脑立体定向止痛手术治疗中枢性疼痛

STEREOTACTIC NEUROSURGERY FOR CENTRAL PAIN

目的:研究脑立体定向止痛手术治疗中枢性疼痛(centralpain,CP)的临床应用。方法:CP患者12例,包括丘脑或桥脑梗塞6例、丘脑出血2例、丘脑坏死1例、脊髓损伤或病变3例。局麻下行单纯毁损右侧中脑脊髓丘脑束1例、左侧丘脑腹后外侧核(theventralisposterolateralisnucleus,VPL)1例、双侧扣带回前部2例,联合毁损疼痛对侧中脑脊髓丘脑束或三叉丘系加双侧扣带回前部8例。采用视觉模拟尺(visualanalogscale,VAS)和McGill疼痛问卷量表(McGillpainquestion-naire,MPQ)分别在术前和术后进行评分,同时记录手术前后患者使用镇痛剂的种类和最大剂量。将术后不同时间的VAS、MPQ评分与术前的评分进行比较,采用小样本自身配对t检验。结果:术后1个月之内,11例止痛效果稳定,1例VPL毁损疼痛有所恢复,全部病例不再使用麻醉镇痛剂,VAS评分和MPQ评分较术前均显著降低(P<0.01)。8例对侧中脑加双侧扣带回前部联合毁损,2例术后12周内疼痛加重,另6例术后6个月止痛效果满意,VAS评分和MPQ评分较术前明显降低(P<0.01),均不服用麻醉镇痛剂。单纯VPL毁损术后6周疼痛加重;单纯中脑毁损术后第7周疼痛复发,单纯双侧扣带回前部毁损2例,分别于术后11周和8个月疼痛复发。结论:脑立体定向止痛手术对CP具有一定的治疗作用,中脑加双侧扣带回前部联合毁损的效果好于单纯中脑、VPL核或扣带回前部毁损,超过1年的长期疗效有待于进一步观察。

Objective： To study the stereotactic neurosurgery for the treatment of central pain （CP）. Methods： 12 patients with CP were employed clinically including 6 cases of thalamus or pontine infarction, 2 cases of thalamus haemorrhage, one case of thalamus necrosis and 3 cases of spinal pathology. The contralateral mesencephalotomy and bilateral anterior cingulotomy were co-performed in 8 patients. Other targets included the mesencephalon tract, the ventralis posterolateralis nucleus of thalamus and the anterior cingulate gyrus. Statistical analyses were conducted using paired t test. Results： The short-term （ 1 month） follow-up results showed a significant reduction in patients＇pain scores （P 〈 0.01 ）. The daily narcotic dosage of all patients decreased remarkably. In the long-term follow-up period, the pain relief effect of the co-operation of contralateral mesencephalotomy and bilateral anterior cingulotomy was better than the lesion of mesencephalon, the ventralis posterolateralis nucleus of thalamus and the anterior cingulate gyrus. There were no serious complication and surgery-related mortality. Conclusion： Stereotactic neurosurgery procedure is effective in relieving CP. The co-operation of mesencephalotomy and bilateral anterior cingulotomy is more beneficial to the patients with CP.