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.     

运动皮质电刺激术治疗顽固性神经病理性疼痛

目的研究运动皮质电刺激术（motor cortex stimulation,MCS）治疗顽固性神经病理性疼痛的临床应用。方法脑卒中后疼痛9例,脊髓损伤后疼痛3例,幻肢痛2例。均行MCS治疗,同期植入刺激电极和脉冲发生器。采用视觉模拟疼痛评分（VAS）评价疗效。结果术后疼痛均不同程度减轻,1个月以内镇痛疗效较满意,VAS评分较术前显著降低（P〈0．01）。随访1。5年．多数病人镇痛效果出现波动,调整刺激参数后仍能获得镇痛疗效,疼痛较术前减轻10％～90％,脑卒中后疼痛的长期疗效要好于脊髓损伤后疼痛和幻肢痛。结论MCS是治疗神经病理性疼痛的一种新方法,具有疗效肯定、可调节等优点,术后刺激参数的调整对疗效的影响至关重要。     

脊髓电刺激治疗神经病理性疼痛疗效评定

目的探讨脊髓电刺激疗法(SCS)对神经病理性疼痛的临床疗效。方法从我院接受治疗的神经病理性疼痛患者中选取符合要求的38例患者为研究对象,随机数表法分为A组(20例,硬膜外腔SCS治疗)、B组(18例,传统药物治疗)。采用视觉模拟评分法(VAS)、Oswestry功能障碍指数(ODI)和生命质量评分(QOL)分析治疗前、治疗后3个月、12个月、24个月、36个月的疗效。结果经治疗后,2组VAS值、ODI指数、QOL评分显著降低,与治疗前相比差异有统计学意义(P0.01),且评分的降低具有时间依赖性。A组治疗后各时间段的VAS值、QOL评分、ODI指数较B组改善更为显著(P0.01)。结论与传统药物治疗相比,脊髓电刺激疗法对神经病理性疼痛疗效更为显著,值得临床推广应用。     

高颈段脊髓电刺激治疗脊髓损伤后节段下疼痛1例报告并文献复习

目的探讨脊髓电刺激治疗脊髓损伤后节段下疼痛的可行性。方法对1例经脊髓电刺激治疗的脊髓损伤后节段下疼痛患者的临床资料进行回顾、随访,并复习文献。结果术后1个月患者疼痛缓解50%,2年时患者脉冲发生器开启前后VAS评分缓解30%,SF-36各项计分缓解5%～75%。结论脊髓电刺激可用于脊髓损伤后节段下疼痛的治疗,改善患者生活质量。     

脊髓电刺激治疗带状疱疹后神经痛的临床研究

目的探讨脊髓电刺激治疗带状疱疹后神经痛的疗效。方法回顾性分析自2014年10月至2015年10月收治的5例带状疱疹后神经痛经脊髓电刺激手术治疗患者的临床资料,结合复习文献进行分析。脊髓电刺激手术分两期进行,若经电刺激Ⅰ期手术测试有效,则Ⅱ期手术植入脉冲发生器。手术前后采用疼痛视觉模拟评分(VAS)和疼痛伤残量表(PDI)评估疗效,随访18个月。患者手术后VAS评分较术前下降50%,判定为有效。结果本研究纳入的5例患者中,3例患者经电刺激Ⅰ期手术测试有效后Ⅱ期手术植入脉冲发生器,Ⅰ期手术测试有效率为60%(3/5例)。Ⅱ期手术植入脉冲发生器的患者VAS评分术前均为10分,术后VAS分别为2、4和10分;PDI评分术前分别为52、56和49分,术后分别为16、30和49分;手术有效率为66.7%(2/3例)。所有患者围手术期和术后未出现并发症。结论脊髓电刺激治疗带状疱疹后神经痛安全、有效。     

脊髓和马尾神经损伤后慢性神经源性疼痛外科治疗策略

目的 探讨脊髓和马尾神经损伤后慢性神经源性疼痛的神经外科治疗策略.方法 脊髓和马尾神经损伤后慢性神经源性疼痛20例,年龄28～81岁,病程8个月～50年.共行镇痛手术23次,其中,脊髓背根入髓区显微外科切开术19次,脊髓电刺激术3次,鞘内靶控输注系统植入术1次.采用视觉模拟评分（VAS）来评估手术疗效,以术后疼痛缓解大于75%为疗效优秀,疼痛缓解50%～75%为良好,疼痛缓解小于50%为差.结果 随访6个月～4年,10例疼痛消失,停用镇痛剂,生活质量改善;7例疼痛明显减轻,VAS 2～4分,其中,5例停用镇痛剂,2例镇痛剂使用量明显下降,生活质量改善;3例疼痛无明显改善.结论 脊髓背根入髓区显微外科切开术和脊髓电刺激术对脊髓和马尾神经损伤后慢性神经源性疼痛患者疗效满意,但其适应证有差别,应根据患者的损伤节段、损伤程度和疼痛部位等具体情况选择手术方式.     

