原发性三叉神经痛和疱疹后三叉神经痛临床特征及射频热凝术后效果分析

摘要 目的：探讨原发性三叉神经痛（PTN）和疱疹后三叉神经痛（PHN）的临床特征,并比较经卵圆孔射频热凝术（RF-TC）治疗PTN和PHN的临床疗效。方法：随机选取2019年1月至2020年8月在我院治疗的三叉神经痛患者123例,其中原发性三叉神经痛90例,带状疱疹后神经痛33例。所有患者均通过RF-TC进行治疗,治疗后通过视觉模拟量表（VAS）、巴罗神经研究所疼痛强度量表对面部疼痛评分进行疼痛评估,通过巴罗神经研究所麻木评分进行麻木评定,通过健康问卷-9对患者抑郁情况进行评估,通过匹斯堡睡眠质量指数测量患者心理状态。结果：PTN患者发病年龄显著低于PHN患者（P<0.05）,而病程显著高于PHN患者（P<0.05）;PHN患者的眼支发生率高于PTN患者（39.39% vs 8.89%, P<0.05）。两组患者经RF-TC治疗前后VAS评分无显著差异（P>0.05）。PHN组从轻度到重度影响睡眠质量的比例显著高于PTN组（30.30% vs 10.00%, P<0.05）。PTN组患者治疗后中重度抑郁患者比例显著高于PHN组患者（21.11% vs 9.09%, P<0.05）。两组患者经RF-TC治疗后,临床治疗有效率、面麻木程度以及巴罗神经研究所疼痛强度量表评定的面部疼痛无显著差异（P>0.05）。结论：经卵圆孔射频热凝术治疗原发性三叉神经痛和带状疱疹后三叉神经痛是安全有效的,但治疗后疱疹后三叉神经痛失眠的发生率较高,而原发性三叉神经痛的抑郁发生率较高。     

带状疱疹后遗神经痛的动物模型及病理机制研究

带状疱疹后遗神经痛(postherpetic neuralgia,PHN)是带状疱疹最常见的并发症,其发生率随年龄的增加而增加,并且严重影响患者的生活质量。目前PHN的治疗多采用复合用药,但效果不佳。阻碍其治疗发展的关键是对PHN的发病机制不甚清楚,究其根本原因是缺乏与临床符合的动物模型。目的:综述带状疱疹病毒感染模型的改良和进展,使PHN的病理机制得到进一步揭示。内容:介绍与PHN相关的水痘-带状疱疹病毒潜伏感染模型、体外模型及慢性感染模型,综述与PHN发生发展有关的潜伏机制、与其他神经病理性痛相似的机制及近年来较为关注的中枢与外周损伤机制。趋向:进一步研究与人类水痘带状疱疹病毒感染更为相似的动物模型,并随其改良和进展,使发生PHN的机制得到进一步的阐释。     

加巴喷丁联合射频脉冲、神经阻滞治疗带状疱疹后神经痛的效果

摘要 目的：探讨加巴喷丁联合脉冲射频、神经阻滞治疗带状疱疹后遗神经痛的效果。方法：本研究选取106例确诊为带状疱疹后遗神经痛的患者,采用随机数表法将其分为对照组A（36例）、试验组B（35例）和试验组C（35例）。A组患者采用口服加巴喷丁进行治疗,B组患者采用加巴喷丁联合神经阻滞治疗,C组患者采用加巴喷丁联合脉冲射频治疗,观察比较三组患者的治疗效果,分别对视觉模拟评分（VAS）、夜间睡眠评分（SRSS）、疼痛程度（NRS）、不良反应及综合疗效进行统计评估。结果：治疗3天、7天、14天和1月后,与对照组A比较,B、C组患者的VAS、SRSS和NRS评分较治疗前均有显著降低（P<0.05）;试验组B、C不良反应发生率分别为8.57%（3/35）和5.71%（2/35）,对照组A不良反应发生率为22.22%（8/36）,试验组不良反应发生率显著低于对照组,差异具有统计学意义（P<0.05）。结论：相较于使用加巴喷丁和加巴喷丁联合神经阻滞这两种治疗方案,加巴喷丁联合射频脉冲及神经阻滞治疗带状疱疹后遗神经痛能够在短期内有效缓解患者疼痛并改善睡眠状况。     

普瑞巴林、加巴喷丁联合神经阻滞治疗带状疱疹后神经痛的临床疗效比较

目的:比较普瑞巴林、加巴喷丁联合神经阻滞治疗带状疱疹后神经痛(PHN)的临床疗效。方法:选择2014年8月至2016年11月我院门诊收治的带状疱疹后神经痛患者80例,并将其随机分为两组,每组40例。A组患者接受普瑞巴林联合神经阻滞治疗,B组患者接受加巴喷丁联合神经阻滞治疗,比较两组患者治疗前后的视觉疼痛模拟(VAS)评分、失眠严重程度指数(ISI)评分、生活质量满意指数(LSIB)评分及治疗期间不良反应的发生情况。结果:A组患者治疗后4、7、14 d的VAS评分均显著低于B组(P0.05),LSIB评分显著高于B组(P0.05),A组患者治疗后4、7 d的ISI评分均显著低于B组(P0.05);A组发生不良反应的总发生率显著低于B组(P0.05)。结论:普瑞巴林联合神经阻滞治疗PHN缓解疼痛和失眠的效果显著优于巴喷丁联合神经阻滞治疗,其可显著提高患者的生活质量,并减少不良反应。     

