运动皮质电刺激治疗神经病理性疼痛的研究进展

背景 神经病理性疼痛表现为慢性、顽固性疼痛,发病机制仍不十分清楚.临床疗效不佳,探讨新的治疗神经病理性疼痛的方法,越来越受到更多临床医生的关注.目前神经病理性疼痛运动皮质刺激(motor cortex stimulation,MCS)的临床应用和研究较多. 目的 探讨慢性、顽固性神经病理性疼痛安全、有效的非药物治疗方法. 内容 总结分析近20年来国外MCS临床应用及研究有关文献,探讨其方法、可能的治疗机制及研究进展,对MCS临床疗效及优、缺点进行分析. 趋向 MCS是临床上治疗慢性、顽固性神经病理性疼痛较为理想的方法,但还存在一些问题,应进行更多研究、不断改进及完善.     

Efficacy of motor cortex stimulation for intractable central neuropathic pain: comparison of stimulation parameters between post-stroke pain and other central pain

Motor cortex stimulation (MCS) has now become the preferred option for neurosurgical management of intractable central neuropathic pain such as post-stroke pain and trigeminal neuropathic pain. However, the efficacy of MCS for other central neuropathic pain such as pain resulting from spinal cord or brainstem lesions is unclear. We retrospectively reviewed 11 consecutive patients with intractable central neuropathic pain who underwent MCS in our institution. Eight patients had poststroke pain caused by thalamic hemorrhage (n = 5) or infarction (n = 3) (thalamic group). Two patients had postoperative neuropathic pain caused by spinal cord lesions, and one patient had facial pain caused by a brainstem lesion associated with multiple sclerosis (brainstem-spinal group). Visual analog scale and stimulation parameters were evaluated at 1 and 6 months postoperatively. MCS was effective for six of eight patients in the thalamic group, and all three patients in the brainstem-spinal group. These efficacies continued for 6 months after surgery without significant change in the stimulation parameters compared with the parameters at 1 month in both groups. The mean amplitude at 1 month and frequency at 6 months after surgery were significantly higher in the brainstem-spinal group than the thalamic group, although the patient number was small. MCS is effective for other central neuropathic pain, but higher intensity stimulation parameters may be necessary to gain adequate pain reduction.     

Efficacy and safety of motor cortex stimulation for chronic neuropathic pain: critical review of the literature

OBJECT: The authors systematically reviewed the published literature to evaluate the efficacy of and adverse effects after motor cortex stimulation (MCS) for chronic neuropathic pain. METHODS: A search of the PubMed database (1991-2006) using the key words "motor cortex," "stimulation," and "pain" yielded 244 articles. Only original nonduplicated articles were selected for further analysis; 14 studies were identified for critical review. All were series of cases and none was controlled. The outcomes in 210 patients were assessed and expressed as the percentage of patients that improved with the procedure. Results A good response to MCS (pain relief > or = 40-50%) was observed in approximately 55% of patients who underwent surgery and in 45% of the 152 patients with a postoperative follow-up > or = 1 year. Visual analog scale scores were provided in 76 patients, revealing an average 57% improvement in the 41 responders. A good response was achieved in 54% of the 117 patients with central pain and 68% of the 44 patients with trigeminal neuropathic pain. Adverse effects were reported in 10 studies, including 157 patients. Infections (5.7%) and hardware-related problems (5.1%) were relatively common complications. Seizures occurred in 19 patients (12%) in the early postoperative period, but no chronic epilepsy was reported. Conclusions The results of the authors' review of the literature suggest that MCS is safe and effective in the treatment of chronic neuropathic pain. Results must be considered with caution, however, as none of the trials were blinded or controlled. Studies with a better design are mandatory to confirm the efficacy of MCS for chronic neuropathic pain.     