TENS加激光治疗脊髓损伤中枢性疼痛临床观察

目的探讨经皮神经电刺激联合激光治疗脊髓损伤后中枢性疼痛的临床效果。方法对53例脊髓损伤后中枢性疼痛患者采取经皮神经电刺激和激光治疗,采用McGill疼痛问卷和疼痛视觉拟评分法(VAS)评定治疗前和治疗4周后效果。结果治疗前后各项疼痛评分明显下降(P<0.05),效果明显。结论经皮神经电刺激联合激光治疗脊髓损伤后中枢性疼痛效果明显,疗效肯定。     

高颈段脊髓电刺激治疗重度意识障碍的疗效分析

目的探讨高颈段脊髓电刺激（spinal cord stimulation,SCS）对重度意识障碍病人的促醒疗效。方法回顾性分析22例重度意识障碍病人的临床资料,其中植物状态8例,最小意识状态14例。病人在原发病急性期后3个月接受电生理评估,15例病人在满足电生理评估标准后接受高颈段SCS治疗,余9例未接受治疗。结果所有病人随访9个月,接受SCS治疗的15例病人中清醒9例,GOS评分：轻度残疾2例,中度残疾2例,重度残疾5例;刺激后脑血流量较刺激前增加了36．6％（t=2．775,P〈0．05）。未接受SCS治疗的病人均未清醒。结论高颈段SCS是治疗重度意识障碍病人较为适合的方法。     

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.     

脊髓电刺激术治疗遗传性脊髓小脑性共济失调1例报道并文献复习

目的 探讨脊髓电刺激术（SCS）治疗遗传性脊髓小脑共济失调（SCA）步态障碍的有效性及可行性。方法 回顾性分析2021年7月SCS治疗的1例6型遗传性SCA(SCA-6型)的临床资料,并结合文献进行复习。结果 成功实施SCS,电极靶点设置在T9～11硬脊膜外间隙,在神经电生理监测下将电极调整至生理中线处。术后复查胸椎CT并三维重建示电极位置满意,术后2周开机行电刺激,制定个体化调控方案。术后1个月,开机状态下,病人步态不稳及平衡障碍明显改善。术后7个月,Tinetti步态与平衡试验量表评分由术前14分提升到24分;Barthel指数由40分提升至80分。术后1年,Tinetti步态与平衡试验量表评分达到25分,Barthel指数提升至85分。结论 我们探索性地将SCS应用于SCA病人,术后病人步态及平衡障碍显著改善。这为步态障碍病人提供了一种可行的、有效的治疗方式。由于目前国内尚无相关报道,这方面的经验尚少,需进一步开展多中心的临床随机对照研究,验证SCS治疗步态障碍的疗效,并探索最佳靶点位置、刺激参数等,以更好地帮助共济失调病人改善症状。     

Allodynia,Hyperalgesia, (Quantitative) Sensory Testing and Conditioned Pain Modulation in Patients With Complex Regional Pain Syndrome Before and After Spinal Cord Stimulation Therapy

ObjectivesComplex regional pain syndrome (CRPS) is a chronic debilitating disease characterized by sensory abnormalities. Spinal cord stimulation (SCS) is an effective therapy for CRPS, but few studies have investigated the effects of SCS therapy on sensory characteristics. Therefore, this study investigated the effect of SCS on allodynia, hyperalgesia, electrical quantitative sensory testing (QST) parameters, and conditioned pain modulation (CPM) effect.Materials and MethodsThis study is part of a multicenter randomized controlled trial (ISRCTN 36655259). Patients with CRPS in one extremity and eligible for SCS were included. The outcome parameters allodynia (symptom and sign), hyperalgesia (symptom), sensory thresholds with QST, CPM effect, and pain scores were tested before and after three months of SCS (40-Hz tonic SCS). Both the CRPS-affected extremity and the contralateral, clinically unaffected extremity were used to test three sensory thresholds with electrical QST: current perception threshold (CPT), pain perception threshold (PPT), and pain tolerance threshold (PTT). The PTT also was used as a test stimulus for the CPM paradigm both before and after the conditioning ice-water test. Nonparametric testing was used for all statistical analyses.ResultsIn total, 31 patients were included for analysis. Pain, allodynia (sign and symptom), and hyperalgesia (symptom) were all significantly reduced after SCS therapy. On the unaffected side, none of the QST thresholds (CPT, PPT, and PTT) was significantly altered after SCS therapy. However, the CPT on the CRPS-affected side was significantly increased after SCS therapy. A CPM effect was present both before and after SCS.ConclusionsStandard 40-Hz tonic SCS significantly reduces pain, hyperalgesia, and allodynia in patients with CRPS. These findings suggest that SCS therapy should not be withheld from patients who suffer from allodynia and hyperalgesia, which contradicts previous findings derived from retrospective analysis and animal research.ISRCTN Registry: The ISRCTN registration number for the study is ISRCTN 36655259.     

