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。     

脊髓后根入髓区切开术治疗臂丛神经根撕脱后疼痛

目的 研究脊髓后根入髓区(DREZ)切开术治疗臂丛神经根撕脱后疼痛的临床应用.方法 本组58例,男53例,女5例,年龄30～71岁.左侧35例,右侧23例,疼痛病程6个月- 50年.术前经镇痛药物及多种止痛手术治疗均无效.结果 患者均在全麻下行DREZ切开术治疗,术后6个月、12个月和超过24个月的止痛疗效良好和优秀的比例分别为87.9％、84.5％和80.0％.无严重并发症出现.结论 DREZ切开术能够有效消除臂丛神经根撕脱后疼痛,疗效确切,效果持久,安全性较高.     

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.     

精神发育迟滞伴严重行为障碍的立体定向外科治疗

目的总结32例脑立体定向双侧杏仁核毁损和扣带回前部切开术治疗精神发育迟滞伴严重行为障碍的临床疗效。方法所有患者均明确诊断为精神发育迟滞伴严重行为障碍,经3年以上的药物治疗无效。术前患者精神发育迟滞程度经韦氏智力测试评估分级,临床症状严重程度经临床大体评定量表(GAS)评估。手术采用脑立体定向,磁共振定位后,双侧杏仁核毁损、扣带回前部切开。手术后随访时间不少于24个月,再次进行病情严重程度评估。结果患者术后经磁共振复查,手术靶点准确无误。手术后的GAS平均分对比手术前有明显提高,患者总体生活质量改善。精神发育迟滞程度在轻度的患者,手术疗效优于中度和重度的精神发育迟滞患者。本组患者未出现严重手术并发症。结论脑立体定向双侧杏仁核毁损联合扣带回前部切开术对于控制轻度精神发育迟滞患者的行为障碍效果较好,生活质量改善明显。     

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.     

双侧内囊前肢和扣带回毁损术治疗难治性强迫症(附34例临床分析)

目的 探讨双侧内囊前肢和双侧扣带回毁损术治疗难治性强迫症的临床疗效.方法 对34例难治性强迫症患者,采用立体定向双侧内囊前肢与扣带回前部毁损术,并分别在术前与术后2周、6个月、1年、2年由精神科医师进行YBOCS、HAMA、HAMD量表评定以及术后疗效评定.5例患者在术后6个月因疗效不佳而接受二次手术.结果 难治性强迫症患者术后各期YBOCS、HAMA、HAMD评分与术前比较均明显下降.术后6个月的总有效率(70.6%)明显低于术后2周的总有效率(94.1%),但术后1年、2年的总有效率与术后6个月的总有效率比较无明显差异.结论 立体定向双侧内囊前肢与双侧扣带回前部毁损术对难治性强迫症患者疗效显著,并可保持较好的远期疗效.     

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.     

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.     

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。     

Drezotomía en el tratamiento del dolor por desaferentización: revisión de resultados y análisis de factores predictores de éxito

Background and objectivesThe treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success.Patients and methodsA retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success.ResultsA total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥ 50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p = .001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits.ConclusionDorsal root entry zone surgery is effective and safe for treating patients with deafferentation pain, especially after brachial plexus injury. It can be considered an alternative treatment after failed neurostimulation techniques for pain control. However, its indication should be considered as the first therapeutic option after medical therapy failure due to its good long-term results.     

Single-unit analysis of the spinal dorsal horn in patients with neuropathic pain.

Despite the key role played by the dorsal horn of the spinal cord in pain modulation, single-unit recordings have only been performed very rarely in this structure in humans. The authors report the results of a statistical analysis of 64 unit recordings from the human dorsal horn. The recordings were done in three groups of patients: patients with deafferentation pain resulting from brachial plexus avulsion, patients with neuropathic pain resulting from peripheral nerve injury, and patients with pain resulting from disabling spasticity. The patterns of neuronal activities were compared among these three groups. Nineteen neurons were recorded in the dorsal horns of five patients undergoing DREZotomy for a persistent pain syndrome resulting from peripheral nerve injury (i.e., nondeafferented dorsal horns), 31 dorsal horn neurons were recorded in nine patients undergoing DREZotomy for a persistent pain syndrome resulting from brachial plexus avulsion (i.e., deafferented dorsal horns), and 14 neurons were recorded in eight patients undergoing DREZotomy for disabling spasticity. These groups were compared in terms of mean frequency, coefficient of variation of the discharge, other properties of the neuronal discharge studied by the nonparametric test of Wald-Wolfowitz, and the possible presence of bursts. The coefficient of variation tended to be higher in the deafferented dorsal horn group than in the other two groups. Two neurons displaying burst activity could be recorded, both of which belonged to the deafferented dorsal horn group. A significant difference was found in term of neuronal behavior between the peripheral nerve trauma group and the other groups: The brachial plexus avulsion and disabling spasticity groups were very similar, including various types of neuronal behavior, whereas the peripheral nerve lesion group included mostly neurons with "nonrandom" patterns of discharge (i.e., with serial dependency of interspike intervals).     