Efficacy of high-intensity laser therapy in the treatment of chronic neck pain: a randomized double-blind placebo-control trial

The aim of the study was to investigate the effect of high-intensity laser therapy (HILT) in treatment of patients with chronic neck pain (CNP) on cervical range of motion (ROM), pain, and functional activity. Sixty male patients participated in this study with mean (SD) age of 35.47 (4.18) years. Patients were randomly assigned into two groups and treated with HILT plus exercise (HILT?+?EX) and placebo laser plus exercise (PL?+?EX) in groups 1 and 2, respectively. The outcomes measured were cervical ROM, pain level by visual analog scale (VAS), and functional activity by neck disability index (NDI) score. Statistical analyses were performed to compare the differences between baseline and post-treatment. The level of statistical significance was set as p?<?0.05. Cervical ROM significantly increased after 6 weeks of treatment in all groups. VAS and NDI results showed significant decrease post-treatment in both groups. HILT?+?EX effectively increased cervical ROM and decreased VAS and NDI scores after 6 weeks of treatment compared to PL?+?EX. HILT?+?EX is an effective physical therapy modality for patients with CNP compared to PL?+?EX therapy. The combination of HILT?+?EX effectively increased cervical ROM, functional activity, and reduced pain after 6 weeks of treatment.     

Efficacy of cranial electrotherapy stimulation for neuropathic pain following spinal cord injury: a multi-site randomized controlled trial with a secondary 6-month open-label phase

Background

Chronic pain is a significant problem for many individuals following spinal cord injury (SCI). Unfortunately, SCI-related neuropathic pain has proven to be largely refractory to analgesic medications and other available treatments. Cranial electrotherapy stimulation (CES) has been effective in managing some types of pain. It involves the application of a small amount of current through the head via ear clip electrodes.

Objective

Explore the effectiveness of CES for neuropathic pain in persons with SCI and chronic pain.

Study design

Multi-site, double-blind, sham-controlled study.

Participants

Adults with SCI and chronic neuropathic pain at or below the level of injury were randomized to receive active or sham CES.

Intervention

Application of active CES or sham CES 1 hour daily for 21 days. Six-month open-label phase to assess ‘as-needed’ CES use.

Outcome measures

Change in pre- to post-session pain ratings as well as change in pain intensity, pain interference, pain quality, pain beliefs and coping strategies, general physical and mental health status, depressive symptomatology, perceived stress, and anxiety pre- to post-treatment.

Results

The active group reported a significantly greater average decrease in pain during daily treatments than the sham group (Kruskal–Wallis chi-square = 4.70, P < 0.05). During the 21-day trial, there was a significant group × time interaction for only one outcome variable; the active group showed larger pre- to post-treatment decreases in pain interference than the sham group did (F = 8.50, P < 0.01, d = 0.59).

Conclusions

On average, CES appears to have provided a small but statistically significant improvement in pain intensity and pain interference with few troublesome side effects. Individual results varied from no pain relief to a great deal of relief.     

Topical 2% amitriptyline and 1% ketamine in neuropathic pain syndromes: a randomized, double-blind, placebo-controlled trial

BACKGROUND: A double-blind, randomized, placebo-controlled 3-week study evaluated the efficacy of topical 2% amitriptyline, 1% ketamine, and a combination of both in treating patients with neuropathic pain. METHODS: Ninety-two patients with diabetic neuropathy, postherpetic neuralgia, or postsurgical/posttraumatic neuropathic pain with allodynia, hyperalgesia, or pinprick hypesthesia were randomly assigned to receive one of four creams (placebo, 2% amitriptyline, 1% ketamine, or 2% amitriptyline-1% ketamine combined). The primary outcome measure was change in average daily pain intensity (baseline week vs. final week) using an 11-point numerical pain rating scale. Secondary outcomes included the McGill Pain Questionnaire, measures of allodynia and hyperalgesia, and patient satisfaction. RESULTS: A reduction in pain scores of 1.1-1.5 units was observed in all groups, and there was no difference between groups. Blood concentrations revealed no significant systemic absorption. Minimal side effects were encountered. CONCLUSION: This randomized, placebo-controlled trial examining topical 2% amitriptyline, 1% ketamine, and a combination in the treatment of neuropathic pain revealed no difference between groups. Optimization of doses may be required, because another study has revealed that higher concentrations of these agents combined do produce significant analgesia.     

