Franzini Andrea, Messina Giuseppe, Levi Vincenzo, D'Ammando Antonio, Cordella Roberto, Moosa Shayan, Prada Francesco, Franzini Angelo
1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy.
2Department of Neurosurgery, University of Virginia Health System; and.
J Neurosurg. 2019 Aug 16;133(3):830-838. doi: 10.3171/2019.5.JNS19227. Print 2020 Sep 1.
Central poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.
Clinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.
Four patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8-10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0-6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3-8). The mean percentage of long-term pain reduction was 38.13%.
This series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.
脑卒中后中枢性神经病理性疼痛是一种使人衰弱的综合征，常常对药物治疗有抵抗性。手术措施包括运动皮层刺激和深部脑刺激（DBS），这些已被用于缓解疼痛。本研究的目的是回顾性评估内囊后肢深部脑刺激缓解脑卒中后中枢性神经病理性疼痛及相关下肢痉挛的安全性和长期疗效。
回顾性收集并分析所有接受内囊后肢深部脑刺激以治疗对保守措施难治的脑卒中后中枢性神经病理性疼痛患者的临床和手术数据。此外，评估长期疼痛强度和刺激带来的满意度水平。使用视觉模拟量表（VAS）评估疼痛。从病历、神经学检查和访谈中获取关于步态改善的信息。
自2001年以来，有4例患者接受了该手术。未记录到与手术相关的死亡或并发症。3例患者内囊后肢刺激导致长期疼痛缓解；第4例患者手术未产生任何持久的积极效果。2例患者痉挛减轻且运动能力改善。手术前，平均VAS评分为9分（范围8 - 10分）。在术后即刻以及深部脑刺激系统开启后1周内，平均VAS评分显著降低，平均为3分（范围0 - 6分）。平均随访5.88年后，平均VAS评分仍降至5.5分（范围3 - 8分）。长期疼痛减轻的平均百分比为38.13%。
本系列研究表明，内囊后肢刺激治疗影响下肢的慢性神经病理性疼痛患者是安全有效的。在疼痛和痉挛累及下肢的患者亚组中，该手术可能是比运动皮层刺激或其他神经调节技术更具针对性的治疗方法。