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.     

脊髓电刺激治疗复杂区域性疼痛综合征

目的探讨脊髓电刺激术（spinal cord stimulation,SCS）治疗复杂性区域性疼痛综合征（complex regional pain syndrome,CRPS）的有效性。方法回顾性分析4例CRPS病例,其均经脊髓电刺激手术治疗并随访1年以上,采用视觉模拟疼痛评分（VAS）评估疼痛转归。结果病人术后VAS评分平均降低5．4,3例病人疼痛缓解大于50％,无手术并发症。结论SCS能够安全、有效地治疗CRPS。、     

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.     

Cervicothoracic extradural arachnoid cyst: possible association with obstetric brachial plexus palsy

The association of cervicothoracic extradural arachnoid cysts and obstetric brachial plexus palsy has not previously been reported. We report two patients with this association. The first patient is a 9-month-old boy with left obstetric brachial plexus palsy that developed bilateral leg weakness at 6 months of age owing to compression of the spinal cord by a C6 to T8 left cervicothoracic extradural arachnoid cyst. The second patient is a 3-year-old girl with bilateral brachial plexus palsy and spastic paraparesis who had magnetic resonance imaging at 3 days of age that showed intraspinal cord injury and a cervicothoracic extradural arachnoid cyst compressing the spinal cord. We believe that the association of cervicothoracic epidural arachnoid cysts and obstetric brachial plexus palsy in these patients was causal and recommend that the possibility of a cervicothoracic epidural arachnoid cyst be considered in patients with brachial plexus palsy and evidence of spinal cord injury.     

High-Level Cervical Spinal Cord Stimulation Used to Treat Intractable Pain Arising from Transverse Myelitis Caused by Schistosomiasis

The efficacy of spinal cord stimulation (SCS) for treatment of various chronic painful conditions is well established. Very few reports have documented the use of SCS for treatment of chronic pain after spinal cord injury. We present a case showing a good outcome after such treatment, and suggest that high cervical stimulation may be efficacious. A 53-year-old male underwent SCS on the C1-3 level for treatment of intractable neuropathic pain below the T3 level, and in the upper extremities, arising from spinal cord injury resulting from transverse myelitis caused by schistosomiasis. High cervical SCS significantly improved the pain in the upper extremities and at the T3-T10 dermatome level. The patient continues to report excellent pain relief 9 months later. The present case suggests that high cervical stimulation may improve chronic pain in the upper extremities and the T3-T10 dermatome level arising from spinal cord injury.     

Spinal Cord Stimulation,Conception, Pregnancy,and Labor: Case Study in a Complex Regional Pain Syndrome Patient

Introduction. Interventional modalities for pain treatment are reserved for patients failing multidisciplinary pain management, including psychological, physical, pharmacological, and anesthetic techniques. Objective. Medications for intractable pain may be unacceptable because the risk of teratogenic effects. The purpose of this study is to find out whether spinal cord stimulation may be safe during conception, pregnancy, and delivery. Materials and Methods. We report a 30-year old, female, neonatal nurse who developed left hand burning pain, swelling, coldness, and weakness following a mild brachial plexus injury in a motor vehicle accident. The patient responded well to a combination of Neurontin, Trazadone, Ultram, and Vicodin. A year later, the patient married and wanted to become pregnant but was afraid of possible teratogenic effects of the medications. Therefore, she requested an interventional modality for control of her symptoms. We recommended spinal cord stimulation (SCS) based on our excellent experience with this modality in the management of complex regional pain syndromes (CRPS). However, we did inform the patient that no data had been published regarding the safety of this modality in pregnancy and labor. Results. Cervical SCS resulted in excellent pain control and discontinuation of the medications. Thirteen months later, she delivered a healthy five pound baby girl. Mother and baby were discharged home in two days. The SCS was not turned off at any time during the labor and delivery. Conclusion. SCS was safe for implantation in our case study of a pregnant woman. This may constitute a new indication for SCS in patients otherwise successfully managed with non-interventional modalities for pain control.     

Spinal Cord Stimulation for Pain Management in Ankylosing Spondylitis: A Case Report

Introduction. The classic presentation of ankylosing spondylitis not only impairs spinal mobility but also imposes functional limitations, and fatigue is common. Methods. We report here the outcomes of spinal cord stimulation (SCS) in the case of a 47‐year‐old man with low back and hip/thigh pain due to ankylosing spondylitis, with failed responses to conservative therapies aimed at treating this pain. Results. Spinal cord stimulation induced axial low back and bilateral hip paresthesia resulting in complete subjective pain relief, cessation of analgesic medications, reduced fatigue, and improved sleep patterns. SCS also resulted in improved socioeconomic outcomes with a return to work. Conclusions. With further research in patients with broader presentations of the disease, SCS may prove efficacious in suppressing intractable pain symptoms due to ankylosing spondylitis, thus improving quality of life measures.