运动皮层电刺激治疗中枢性卒中后疼痛四例并文献复习

doi:10.3877/cma.j.issn.2095-123X.2024.01.006

目的

分析总结运动皮层电刺激（MCS）治疗中枢性卒中后疼痛（CPSP）的经验及临床应用。

方法

选择武装警察部队特色医学中心疼痛科自2020年1月至2021年12月行MCS治疗的4例CPSP患者为研究对象，记录患者术前及术后2周、6和12个月的疼痛数字评分（NRS）及疼痛缓解率。

结果

4例患者术后测试调控阶段NRS 2~3分，缓解74%；术后2~6个月NRS 3~5分，缓解50%；调节刺激参数后疼痛再次得到缓解，术后6~12个月NRS 1~3分，缓解76%。4例患者四肢肌力与术前相同，术后均未发生硬膜下积液、血肿、偏瘫、癫痫、感染等并发症。

结论

MCS是治疗药物难治性CPSP患者安全有效的方法之一，可提升患者生活质量。MCS的疗效取决于患者的正确选择、电极的准确定位和参数的优化调整。

关键词: 中枢性卒中后疼痛, 运动皮层电刺激, 止痛机制, 技术要点, 预测因素

Objective

To analyze and summarize the experience of motor cortex electrical stimulation (MCS) in the treatment of central post-stroke pain (CPSP), and to discuss the clinical application of MCS.

Methods

Four CPSP patients who were treated with MCS from January 2020 to December 2021 in the Pain Department of the Special Medical Center of the Armed Police Force were selected as the study subjects, and their pain numerical scores (NRS) and pain relief rates were recorded before and 2 weeks, 6 months and 12 months after surgery.

Results

The NRS of 4 patients during the postoperative control stage was 2-3 scores, with 74% remission; After 2-6 months of surgery, NRS scores of 3-5 and 50% remission; After adjusting the stimulation parameters, the pain was relieved again, with the NRS 1-3 scores and 76% remission at 6 to 12 months after surgery. The muscle strength of the limbs of the 4 patients was the same as before, and there were no complications such as subdural effusion, hematomas, hemiplegia, epilepsy, and infection after operation.

Conclusion

MCS is one of the safe and effective methods to treat refractory CPSP patients, which can improve the quality of life of patients. The efficacy of MCS depends on the correct selection of patients, the accurate positioning of electrodes and the optimization of parameters.

Key words: Central post-stroke pain, Motor cortex electrical stimulation, Analgesic mechanism, Key technical points, Predictors

图1 术前行脑功能MRI示：诱发患者主要疼痛部位时中央回附近激活A：矢状位；B：冠状位；C：轴位；D：头动评估图（患者头部移动幅度≤2 mm或头部移动角度≤2°）

Fig.1 Preoperative functional MRI of the brain showed activation near the central gyrus when the main pain site was induced

图2 CPSP患者术后头颅影像学检查结果A：术后3 d头颅CT未见异常；B：术后6个月头颅X线检查示电极位置稳定

Fig.2 Postoperative head imaging results of a CPSP patient

表1 4例患者的临床资料

Tab.1 Clinical data of 4 patients

序号	性别	年龄（岁）	NRS（分）				MCS参数（频率/脉宽/强度）	四肢肌力
序号	性别	年龄（岁）	术前	术后测试	术后6个月	术后12个月	MCS参数（频率/脉宽/强度）	术前	术后
病例1	男	68	8	2	4	3	30 Hz/300 μs/9.0 V	3	3
病例2	女	51	9	2	3	2	60 Hz/130 μs/2.5 V	4	4
病例3	女	58	9	2	5	1	65 Hz/105 μs/2.0 V	3	3
病例4	男	64	8	3	5	2	40 Hz/110 μs/3.0 V	4	4

