EA 4391, Faculté de Médecine de Créteil, Université Paris-Est-Créteil, Créteil, France.
J Pain. 2011 Oct;12(10):1102-11. doi: 10.1016/j.jpain.2011.05.004. Epub 2011 Jul 31.
This study was designed to assess the value of repetitive transcranial magnetic stimulation (rTMS) to predict the efficacy of epidural motor cortex stimulation (EMCS) to treat neuropathic pain. We have included 59 patients treated by EMCS for more than 1 year and in whom active and sham 10Hz-rTMS sessions were performed as preoperative tests, targeted over the cortical representation of the painful area. Analgesic effects were rated on a visual analogue scale. The real rTMS efficacy was determined by subtracting the effect of the sham stimulation on pain scores from that of the active stimulation (active-sham calculation). Pain scores were significantly reduced by active rTMS and EMCS, but not by sham rTMS. Twenty-six of the 33 patients (79%) who responded to active rTMS and all the 21 patients (100%) who responded for active-sham calculation also responded to EMCS. The response observed in active-sham calculation had a positive predictive value of 1.0, but a negative predictive value of .6 regarding EMCS outcome. The analgesic effect of rTMS or EMCS was not influenced by the side, origin, or duration of pain or by the presence of motor or sensory deficit in the painful area. Poorer results were observed in case of lower limb pain for rTMS and in older patients for EMCS. This study confirms that neuropathic pain can be significantly relieved by motor cortex rTMS or EMCS. A positive outcome of EMCS can be predicted by a real response to rTMS, but not on clinical grounds.
Single sessions of sham-controlled preoperative rTMS tests can be used to confirm the indication of EMCS therapy but have no value to exclude patients from this therapy. New rTMS protocols remain to be assessed to improve the usefulness of preoperative rTMS in EMCS practice.
本研究旨在评估重复经颅磁刺激（rTMS）在预测硬膜外运动皮层刺激（EMCS）治疗神经性疼痛疗效中的价值。我们纳入了 59 例接受 EMCS 治疗超过 1 年的患者，在这些患者中，在疼痛区域的皮质代表区进行了主动和假 10Hz-rTMS 治疗作为术前测试。采用视觉模拟评分法评定镇痛效果。通过从主动刺激的疼痛评分中减去假刺激的效果来确定真实 rTMS 的疗效（主动-假计算）。主动 rTMS 和 EMCS 可显著减轻疼痛评分，但假 rTMS 无此作用。26 例对主动 rTMS 有反应的 33 例患者（79%）和所有对主动-假计算有反应的 21 例患者（100%）均对 EMCS 有反应。主动-假计算的反应对 EMCS 结果具有 1.0 的阳性预测值，但阴性预测值为.6。rTMS 或 EMCS 的镇痛效果不受疼痛的侧别、起源或持续时间、疼痛区域的运动或感觉缺陷的影响。rTMS 治疗时下肢疼痛或 EMCS 治疗时患者年龄较大时，结果较差。本研究证实，运动皮层 rTMS 或 EMCS 可显著缓解神经性疼痛。EMCS 的阳性结果可通过 rTMS 的真实反应预测，但仅凭临床依据无法预测。
单次假对照术前 rTMS 测试可用于确认 EMCS 治疗的适应证，但无价值排除该治疗的患者。需要评估新的 rTMS 方案以提高术前 rTMS 在 EMCS 实践中的有用性。
