Kollenburg Linda, Arnts Hisse, Green Alexander, Strauss Ido, Vissers Kris, Vinke Saman, Kurt Erkan
Radboud University Medical Center, Department of Neurosurgery, Functional Neurosurgery Unit, Nijmegen, 6525 GA, Netherlands.
Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neuroscience and Surgery, University of Oxford, Oxford OX39DU, UK.
Brain Commun. 2024 Oct 16;6(5):fcae368. doi: 10.1093/braincomms/fcae368. eCollection 2024.
Chronic pain causes a major burden on patient's lives, in part due to its profound socioeconomic impact. Despite the development of various pharmacological approaches and (minor) invasive treatments, a subset of patients remain refractory, hence why alternative targeted neurosurgical interventions like cingulotomy and deep brain stimulation of the anterior cingulate cortex should be considered in the last resort. Despite clinical evidence supporting the potential of these treatments in the management of chronic intractable pain, physicians remain reluctant on its clinical implementation. This can be partially attributed to the lack of clear overviews summarizing existent data. Hence, this article aims to evaluate the current status of cingulotomy and deep brain stimulation of the anterior cingulate cortex in the treatment of chronic intractable pain, to provide insight in whether these neurosurgical approaches and its target should be reconsidered in the current era. In the current study, a literature searches was performed using the PubMed database. Additional articles were searched manually through reviews or references cited within the articles. After exclusion, 24 and 5 articles remained included in the analysis of cingulotomy and deep brain stimulation of the anterior cingulate cortex, respectively. Results indicate that various surgical techniques have been described for cingulotomy and deep brain stimulation of the anterior cingulate cortex. Cingulotomy is shown to be effective 51-53% and 43-64% of patients with neoplastic and non-neoplastic pain at ≤6 months follow-up, and 82% (9/11) and 76% (90/118) at ≥ 12months follow-up, respectively. With regard to deep brain stimulation of the anterior cingulate cortex, no data on neoplastic pain was reported, however, 59% (10/17) and 57% (8/14) of patients with non-neoplastic pain were considered responders at ≤ 6 months and ≥ 12months follow-up, respectively. The most reported adverse events include change in affect (>6.9%, >29/420) and confusion (>4.8%, >20/420) for cingulotomy, and infection (12.8%, 6/47), seizures (8.5%, 4/47) and decline in semantic fluency (6.4%, 3/47) for deep brain stimulation of the anterior cingulate cortex. It can be concluded that cingulotomy and deep brain stimulation of the anterior cingulate cortex are effective last resort strategies for patients with refractory non-neoplastic and neoplastic pain, especially in case of an affective emotional component. Future research should be performed on the cingulum as a neurosurgical target as it allows for further exploration of promising treatment options for chronic intractable pain.
慢性疼痛给患者的生活带来了沉重负担，部分原因是其深远的社会经济影响。尽管已经开发出各种药物治疗方法和（微创）侵入性治疗手段，但仍有一部分患者对这些治疗无效，因此，在最后手段中应考虑采用如扣带回切开术和前扣带回皮质深部脑刺激等替代性靶向神经外科干预措施。尽管有临床证据支持这些治疗方法在慢性顽固性疼痛管理中的潜力，但医生们仍对其临床应用持谨慎态度。这部分可归因于缺乏总结现有数据的清晰概述。因此，本文旨在评估扣带回切开术和前扣带回皮质深部脑刺激在治疗慢性顽固性疼痛方面的现状，以深入了解在当前时代是否应重新考虑这些神经外科方法及其靶点。在本研究中，使用PubMed数据库进行了文献检索。通过文章内的综述或参考文献手动搜索了其他文章。排除后，分别有24篇和5篇文章纳入了扣带回切开术和前扣带回皮质深部脑刺激的分析。结果表明，已经描述了多种用于扣带回切开术和前扣带回皮质深部脑刺激的手术技术。扣带回切开术在随访≤6个月时对肿瘤性和非肿瘤性疼痛患者的有效率分别为51%-53%和43%-64%，在随访≥12个月时分别为82%（9/11）和76%（90/118）。关于前扣带回皮质深部脑刺激，未报告肿瘤性疼痛的数据，然而，在随访≤6个月和≥12个月时，分别有59%（10/17）和57%（8/14）的非肿瘤性疼痛患者被认为是有反应者。最常报告的不良事件包括扣带回切开术的情感变化（>6.9%，>29/420）和意识模糊（>4.8%，>20/420），以及前扣带回皮质深部脑刺激的感染（12.8%，6/47）、癫痫发作（8.5%，4/47）和语义流畅性下降（6.4%，3/47）。可以得出结论，扣带回切开术和前扣带回皮质深部脑刺激是治疗顽固性非肿瘤性和肿瘤性疼痛患者的有效最后手段策略，特别是在存在情感情绪成分的情况下。未来应针对扣带回作为神经外科靶点进行研究，因为这有助于进一步探索慢性顽固性疼痛的有前景的治疗选择。