表1 4例患者的临床资料

Tab.1 Clinical data of 4 patients

序号	性别	年龄（岁）	NRS（分）				MCS参数（频率/脉宽/强度）	四肢肌力
序号	性别	年龄（岁）	术前	术后测试	术后6个月	术后12个月	MCS参数（频率/脉宽/强度）	术前	术后
病例1	男	68	8	2	4	3	30 Hz/300 μs/9.0 V	3	3
病例2	女	51	9	2	3	2	60 Hz/130 μs/2.5 V	4	4
病例3	女	58	9	2	5	1	65 Hz/105 μs/2.0 V	3	3
病例4	男	64	8	3	5	2	40 Hz/110 μs/3.0 V	4	4

[1]	Guédon A, Thiebaut JB, Benichi S, et al. Dejerine-roussy syndrome: historical cases[J]. Neurology, 2019, 93(14): 624-629. DOI: 10.1212/WNL.0000000000008209.
[2]	Sprenger T, Seifert CL, Valet M, et al. Assessing the risk of central post-stroke pain of thalamic origin by lesion mapping[J]. Brain, 2012, 135(Pt 8): 2536-2545. DOI: 10.1093/brain/aws153.
[3]	Morishita T, Inoue T. Brain stimulation therapy for central post-stroke pain from a perspective of interhemispheric neural network remodeling[J]. Front Hum Neurosci, 2016, 10: 166. DOI: 10.3389/fnhum.2016.00166.
[4]	Dastin-van Rijn EM, König SD, Carlson D, et al. Personalizing dual-target cortical stimulation with Bayesian parameter optimization successfully treats central post-stroke pain: a case report[J]. Brain Sci, 2021, 12(1): 25. DOI: 10.3390/brainsci12010025.
[5]	水源,李勇杰,胡永生.运动皮层电刺激治疗丘脑痛一例[C]//中华医学会神经外科学分会第九次学术会议论文集,济南, 2010.北京:中华医学会, 2010.
[6]	刘长青,程前,关宇光,等.运动皮层电刺激治疗丘脑痛3例并文献复习[J].中国临床神经外科杂志, 2019, 24(6): 336-338. DOI: 10.13798/j.issn.1009-153X.2019.06.006.
[7]	Malfitano C, Rossetti A, Scarano S, et al. Efficacy of repetitive transcranial magnetic stimulation for acute central post-stroke pain: a case study[J]. Front Neurol, 2021, 12: 742567. DOI: 10.3389/fneur.2021.742567.
[8]	Kumar G, Soni CR. Central post-stroke pain: current evidence[J]. J Neurol Sci, 2009, 284(1-2): 10-17. DOI: 10.1016/j.jns.2009.04.030.
[9]	Tsubokawa T, Katayama Y, Yamamoto T, et al. Chronic motor cortex stimulation for the treatment of central pain[J]. Acta Neurochir Suppl (Wien), 1991, 52: 137-139. DOI: 10.1007/978-3-7091-9160-6_37.
[10]	Lefaucheur JP, Drouot X, Cunin P, et al. Motor cortex stimulation for the treatment of refractory peripheral neuropathic pain[J]. Brain, 2009, 132(Pt 6): 1463-1471. DOI: 10.1093/brain/awp035.
[11]	Rasche D, Tronnier VM. Clinical significance of invasive motor cortex stimulation for trigeminal facial neuropathic pain syndromes[J]. Neurosurgery, 2016, 79(5): 655-666. DOI: 10.1227/NEU.0000000000001353.
[12]	Finnerup NB. A review of central neuropathic pain states[J]. Curr Opin Anaesthesiol, 2008, 21(5): 586-589. DOI: 10.1097/ACO.0b013e32830a4c11.
[13]	Hosomi K, Seymour B, Saitoh Y. Modulating the pain network--neurostimulation for central poststroke pain[J]. Nat Rev Neurol, 2015, 11(5): 290-299. DOI: 10.1038/nrneurol.2015.58.
[14]	Kim J, Ryu SB, Lee SE, et al. Motor cortex stimulation and neuropathic pain: how does motor cortex stimulation affect pain-signaling pathways[J]. J Neurosurg, 2016, 124(3): 866-876. DOI: 10.3171/2015.1.JNS14891.
[15]	McCormick DA, Wang Z. Serotonin and noradrenaline excite GABAergic neurones of the guinea-pig and cat nucleus reticularis thalami[J]. J Physiol, 1991, 442: 235-255. DOI: 10.1113/jphysiol.1991.sp018791.
[16]	杨菲.实验性中枢中风后疼痛:丘脑核团定位、机制探讨及药物评价[D].西安:第四军医大学, 2014. DOI: 10.7666/d.D527775.
[17]	Kumar G, Soni CR. Central post-stroke pain: current evidence[J]. J Neurol Sci, 2009, 284(1-2): 10-17. DOI: 10.1016/j.jns.2009.04.030.
