功。术后并发生症包括:手术同侧下肢麻木33例(31.4%)、下肢深感觉障碍20例(19.0%)、下肢无力9例(8.6%),手术对侧肢体麻木5例(4.8%),硬脊膜漏1例(1.0%);无一例出现切口愈合不良和感染。105例患者的随访时间为(47.3±25.5)个月(10~144个月)。至末次随访,105例患者疼痛的中位改善率(上、下四分位数)为100%(60%,100%);其中,74例(70.5%)为优秀,9例(8.6%)为良好,22例(20.9%)为差。单因素分析结果显示,性别、年龄、损伤原因、疼痛出现的时间、疼痛形式、性质及术后并发症对患者的疗效均无影响(均P>0.05),而病程和脊髓萎缩程度对疗效有影响(均P<0.05)。进一步多因素logistic回归分析结果显示,轻度脊髓萎缩是影响患者疗效的独立保护因素(OR=95.952,95%CI:4.171~2207.414,P=0.004)。结论DREZ毁损术治疗臂丛神经损伤后神经病理性疼痛疗效较好且多较持久;同时有轻度脊髓萎缩的患者手术疗效较好。     

应用显微外科技术治疗臂丛根性撕脱伤临床疗效的初步观察

目的 评价显微外科技术实施神经移位加神经移植治疗臂丛根性撕脱伤的临床疗效.方法 应用显微外科技术,对9例臂丛根性撕脱伤患者采取膈神经、副神经、颈丛运动支、健侧C7和肋间神经移位加神经移植,修复肌皮神经、肩胛上神经、腋神经、上干前股、上干后股和桡神经深支.术后进行上肢功能检查及肌电图检查.结果 随访18～48个月,术后9例患者上肢大部分功能均得到不同程度的恢复.肌电图示肌肉强收缩时均为单纯-混合相.结论 臂丛神经根性撕脱伤应尽早手术治疗,利用显微技术精确地吻合神经是手术成功的关键,移位神经至受体神经距离不够者,可采用其他神经桥接.     

脊髓背根入髓区毁损术治疗脊髓和马尾神经损伤后疼痛

目的 探讨脊髓和马尾神经损伤后疼痛的神经外科治疗方法、效果和安全性.方法 脊髓和马尾神经损伤后疼痛患者14例,年龄28～72岁,病程8个月-28年;疼痛位于下肢感觉减退和缺失区,为烧灼、压榨或痉挛样疼痛,视觉模拟疼痛评分(Visual analogy scale,VAS)8～10分;均伴有不同程度的下肢肌力下降.14例患者共行脊髓背根入髓区(dorsal root entry zone,DREZ)毁损术15次.结果 随访3个月-3年.6例疼痛消失,5例疼痛明显减轻,停用或少量使用镇痛剂,VAS 2～4分;3例疼痛无明显改善.所有病例无严重手术并发症.结论 DREZ毁损术对脊髓和马尾神经损伤后慢性神经病理性疼痛安全有效.     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

The influence of comorbid depression on seizure severity

PURPOSE: To determine the relation between depressive symptoms and seizure severity among people with epilepsy. METHODS: A postal questionnaire was used to survey a nationwide community sample about seizures and depression. The Seizure Severity Questionnaire (SSQ) assessed the severity and bothersomeness of seizure components. The Centers for Epidemiological Studies-Depression scale categorized levels of depression. RESULTS: Respondents categorized as having current severe (SEV, n = 166), mild-moderate (MOD, n = 74), or no depression (NO, n = 443) differed significantly in SSQ scores (all p < 0.0001). People with SEV or MOD reported significantly worse problems than did those with NO depression for overall seizure recovery (mean, 5.3, 4.9, 4.5, respectively); overall severity (5.0, 4.5, 4.2); and overall seizure bother (5.3, 4.8, 4.4) (all p < 0.005). Cognitive, emotional, and physical aspects of seizure recovery also were rated worse among people with SEV than with NO depression (all p < 0.05). Symptoms of depression were significantly correlated with higher levels of all components of generalized tonic-clonic seizure severity (r = 0.33-0.48; all p < 0.0001), and partial seizures (r = 0.31-0.38; all p < 0.01). CONCLUSIONS: Clinically depressed people with epilepsy reported higher levels of perceived severity and bother from seizures, as well as greater problems with overall seizure recovery than did nondepressed people experiencing similar types of seizures. The pervasive influence of depressive symptoms on reports of seizure activity suggests that people with epilepsy should be screened for depression. These data highlight the importance of detecting and treating depression among people with epilepsy.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.