Jakobs Martin, Unterberg Andreas, Treede Rolf-Detlef, Schuh-Hofer Sigrid, Ahmadi Rezvan
Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
Centre for Biomedicine and Medical Technology, Mannheim, Germany.
Acta Neurochir (Wien). 2016 Sep;158(9):1767-74. doi: 10.1007/s00701-016-2881-6. Epub 2016 Jul 2.
Neurosurgical pain management of drug-resistant trigeminal neuralgia (TN) is highly challenging. Microvascular decompression is a first-line neurosurgical approach for classical TN with neurovascular conflict, but can show clinical relapse despite proper decompression. Second-line destructive techniques like radiofrequency thermocoagulation have become reluctantly used due to their potential for irreversible side effects. Subcutaneous peripheral nerve field stimulation (sPNFS) is a minimally invasive neuromodulatory technique which has been shown to be effective for chronic localised pain conditions. Reports on sPNFS for the treatment of trigeminal pain (sTNFS) are still sparse and primarily focused on pain intensity as outcome measure. Detailed data on the impact of sTNFS on attack frequency are currently not available.
Patients were classified according to the International Headache Society classification (ICHD-3-beta). Three patients had classical TN without (n = 3) and another three TN with concomitant persistent facial pain (n = 3). Two patients suffered from post-herpetic trigeminal neuropathy (n = 2). All eight patients underwent a trial stimulation of at least 7 days with subcutaneous leads in the affected trigeminal area connected to an external neurostimulator. Of those, six patients received permanent implantation of a neurostimulator. During the follow-up (6-29 months, mean 15.2), VAS-scores, attack frequencies, oral drug intake, complications and side effects were documented.
Seven out of eight patients responded to sTNFS (i.e. ≥50 % pain reduction) during the test trial. The pain intensity (according to VAS) was reduced by 83 ± 16 % (mean ± SD) and the number of attacks decreased by 73 ± 26 % (mean ± SD). Five out of six patients were able to reduce or stop pain medication. One patient developed device infection. Two patients developed stimulation-related side effects which could be resolved by reprogramming.
Treatment by sTNFS is a beneficial option for patients with refractory trigeminal pain. Prospective randomised trials are required to systematically evaluate efficacy rates and safety of this low-invasive neurosurgical technique.
耐药性三叉神经痛（TN）的神经外科疼痛管理极具挑战性。微血管减压术是经典型伴有神经血管冲突的TN的一线神经外科治疗方法，但即便减压得当仍可能出现临床复发。像射频热凝术这样的二线毁损性技术因存在不可逆副作用的风险而只能勉强使用。皮下外周神经场刺激（sPNFS）是一种微创神经调节技术，已被证明对慢性局部疼痛有效。关于sPNFS治疗三叉神经痛（sTNFS）的报道仍然很少，且主要关注疼痛强度这一结果指标。目前尚无关于sTNFS对发作频率影响的详细数据。
根据国际头痛协会分类（ICHD - 3 - beta）对患者进行分类。3例为无伴随症状的经典型TN（n = 3），另外3例为伴有持续性面部疼痛的TN（n = 3）。2例患有疱疹后三叉神经病变（n = 2）。所有8例患者均在患侧三叉神经区域皮下放置电极并连接外部神经刺激器进行了至少7天的试验性刺激。其中，6例患者接受了神经刺激器永久植入。在随访期间（6 - 29个月，平均15.2个月），记录视觉模拟评分（VAS）、发作频率、口服药物摄入量、并发症及副作用。
8例患者中有7例在试验性刺激期间对sTNFS有反应（即疼痛减轻≥50%）。疼痛强度（根据VAS）降低了83±16%（平均值±标准差），发作次数减少了73±26%（平均值±标准差）。6例患者中有5例能够减少或停用止痛药物。1例患者发生了器械感染。2例患者出现了与刺激相关的副作用，通过重新编程得以解决。
sTNFS治疗是难治性三叉神经痛患者的一个有益选择。需要进行前瞻性随机试验以系统评估这种低侵入性神经外科技术的有效率和安全性。
