岛叶和扣带回前部皮质深部刺激治疗中枢神经性疼痛：分解疼痛知觉。
Insular and anterior cingulate cortex deep stimulation for central neuropathic pain: Disassembling the percept of pain.
机构信息
From the Pain Center (L.M.B., L.M.B.M., R.D.T.d.S., F.V., J.R., M.J.T., D.C.d.A.), Instituto do Câncer do Estado de São Paulo; Pain Center (R.G.G., V.S., A.L.d.L.R., D.T.R.M.F., P.M.L.S., M.A.M., S.R.D.T.d.S., A.M.B.L.F., M.J.T., D.C.d.A.), LIM62 Neurosurgery LIM, Department of Neurology, Instituto de Ortopedia e Traumatologia (L.T.Y.), Division of Physical Medicine and Rehabilitation, and Laboratory of Psychiatric Neuroimaging (LIM-21) (F.L.d.S.D.), Department and Institute of Psychiatry, School of Medicine, University of São Paulo; Service of Interdisciplinary Neuromodulation (R.G.G., V.S., A.R.B., M.J.T., D.C.d.A.), Laboratory of Neuroscience (LIM27) and National Institute of Biomarkers in Neuropsychiatry, Department and Institute of Psychiatry, Neuroradiology Section (L.T.L., F.E.F.d.S.), Instituto de Radiologia, and Department of Radiology (C.R.O., C.A.B.), University of São Paulo School of Medicine; Center for Mathematics, Computation and Cognition (A.F.B.), Federal University of ABC, São Bernardo do Campo; School of Medicine (R.G.G.), University of City of São Paulo; Department of Anatomy (C.D.), Institute of Biomedical Sciences of University of São Paulo, Brazil; and Central Integration of Pain (NeuroPain) (L.G.-L.), Lyon Centre for Neurosciences, Inserm U1028, University Claude Bernard Lyon 1, and Hospices Civils de Lyon, France.
出版信息
Neurology. 2019 Apr 30;92(18):e2165-e2175. doi: 10.1212/WNL.0000000000007396. Epub 2019 Apr 5.
OBJECTIVE
To compare the analgesic effects of stimulation of the anterior cingulate cortex (ACC) or the posterior superior insula (PSI) against sham deep (d) repetitive (r) transcranial magnetic stimulation (TMS) in patients with central neuropathic pain (CNP) after stroke or spinal cord injury in a randomized, double-blinded, sham-controlled, 3-arm parallel study.
METHODS
Participants were randomly allocated into the active PSI-rTMS, ACC-rTMS, sham-PSI-rTMS, or sham-ACC-rTMS arms. Stimulations were performed for 12 weeks, and a comprehensive clinical and pain assessment, psychophysics, and cortical excitability measurements were performed at baseline and during treatment. The main outcome of the study was pain intensity (numeric rating scale [NRS]) after the last stimulation session.
RESULTS
Ninety-eight patients (age 55.02 ± 12.13 years) completed the study. NRS score was not significantly different between groups at the end of the study. Active rTMS treatments had no significant effects on pain interference with daily activities, pain dimensions, neuropathic pain symptoms, mood, medication use, cortical excitability measurements, or quality of life. Heat pain threshold was significantly increased after treatment in the PSI-dTMS group from baseline (1.58, 95% confidence interval [CI] 0.09-3.06]) compared to sham-dTMS (-1.02, 95% CI -2.10 to 0.04, = 0.014), and ACC-dTMS caused a significant decrease in anxiety scores (-2.96, 95% CI -4.1 to -1.7]) compared to sham-dTMS (-0.78, 95% CI -1.9 to 0.3; = 0.018).
CONCLUSIONS
ACC- and PSI-dTMS were not different from sham-dTMS for pain relief in CNP despite a significant antinociceptive effect after insular stimulation and anxiolytic effects of ACC-dTMS. These results showed that the different dimensions of pain can be modulated in humans noninvasively by directly stimulating deeper SNC cortical structures without necessarily affecting clinical pain per se.
CLINICALTRIALSGOV IDENTIFIER
NCT01932905.
目的
在一项随机、双盲、假设备对、三臂平行研究中，比较刺激前扣带皮层（ACC）或后上岛（PSI）与假深（d）重复（r）经颅磁刺激（TMS）对中风或脊髓损伤后中枢性神经痛（CNP）患者的镇痛效果。
方法
参与者被随机分配到主动 PSI-rTMS、ACC-rTMS、假 PSI-rTMS 或假 ACC-rTMS 组。刺激进行 12 周，在基线和治疗期间进行全面的临床和疼痛评估、心理物理学和皮质兴奋性测量。该研究的主要结局是最后一次刺激后疼痛强度（数字评定量表[NRS]）。
结果
98 例患者（年龄 55.02 ± 12.13 岁）完成了研究。研究结束时，各组间 NRS 评分无显著差异。主动 rTMS 治疗对日常生活活动中的疼痛干扰、疼痛维度、神经病理性疼痛症状、情绪、药物使用、皮质兴奋性测量或生活质量无显著影响。与假 dTMS 相比，PSI-dTMS 组的热痛阈在治疗后从基线显著升高（1.58，95%置信区间[CI]0.09-3.06]）（1.02，95%CI-2.10 至 0.04，=0.014），而与假 dTMS 相比，ACC-dTMS 导致焦虑评分显著降低（-2.96，95%CI-4.1 至-1.7]）（-0.78，95%CI-1.9 至 0.3；=0.018）。
结论
尽管岛叶刺激后有明显的镇痛作用，ACC-dTMS 有抗焦虑作用，但 ACC-和 PSI-dTMS 与假 dTMS 相比，对 CNP 的疼痛缓解无差异。这些结果表明，通过直接刺激更深的 SNC 皮质结构，可以非侵入性地调节人类疼痛的不同维度，而不一定影响本身的临床疼痛。
临床试验.gov 标识符：NCT01932905。
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