Recovery of pain control by intensive reprogramming after loss of benefit from motor cortex stimulation for neuropathic pain

INTRODUCTION: Motor cortex stimulation (MCS) may serve as an adjunct in managing neuropathic pain after other conservative and interventional methods have failed. However, the magnitude and duration of the benefit are highly variable, with a significant percentage of patients losing pain relief over time. We investigated whether intensive reprogramming could recapture the beneficial effects of MCS. METHODS: Six patients who had previously undergone MCS implantation for neuropathic pain but had lost benefit were brought back for 1-5 days of intensive reprogramming. Four patients were evaluated as inpatients while the others were seen as outpatients during multiple visits over several days. Several hours a day were spent with each patient. Patients completed visual analog scale (VAS) ratings at intervals throughout the reprogramming period to judge effectiveness of stimulation. Pre- and postadjustment VAS were compared using a paired t test. RESULTS: The patients' average age was 50 years (range 26-71). The diagnoses were trigeminal neuropathic pain (2 patients), complex regional pain syndrome I (2), phantom limb pain (1) and poststroke pain (1). The mean duration of pain was 6 years. The MCS benefit had initially lasted for a mean of 7.16 months (range 2-18 months). After reprogramming, 5 of 6 patients experienced improvement in pain. Average VAS scores decreased from 7.44 to 2.28 (p < 0.001) in those patients who responded to reprogramming. The average stimulation parameters in these patients were 5 V amplitude (range 1.7-10), 313 micros pulse width (range 240-390) and frequency of 84 Hz (range 55-130). Three patients experienced seizures during reprogramming. The mean seizure threshold was 8.9 V. No patient experienced seizures at their therapeutic settings. Pain control has been maintained after discharge. CONCLUSION: Intensive reprogramming can recapture the benefit of MCS in patients who have lost pain control. The use of broad dipoles using two contacts rather than one contact of the 1 x 4 electrode array improved the ability to recapture beneficial stimulation. There is a significant risk of seizures during aggressive reprogramming.     

Efficacy of celecoxib versus ibuprofen in the treatment of acute pain: a multicenter,double-blind,randomized controlled trial in acute ankle sprain

Ankle sprain is a common acute soft-tissue injury that often results in pain, inflammation, and ecchymosis. In this multicenter, double-blind, randomized parallel-group study, 445 adult patients received celecoxib 400 mg/day, ibuprofen 2,400 mg/day, or placebo for 10 days. Patients had experienced grade 1 or 2 ankle sprains within 48 hours and had moderate to severe ankle pain. Patient's Global Assessment of Ankle Injury responses, given on days 4 and 8, showed that the celecoxib group improved significantly more than the placebo group did, with 67% of the celecoxib group versus 55% of the placebo group improving at day 4 (P < .05). Patient's Assessment of Ankle Pain Visual Analog Scale on Weight Bearing responses, also given on days 4 and 8, showed that celecoxib was as efficacious in the treatment of ankle sprain as the maximum therapeutic dosage of ibuprofen and that, compared with placebo, it reduced pain significantly more (P < .05). The celecoxib group recovered and returned to function earlier (after 5 days) than did either the placebo group (8 days) or the ibuprofen group (6 days); the celecoxib-placebo difference was significant. Celecoxib, a cyclo-oxygenase-2-specific inhibitor with platelet-function-sparing properties, may be useful as a multimodal adjuvant in the treatment of ankle sprain.     

Precentral cortex stimulation for the treatment of central neuropathic pain: results of a prospective study in a 20-patient series

The authors report a series of 23 patients with central neuropathic pain who were treated with the recently developed technique of precentral cortex stimulation (PCS). Of the 20 patients with a follow-up of more than 1 year (mean of 23 months) 25% had an excellent, 35% a good and 15% a fair relief of pain. In 25% the method failed. On the basis of these findings and the literature data (127 reported cases), the authors advocate PCS in patients with severe and medically refractory poststroke pain.     