Spinal Cord Stimulation in Complex Regional Pain Syndrome Type I of Less Than 12‐Month Duration

Introduction: Complex regional pain syndrome type 1 (CRPS‐1) has a 31% probability of becoming chronic. The early use of spinal cord stimulation (SCS) has been recommended as a strategy to prevent chronicity and functional impairment. Methods: In a prospective study, we treated 74 CRPS‐1 patients with a mean disease duration of 17 weeks with standard therapy consisting of physical therapy, topical dimethyl sulfoxide, analgesics, transcutaneous stimulation, and sympathetic blockade. Patients who did not respond to standard therapy were offered a treatment with SCS. In these patients, we investigated the impact on pain, quality of life, and function. Results: Out of these 74 patients treated with standard therapy, six patients were included for early SCS treatment. The overall mean pain relief after one year was 35%. The mental component of the Short Form 36 improved; however, there was no effect on the physical component. None of the SCS treated patients showed a clear improvement in functional outcome. Discussion: We conclude that the feasibility of performing a randomized controlled trial on early SCS therapy in CRPS‐1 is low because of the good disease improvement with standard therapy in the first year after onset. This study raises questions about the need to use SCS early in the course of CRPS‐1 because of the probable lack of additional benefit compared with SCS in chronic CRPS‐1.     

Direct Sciatic Nerve Electrical Stimulation for Complex Regional Pain Syndrome Type 1

ObjectiveFoot and leg pain in complex regional pain syndrome (CRPS) presents a challenge even with neuromodulation techniques such as spinal cord stimulation (SCS). We report our experience with a novo technique of direct sciatic nerve electrical stimulation (DISNES) for intractable foot and leg pain in CRPS I.Materials and MethodsFollowing Research Ethics Board (REB) approval, data were gathered for 16 patients (10 women and 6 men, age 26–61 years) who had been subjected to ipsilateral DISNES. All 16 patients had failed conventional medical management. As well, seven subjects were previously treated with SCS for CRPS I pain. These subjects reported pain relief in the thigh and leg, however the SCS was unable to alleviate the disabling foot pain despite varied and multiple programming techniques. The remaining nine subjects were treated primarily with DISNES. Evaluation was done using visual analog scale (VAS), Oswestry Disability Index version 2 (ODI), and quality of life (EQ-5D and SF-36) scores done both pre-DISNES and at two follow-ups.ResultsVAS scores decreased by 59% at follow-up (F/U) 1 (P = 0.00001) and 46% F/U 2. ODI improving by 40% F/U 1 (P = 0.0038) and 37% F/U 2. SF-36 scores improved by 69% F/U 1 (P = 0.015) and 80% F/U 2. EQ-5D scores improved significantly by F/U 1 (P = 0.00030) but insignificantly at F/U 2 (P = 0.81). There was also a rapid resolution of autonomic features such as edema, hyperemia, and allodynia (within 7–10 days). Three subjects returned to work post-DISNES.ConclusionOur study shows that DISNES helps to control the disabling foot pain in CRPS I, thus improving the quality of life, improving ambulation and decreasing disability. DISNES also alleviates autonomic features and dystonia in CRPS I. Further studies are needed to determine long-term efficacy as this study pool is limited in size and follow-up period.     

