枕神经刺激治疗顽固性枕神经痛:一种开放式手术技术。

Philippe Magown, René Garcia, I. Beauprie, Ivar M Mendez
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引用次数: 36

摘要

枕神经痛(ON)被定义为一种发作性刺痛,发生在枕骨大神经或小枕骨神经或第三枕骨神经的皮肤分布疼痛常被描述为尖锐、射痛、刺痛或电性疼痛,优先为单侧且缓解,辐射至枕部和额部,相关症状提示疼痛源自颈部。ON往往成为慢性的,必须与牵涉到枕部的疼痛区分开来。枕神经痛的病因包括外伤性(72%)、退行性(14%)和肿瘤性或特发性(14%)。大多数病例是由于颈部的屈伸性损伤(即颈部扭伤)引起的,通常是由追尾机动车碰撞引起的ON的治疗方式各不相同,从保守措施(通常是一线治疗)到注射和手术干预。在大多数情况下,局部麻醉神经阻滞等注射最初是有效的,并且作为诊断工具也很有帮助。最近,A型肉毒杆菌毒素注射已被用于不同的结果,4,14和最近的系统评价是模棱两可的,因为少数患者手术方法是指医学上难治性ON,通常被认为是最后的手段。手术方式包括减压、消融和刺激手术。这些手术的临床疗效各不相同,而且每种手术都有其自身的并发症。枕神经电刺激曾被报道为一种非消融性治疗方法。6、9、12、20-22、27描述的枕神经电刺激技术使用透视经皮入路插入刺激电极。然而,这种盲目的方法并不能保证电极直接接触神经干。据报道,疼痛缓解的有效率在60%到90%之间21,并且会随着电极导线的错位或移动而大大降低。众所周知,经皮枕骨电极容易发生移位,并随之失去刺激,即使采用了细致的锚固技术,也经常需要手术修复迁移率与研究相关,范围从零到100%,平均约为15%;读者可参考Jasper等人对植入枕神经刺激器的系统综述11了解更多细节。我们假设电极相对于神经干的次佳定位和经皮放置电极在高度移动的颈椎区域的迁移是刺激丧失的原因。为了解决电极定位和移动的问题,我们开发了一种开放的手术入路,可以看到枕神经,并确保电极精确地固定在神经主干上。
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Occipital nerve stimulation for intractable occipital neuralgia: an open surgical technique.
Occipital neuralgia (ON) is defined as a paroxysmal jabbing pain in the cutaneous distribution of the greater or lesser occipital or third occipital nerve.10 The pain is frequently described as sharp, shooting, stabbing or electrical, preferentially unilateral and remitting, radiating to the occipital and frontal areas, with associated symptoms suggesting a pain origin from the neck.2,3 ON tends to become chronic and must be distinguished from referred pain to the occiput. Etiologies of occipital neuralgia include traumatic (72% of this series), degenerative (14% of this series), and oncological or idiopathic (14% of this series). Most cases arise from a flexion-extension injury to the neck (i.e., whiplash), which commonly results from a rear-end motor vehicle collision.8 Treatment modalities for ON vary from conservative measures, which are usually the frontline treatments, to injections and surgical interventions. Injections such as regional anesthetic nerve block are initially effective in the majority of cases and are also helpful as a diagnostic tool.5,19,28 More recently, botulinum toxin A injection has been used with varied results,4,14 and a recent systematic review was equivocal because of the small number of patients.24 Surgical approaches are indicated for medically intractable ON and are often considered as the last resort. Surgical modalities include decompressive, ablative, and stimulating procedures. The clinical efficacy of these procedures varies, and each has complications of its own. Electrical stimulation of the occipital nerve has been previously reported as a nonablative modality to treat ON.6,9,12,20–22,27 The techniques described for stimulation of the occipital nerve use a fluoroscopic percutaneous approach to insert the stimulating electrode. However, this blind approach does not ensure that the electrode is directly in contact with the nerve trunk. The reported efficacy varies between 60% and 90% of pain relief21 and can diminish substantially with malpositioning or migration of the electrode lead. It is known that percutaneous occipital electrodes are prone to migration with subsequent loss of stimulation and often need surgical revision,13 even after meticulous anchorage techniques.7 Migration rates are study dependent, ranging from zero to 100%, with an average of approximately 15%; the readers are referred to a systematic review on implanted occipital nerve stimulators by Jasper et al.11 for more details. We postulate that suboptimal positioning of the electrode in relation to the nerve trunk and migration of the percutaneously placed electrode in the highly mobile cervical region are the reasons for loss of stimulation. In an attempt to solve the problem of electrode positioning and migration, we developed an open surgical approach that allows visualizing the occipital nerve and ensures meticulous anchoring of the electrode onto the main trunk of the nerve.
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