Treatment of central and neuropathic facial pain by chronic stimulation of the motor cortex: value of neuronavigation guidance systems for the localization of the motor cortex

Thirty two patients with refractory central and neuropathic pain of peripheral origin were treated by chronic stimulation of the motor cortex between May 1993 and January 1997. The mean follow-up was 27. 3 months. The first 24 patients were operated according to the technique described by Tsubokawa. The last 13 cases (8 new patients and 5 reinterventions) were operated by a technique including localization by superficial CT reconstruction of the central region and neuronavigator guidance. The position of the central sulcus was confirmed by the use of intraoperative somatosensory evoked potentials. The somatotopic organisation of the motor cortex was established peroperatively by studying the motor responses at stimulation of the motor cortex through the dura. Ten of the 13 patients with central pain (77%) and nine of the 12 patients with neuropathic facial pain had experienced substantial pain relief (75%). One of the 3 patients with post-paraplegia pain was clearly improved. A satisfactory result was obtained in one patient with pain related to plexus avulsion and in one patient with pain related to intercostal herpes zoster. None of the patients developed epileptic seizures. The position of the stimulating poles effective on pain corresponded to the somatotopic representation of the motor cortex. The neuronavigator localization and guidance technique proved to be most useful identifying the appropriate portion of the motor gyrus. It also allowed the establishment of reliable correlations between electrophysiological-clinical and anatomical data which may be used to improve the clinical results and possibly to extend the indications of this technique.     

Motor cortex stimulation in the treatment of deafferentation pain. I. Localization of the motor cortex

MRI and electrophysiological techniques to localize the primary motor cortex (MC) were performed on patients considered for MC stimulation for the treatment of deafferentation pain. The representation and trajectory of the rolandic fissure (RF) were accurately localized by external cranial landmarks and radiopaque fiducials superimposed on oblique MRI sections. In addition, the scalp distribution of the corticocortical responses elicited by acute epidural stimulation [motor cortex (MC) in frontal and sensory cortex (SC) in parietal scalp regions], and analgesic responses at the topographical representation of the painful periphery elicited by subacute epidural stimulation were found to be simple and reliable procedures to localize MC, SC and RF.     

Diclofenac and oxycodone in treatment of postoperative pain: a double-blind trial

The effects of a prostaglandin synthesis inhibitor (diclofenac, Voltaren) and an opiate (oxycodone, Oxanest) on postoperative pain were compared. Included in the study were 85 candidates for various operations. Patients requesting an analgesic were given either 75 mg of diclofenac or 10 mg of oxycodone as an intramuscular injection. The onset of analgesic effect occurred within 13 +/- 4 min with oxycodone and within 16 +/- 8 min with diclofenac. The analgesic effect of diclofenac was slightly weaker than that of oxycodone (on a pain scale of 1-4, 1.6/2.1 after 0.5 h and 1.5/1.8 after 1 h). The patients again asked for an analgesic after an average of 4.6 h in the oxycodone group and after an average of 6.1 h in the diclofenac group. The average number of injections required until the first postoperative morning was 2.5 in the oxycodone group and 1.8 in the diclofenac group. Side-effects: 21 patients in the oxycodone group reported a total of 39 side-effects and eight patients in the diclofenac group a total of 10 side-effects. Diclofenac is an alternative to opiates in the management of postoperative pain. It is especially useful in patients in whom opiates cause side-effects.     

Efficacy of oral mexiletine for neuropathic pain with allodynia: a double-blind, placebo-controlled, crossover study