Spinal Cord Stimulation: A 20‐Year Retrospective Analysis in 260 Patients

Introduction. Spinal cord stimulation (SCS) is used clinically by many pain physicians and neurosurgeons alike without regard to their own outcome data. Methods. We reviewed our 20‐year experience retrospectively of patients receiving SCS implants and analyzed our data by pain type and group. Results. We present 260 patients, 140 men and 120 women. The most frequent type of pain in our series was neuropathic pain in 44.25% and the most frequent diagnosis was peripheral vascular disease (PVD) with 98 cases. The second was failed back surgery syndrome (FBSS) with 65 cases and the third was complex regional pain syndrome type I (CRPS I), with 40 cases. In CRPS group, the mean visual analog scale (VAS) of this group was 77.89 ± 13.38. In total, 5% had no pain relief, 40% had poor pain relief, 47.5% had good pain relief, and 7.5% had excellent pain relief. In FBSS group, the mean VAS was 79.62 ± 11.69 mm. A total of 13.80% had no pain relief at all, 35.39% had poor pain relief, 50.76% had good pain relief, and there were no patients in this group who had complete pain relief. A total of 98 patients, 78 men and 20 women, were diagnosed with PVD. The mean VAS of this group was 69.75 ± 14.36 mm. A total of 11.22% had poor pain relief, 87.75% had good pain relief. One patient had complete pain relief and all patients in this group perceived at least some improvement in their symptoms. The rate of complications was close to 28% in our overall sample. Conclusions. In conclusion, we demonstrated the utility over time of this type of treatment is comparable with other series of efficacy of SCS. The analgesic efficacy was close to 65% in the overall group. The therapy was not free of complications. The preponderance of our patients was patients with the diagnosis of PVD and our results in this group of patients were excellent. These excellent results of more than 90% improvement suggest to us that SCS be considered as a first‐line approach to the clinical management of patients with pain and ulcer of PVD.     

Long-Term Outcomes of Spinal Cord Stimulation With Paddle Leads in the Treatment of Complex Regional Pain Syndrome and Failed Back Surgery Syndrome

Introduction: Spinal cord stimulation (SCS) is frequently used to treat chronic, intractable back, and leg pain. Implantation can be accomplished with percutaneous leads or paddle leads. Although there is an extensive literature on SCS, the long‐term efficacy, particularly with paddle leads, remains poorly defined. Outcome measure choice is important when defining therapeutic efficacy for chronic pain. Numerical rating scales such as the NRS‐11 remain the most common outcome measure in the literature, although they may not accurately correlate with quality of life improvements and overall satisfaction. Methods: We reviewed the medical records of patients with failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS) implanted with SCS systems using paddle leads between 1997 and 2008 at the Cleveland Clinic with a minimum six‐month follow‐up. Patients were contacted to fill out a questionnaire evaluating outcomes with the NRS‐11 as well as overall satisfaction. Results: A total of 35 eligible patients chose to participate. More than 50% of the patients with CRPS reported greater than 50% pain relief at a mean follow‐up of 4.4 years. Approximately 30% of the FBSS patients reported a 50% or greater improvement at a mean follow‐up of 3.8 years. However, 77.8% of patients with CRPS and 70.6% of patients with FBSS indicated that they would undergo SCS surgery again for the same outcome. Conclusion: Patients with CRPS and FBSS have a high degree of satisfaction, indexed as willingness to undergo the same procedure again for the same outcome at a mean follow‐up of approximately four years. The percentage of satisfaction with the SCS system is disproportionally greater than the percentage of patients reporting 50% pain relief, particularly among patients with FBSS. This suggests that the visual analog scale may not be the optimal measure to evaluate long‐term outcomes in this patient population.     

Spinal cord stimulation for neuropathic pain

Spinal cord stimulation (SCS) is used for more than 40 years to treat localized chronic medically refractory neuropathic pain involving limb(s) and trunk. The most frequent indications remain complex regional pain syndrome (CRPS) failed back surgery syndrome (FBSS), and peripheral neuropathy. Stimulation-induced paresthesias, perceived by the patient, prevent blinded evaluation and increase the placebo effect, decreasing the credibility of the tonic SCS efficacy. Retrospective studies reported that about 50% of the patients are improved more than 50% at short-term, but long-term improvement is less. Several comparative randomized trials (RCT) are now available. In CRPS, a RCT demonstrated the superiority of SCS plus physiotherapy compared to physiotherapy alone. In FBSS, two RCTs have shown that SCS was superior to reoperation and conventional medical treatment, (CMM) respectively. New stimulation waveforms, namely burst, high frequency (10 KHz) stimulation and close-loop SCS, have been proposed recently to avoid the perception of paresthesias and/or increase the pain relief. RCTs in FBSS have suggested that these new SCS modalities were as least as efficient than conventional tonic SCS and perhaps slightly superior. Two RCTs confirmed SCS efficacy in painful diabetic neuropathy in comparison with CMM. Complications are frequent (hardware dysfunction or migration, superficial infection) but exceptionally serious. Consequently, the risk/benefit ratio is favorable to SCS, considering that chronic pain patients undergoing this procedure are usually resistant to all the other therapies.     