[18]	Yamamoto T, Katayama Y, Hirayama T, et al. Pharmacological classification of central post-stroke pain: comparison with the results of chronic motor cortex stimulation therapy[J]. Pain, 1997, 72(1-2): 5-12. DOI: 10.1016/s0304-3959(97)00028-6.
[19]	赵东升,别小华,胡慧敏,等.重复经颅磁刺激对急性颈髓损伤神经调控的疗效观察[J].中华神经创伤外科电子杂志, 2021, 7(1): 33-36. DOI: 10.3877/cma.j.issn.2095-9141.2021.01.008.
[20]	Lefaucheur JP, Ménard-Lefaucheur I, Goujon C, et al. Predictive value of rTMS in the identification of responders to epidural motor cortex stimulation therapy for pain[J]. J Pain, 2011, 12(10): 1102-1111. DOI: 10.1016/j.jpain.2011.05.004.
[21]	André-Obadia N, Peyron R, Mertens P, et al. Transcranial magnetic stimulation for pain control. Double-blind study of different frequencies against placebo, and correlation with motor cortex stimulation efficacy[J]. Clin Neurophysiol, 2006, 117(7): 1536-1544. DOI: 10.1016/j.clinph.2006.03.025.
[22]	Fagundes-Pereyra WJ, Teixeira MJ, Reyns N, et al. Motor cortex electric stimulation for the treatment of neuropathic pain[J]. Arq Neuropsiquiatr, 2010, 68(6): 923-929. DOI: 10.1590/s0004-282x2010000600018.
[23]	Nüssel M, Hamperl M, Maslarova A, et al. Burst motor cortex stimulation evokes sustained suppression of thalamic stroke pain: a narrative review and single-case overview[J]. Pain Ther, 2021, 10(1): 101-114. DOI: 10.1007/s40122-020-00221-0.
[24]	Saitoh Y, Yoshimine T. Stimulation of primary motor cortex for intractable deafferentation pain[J]. Acta Neurochir Suppl, 2007, 97(Pt 2): 51-56. DOI: 10.1007/978-3-211-33081-4_6.
[25]	Katayama Y, Fukaya C, Yamamoto T. Poststroke pain control by chronic motor cortex stimulation: neurological characteristics predicting a favorable response[J]. J Neurosurg, 1998, 89(4): 585-591. DOI: 10.3171/jns.1998.89.4.0585.
[26]	Slotty PJ, Eisner W, Honey CR, et al. Long-term follow-up of motor cortex stimulation for neuropathic pain in 23 patients[J]. Stereotact Funct Neurosurg, 2015, 93(3): 199-205. DOI: 10.1159/000375177.
[27]	Szymoniuk M, Chin JH, Domagalski Ł, et al. Brain stimulation for chronic pain management: a narrative review of analgesic mechanisms and clinical evidence[J]. Neurosurg Rev, 2023, 46(1): 127. DOI: 10.1007/s10143-023-02032-1.
[28]	Tanei T, Kajita Y, Maesawa S, et al. Long-term effect and predictive factors of motor cortex and spinal cord stimulation for chronic neuropathic pain[J]. Neurol Med Chir (Tokyo), 2018, 58(10): 422-434. DOI: 10.2176/nmc.oa.2018-0106.
[29]	Esfahani DR, Pisansky MT, Dafer RM, et al. Motor cortex stimulation: functional magnetic resonance imaging-localized treatment for three sources of intractable facial pain[J]. J Neurosurg, 2011, 114(1): 189-195. DOI: 10.3171/2010.5.JNS091696.
[30]	Henderson JM, Boongird A, Rosenow JM, et al. Recovery of pain control by intensive reprogramming after loss of benefit from motor cortex stimulation for neuropathic pain[J]. Stereotact Funct Neurosurg, 2004, 82(5-6): 207-213. DOI: 10.1159/000082447.
[31]	Delavallée M, Abu-Serieh B, de Tourchaninoff M, et al. Subdural motor cortex stimulation for central and peripheral neuropathic pain: a long-term follow-up study in a series of eight patients[J]. Neurosurgery, 2008, 63(1): 101-105; discussion 105-108. DOI: 10.1227/01.NEU.0000335076.24481.B6.

