Service de Neurochirurgie, Centre Hospitalier Universitaire, Nantes, France.
Neurourol Urodyn. 2013 Jan;32(1):53-7. doi: 10.1002/nau.22269. Epub 2012 Jun 5.
In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication.
The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients.
The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life.
These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation.
在一些患者中，尽管接受了最佳的药物治疗、神经浸润和阴部神经松解术，慢性盆腔和会阴部疼痛仍无法缓解，生活质量也没有得到改善。这些患者的治疗非常复杂，尤其是在神经调节技术（脊髓刺激、S3 神经根刺激和阴部神经直接刺激）失败后。我们报告了首例两例病例，说明了运动皮层刺激（MCS）在这种新适应证中的价值。
介绍了该技术的病史、决策过程、术中发现和结果。通过在外括约肌中记录术中运动诱发电位，确定了阴部皮质区，从而确认其位于初级运动皮层中，位于下肢和上肢位置之间。由于重复经颅磁刺激（rTMS）在确定对 MCS 有反应的患者中的预测价值已得到确立，因此我们对这两名患者均进行了术前 rTMS 治疗。
第一个患者是一名 74 岁女性，左侧会阴疼痛 11 年。第二个患者是一名 45 岁女性，子宫切除术和卵巢切除术 4 年后出现会阴疼痛。分别随访 40 个月和 19 个月后，两名患者均报告疼痛改善 40%至 50%。坐立时疼痛发作的时间明显从几分钟改善到 90 分钟，这大大提高了日常生活活动和生活质量。
这两例首例病例表明，运动皮层刺激是治疗难治性盆腔和会阴疼痛的一种新方法，应在常规神经调节技术（尤其是脊髓刺激）失败后考虑使用。