BACKGROUND AND OBJECTIVES: Mexiletine is an oral sodium channel antagonist that has been reported to be effective in a variety of neuropathic pain syndromes. However, recent reports question the efficacy of oral mexiletine in neuropathic pain. The objectives of this study were to examine the effect of oral mexiletine on pain, neurosensation, allodynia, and quality of life. METHODS: Twenty subjects suffering from neuropathic pain with prominent allodynia were enrolled in a randomized placebo-controlled crossover study. Patients were titrated to a maximum dose of 900 mg/d or dose-limiting side effects, whichever occurred first. At baseline and on days 0, 4, 7, and 10, the following tests were performed: (1) Quality of Life Questionnaires; (2) pain scores; (3) area of allodynia; (4) side effects; (5) neurosensory testing; and (6) peak and trough plasma mexiletine levels. RESULTS: Peak plasma levels occurred on day 10 and were 0.54 microg/mL. There was no significant effect on any quality of life measurement. There was no significant effect on any neurosensory threshold or the area of allodynia. There was a significant effect of mexiletine on stroking-induced pain. There were no significant effects on any other pain score. Side effects were negligible. CONCLUSIONS: At doses of up to 900 mg/d, mexiletine has minimal effects on pain and allodynia of neuropathic pain. However, side effects may preclude higher doses.     

Press tack needle stimulation for blunt chest trauma: a randomized double-blind control trial

Open in a separate window OBJECTIVESBlunt chest trauma is often associated with severe pain, reduced lung function and decreased sleep quality. This study aims to investigate the immediate and long-term effect of acupuncture on these factors using a randomized control double-blind design.METHODSA total of 72 patients were randomized into 2 groups: treatment group (press tack acupuncture) and control group (press tack placebo). The face rating scale, numerical rating scale (NRS), portable incentive spirometer and Verran Snyder-Halpern sleep scale were measured at baseline, immediately after the intervention, and at the 4th day, with 2-weeks and 3-months follow-ups.RESULTSThere were no significant changes between the groups at the baseline measurements, with the exception of hypertension comorbidity. Immediately after the intervention and on the 4th day follow-up, the patients in the treatment group showed a significantly lower face rating scale when compared to the control (P < 0.05). There were no significant changes in any of the other measurements between the groups (P > 0.05). Subgroup analysis revealed that the NRS for turn over on the 4th day was reduced significantly in the treatment group of patients without lung contusion (P < 0.05). For patients without pleural drainage, cough NRS in the treatment group was significantly reduced in the 2-week follow-up (P < 0.05).CONCLUSIONSThis study showed that press tack acupuncture effects on pain reduction were inconclusive. However, future studies on the effect of acupuncture on blunt chest trauma patients are needed.Clinical trial registrationclinicaltirl.gov: {"type":"clinical-trial","attrs":{"text":"NCT04318496","term_id":"NCT04318496"}}NCT04318496.     

Efficacy of glucagon in the relief of ureteral colic following treatment by extracorporeal shock wave lithotripsy: a randomized double-blind trial

In a prospective, double-blind, placebo-controlled study 18 patients were evaluated in regard to the effectiveness of glucagon to treat ureteral colic following extracorporeal shock wave lithotripsy. The study groups were comparable. There was no significant difference between glucagon and placebo in relief of pain or in the amount of gravel passed within 48 hours of treatment. We conclude that despite its desirable physiological attributes, glucagon has no demonstrable benefit in the treatment of ureteral colic following extracorporeal shock wave lithotripsy.     

Image-guided motor cortex stimulation in patients with central pain.

According to recent clinical data, motor cortex stimulation (MCS) is an alternative treatment for central pain syndromes. We present our minimally invasive technique of image guidance for the placement of the motor cortex-stimulating electrode and assess the clinical usefulness of both neuronavigation and vacuum headrest. Five patients suffering from central pain underwent MCS with the guidance of a frameless stereotactic system (BrainLab AG, Munich, Germany). The neuronavigation was used for identification of the precentral gyrus and accurate planning of the single burr hole. The exact location was reconfirmed by an intraoperative stimulation test. Postoperative clinical and neuroradiological evaluations were performed in each patient. The navigation system worked properly in all 5 neurosurgical cases. Determination of the placement of stimulating electrode was possible in every case. All patients obtained postoperative pain relief. No surgical complication occurred, and the postoperative course was uneventful in all patients. This preliminary experience may confirm image guidance as a useful tool for the surgery of MCS. Additionally, minimal and safe exposure can be achieved using a single burr hole and vacuum headrest.