[1]	陈勇, 张玲, 詹永婧, 段毓姣, 徐艳利, 蒋荣猛, 李兴旺. 神经梅毒强化驱梅治疗疗效预测因素的回顾性研究[J]. 中华实验和临床感染病杂志(电子版), 2016, 10(03): 274-279.
[2]	朱信强, 黄海龙, 蒋学通, 吴建强. 腹腔镜下经腹腹膜前腹股沟直疝无张力修补术技术要点及并发症处理[J]. 中华普通外科学文献(电子版), 2019, 13(04): 312-314.
[3]	何坤, 阮嘉后, 储兵, 周载平, 黄锐钦, 胡泽民. 肝癌衍生生长因子在原发性肝内胆管细胞癌中的表达及其临床意义[J]. 中华普通外科学文献(电子版), 2015, 09(04): 291-295.
[4]	黄骁, 项建斌. 局部复发直肠癌的外科治疗进展[J]. 中华结直肠疾病电子杂志, 2021, 10(06): 643-647.
[5]	徐振涛, 冉然, 苏道庆. 硬膜下型腰椎间盘突出症的显微手术治疗[J]. 中华神经创伤外科电子杂志, 2021, 07(02): 127-128.
[6]	程亭秀, 于明琨. 外伤标准大骨瓣减压术的技术要点与改良[J]. 中华神经创伤外科电子杂志, 2016, 02(02): 120-121.
[7]	丁玉菊, 刘照勇, 张波. 获得性脑损伤患者成功拔除气管套管的预测因素研究[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(02): 108-112.
[8]	牟鳄贤, 李卓璇, 董浩, 于淼, 纪娟, 徐佳, 王浩, 刘世伟. 初始腋窝淋巴结转移乳腺癌新辅助治疗后腋窝病理完全缓解的预测因素分析[J]. 中华临床医师杂志(电子版), 2023, 17(10): 1027-1032.
[9]	翁梓珑, 朱丽, 林大卫, 潘文志, 周达新, 葛均波. 国产经导管瓣膜系统治疗重度主动脉瓣狭窄长期预后及其预测因素分析[J]. 中华心脏与心律电子杂志, 2023, 11(02): 114-119.
[10]	郑屹, 谢冰歆, 刘彤. 白细胞端粒长度与心房颤动相关性研究进展[J]. 中华心脏与心律电子杂志, 2022, 10(04): 246-249.
[11]	薛宇龙, 李学文. 冠脉慢血流现象相关预测因素的研究[J]. 中华心脏与心律电子杂志, 2017, 05(04): 225-228.
[12]	李斌, 郭旭峰, 张晓彬, 杨洋, 茅腾, 孙益峰, 李志刚. 机器人辅助微创食管切除术的技术要点分析[J]. 中华胸部外科电子杂志, 2019, 06(01): 46-55.
[13]	赵悦, 马士凤, 周娜, 王茜, 张聪, 刘笑孝, 蒋海燕, 程思琪, 郑荣秀. 儿童代谢健康型肥胖的发病机制及预测指标[J]. 中华肥胖与代谢病电子杂志, 2022, 08(01): 52-55.
[14]	王宇梅, 刘猛. 脑梗死后恶性脑水肿预测因素的研究进展[J]. 中华脑血管病杂志(电子版), 2023, 17(02): 163-166.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Motor cortex electrical stimulation for the treatment of central post-stroke pain: a report of 4 cases and literature review

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Motor cortex electrical stimulation for the treatment of central post-stroke pain: a report of 4 cases and literature review