Spinal Cord Stimulation With Hybrid Lead Relieves Pain in Low Back and Legs

Objective: The failed back surgery syndrome (FBSS) is the most common chronic pain syndrome. Whereas it is relatively easy to achieve pain relief in the lower limbs of FBSS patients with spinal cord stimulation (SCS), it is difficult to manage low back pain with SCS. The performance of a paddle‐shaped SCS lead that can be inserted surgically as well as percutaneously (a hybrid lead) was evaluated in a prospective study on the relief of low back pain and leg pain in patients with FBSS. Materials and Methods: Patients with FBSS being eligible for SCS were enrolled in the study, and a hybrid lead was placed surgically. Outcome measures included pain scores for low back and leg pain assessed by visual analog scale (VAS), pain medication, and patient satisfaction. These scores were assessed before and at regular intervals after implantation. Results: It was shown that a single hybrid lead, generally positioned over the physiological midline of the spinal cord, is capable of alleviating both low back and leg pain in patients with FBSS. Forty‐five subjects were eligible for SCS and received trial stimulation. Forty‐two of them had a successful trial period and were converted to a permanent system. Their average VAS score at baseline was 8.0 for lower limb pain and 7.5 for low back pain. After six months of SCS, these average VAS scores were reduced to 3.2 and 3.5, respectively, and also pain medication was reduced significantly. Conclusion: SCS with a hybrid lead in subjects with FBSS is safe, and causes significant pain relief in both the low back and the lower limbs.     

Application of Spinal Cord Stimulation for the Treatment of Abdominal Visceral Pain Syndromes: Case Reports

Spinal cord stimulation (SCS) has traditionally been applied to the treatment of neuropathic pain with good to excellent outcomes. Visceral pain syndromes can be just as debilitating and disabling as somatic and neuropathic pain, however, there seems to be a general lack of consensus on appropriate treatment strategies for these disorders. We present here several case studies to demonstrate the viscerotomal distribution of abdominal visceral pain pathways and the application of traditional SCS techniques for its management. Nine patients, experiencing abdominal visceral pain due to various conditions including chronic nonalcoholic pancreatitis, post‐traumatic splenectomy, and generalized abdominal pain secondary to laparotomies, were treated with SCS. Efficacy of treatment was evaluated using the Visual Analog Scale (VAS) for pain intensity and a reduction, if any, in opioid intake. There was an overall mean reduction of 4.9 points in the VAS score for pain intensity and a substantial (> 50%) decrease in narcotic use. All patients were followed for more than one year with excellent outcomes and minimal complications. We conclude, based on these case reports, that SCS might be an effective, nondestructive, and reversible treatment modality for abdominal visceral pain disorders.     

Spinal Cord Stimulation for Visceral Pain From Chronic Pancreatitis

Background and Objectives: Spinal cord stimulation (SCS) may reduce pain scores and improve function in patients with various chronic abdominal pain syndromes including chronic pancreatitis. Here described is a large clinical experience in SCS for severe chronic pancreatitis. Methods: SCS was trialed in 30 patients with chronic pancreatitis. SCS trials lasted 7–14 days (median 9 days). SCS lead tips were mostly positioned at the T5 (N= 10) or T6 (N= 10) vertebral level. Results: Twenty‐four patients (80%) reported at least 50% pain relief on completion of the trial. Among these, pre‐trial visual analog scale (VAS) pain scores averaged 8 ± 1.6 (standard deviation) and opioid use averaged 165 ± 120 mg morphine sulfate equivalents. During the trial, VAS pain scores decreased to 3.67 ± 2 cm (p < 0.001, Mann–Whitney Rank Sum Test) and opioid use decreased to 105 ± 101 mg morphine equivalent a day. Six patients failed the trial; one was lost to follow‐up; in three patients after the implantation, the system had to be removed due to infection or lead migration; and 20 were followed for the whole year. For 20 patients followed for the whole year, VAS pain scores remained low (3.6 ± 2 cm; p < 0.001) at one year, as did opioid use (48.6 ± 58 mg morphine equivalents). Conclusions: SCS may be a useful therapeutic option for patients with severe visceral pain from chronic pancreatitis. Prospective trial is warranted.