带状疱疹后遗神经痛的产生机制

带状疱疹后遗神经痛是一种顽固性慢性疼痛综合征,发病率高,治疗棘手,目前多采用复合用药,但效果不佳,原因在于其发病机制尚不清楚,本文就PHN产生机制做一综述。     

带状疱疹并发神经痛患者危险因素的相关研究

目的:探讨带状疱疹患者并发神经痛患者的相关危险因素.方法:采用回顾性分析的方法,对我院100例合并带状疱疹后神经痛(PHN)患者年龄、性别、患病后初诊日、急性期发作频度、急性期疼痛程度、疱疹部位、疼痛的性质等进行统计,并进行多因素Logistic相关分析.结果:不同年龄、性别、及疼痛评分间PHN患病率间差异有统计学意义(P＜0.05或P＜0.01).而患病后初诊日及急性期发作频度、不同疱疹部位的PHN患病率、不同疼痛性质的PHN患病率差异无统计学意义(P＞0.05).Logistic相关分析显示,年龄、性别、不同疼痛程度与PHN患病率存在一定的相关性,相关P值分别为0.003、0.002、0.005,均P＜0.01.结论:年龄、性别、不同疼痛程度可影响PHN的发生.针对急性期PHN患者,应早发现,早治疗,提高患者生活质量.     

A型肉毒素治疗带状疱疹后遗神经痛的临床观察

目的:观察A型肉毒素皮内注射治疗带状疱疹后遗神经痛(Postherpetic Neuralgia,PHN)的临床效果。方法:选择76例胸背部带状疱疹后神经痛患者,采用乒乓球抽签法随机分为观察组与对照组,每组38例患者。在口服药物治疗的基础上,观察组与对照组的局部疼痛敏感点分别皮内注射A型肉毒素与生理盐水。比较两组治疗前与治疗后第1、7、30、60天的视觉模拟评分量表(Visual Analogue Scale,VAS)及睡眠质量评分量表(Quality of Sleep,QS)评分的变化。结果:两组患者治疗后第1、7、30、60天的VAS及QS评分均明显低于治疗前(P0.05),观察组患者治疗后第1、7、30、60天的VAS及QS评分结果明显低于对照组(P0.05)。两组均未见明显的治疗相关并发症。结论:A型肉毒素皮内注射疗法可以显著减轻PHN患者的疼痛及改善睡眠质量。     

带状疱疹后神经痛患者杏仁核的功能连接改变研究

带状疱疹后神经痛(postherpetic neuralgia,PHN)是一种常见的神经病理性疼痛,但其中枢机制尚不明了.杏仁核在疼痛反应中的作用近年来受到关注.本研究的目的在于通过功能磁共振成像,研究带状疱疹后神经痛患者杏仁核各个亚区功能连接(functional connectivity,FC)的改变,探索慢性神经病理性疼痛的中枢机制.8位带状疱疹后神经痛患者和8位健康者进行了普通核磁共振和静息态功能磁共振扫描.将杏仁核各个亚区分别进行的功能连接分析,并将功能连接和被试者的病程、视觉模拟评分(visual analog scale,VAS)进行了相关分析.与健康志愿者相比,PHN患者杏仁核的基底外侧部(laterobasal groups,LB)和皮质部(superficial groups,SF)与多个脑区的FC表现出增强,主要位于颞叶和额叶.同时SF与多个区域的FC出现减低,主要位于额叶和顶叶.颞叶和额叶部分区域与LB的FC强度、与病程长短和VAS评分表现出关联性.研究结果提示,PHN患者杏仁核功能连接的改变提示了在慢性神经病理性疼痛的产生和发展中,杏仁核以及多个涉及情绪、认知、注意的脑区发挥了重要作用.     

带状疱疹后神经痛患者杏仁核的功能连接改变研究（英文）

带状疱疹后神经痛(postherpetic neuralgia,PHN)是一种常见的神经病理性疼痛,但其中枢机制尚不明了.杏仁核在疼痛反应中的作用近年来受到关注.本研究的目的在于通过功能磁共振成像,研究带状疱疹后神经痛患者杏仁核各个亚区功能连接(functional connectivity,FC)的改变,探索慢性神经病理性疼痛的中枢机制.8位带状疱疹后神经痛患者和8位健康者进行了普通核磁共振和静息态功能磁共振扫描.将杏仁核各个亚区分别进行的功能连接分析,并将功能连接和被试者的病程、视觉模拟评分(visual analog scale,VAS)进行了相关分析.与健康志愿者相比,PHN患者杏仁核的基底外侧部(laterobasal groups,LB)和皮质部(superficial groups,SF)与多个脑区的FC表现出增强,主要位于颞叶和额叶.同时SF与多个区域的FC出现减低,主要位于额叶和顶叶.颞叶和额叶部分区域与LB的FC强度、与病程长短和VAS评分表现出关联性.研究结果提示,PHN患者杏仁核功能连接的改变提示了在慢性神经病理性疼痛的产生和发展中,杏仁核以及多个涉及情绪、认知、注意的脑区发挥了重要作用.     

带状疱疹后遗神经痛患者脑基础活动改变的功能核磁共振研究

带状疱疹后遗神经痛(postherpetic neuralgia,PHN)是临床上一种慢性顽固性神经病理性疼痛,然而,对于其潜在的中枢机制还知之甚少.为了进一步探讨带状疱疹后遗神经痛患者的相关脑区活动,利用功能核磁共振成像低频振幅振荡(ALFF)技术观察带状疱疹后遗神经痛患者的基础脑区活动.8名带状疱疹后遗神经痛患者与8名性别、年龄相匹配的健康者行静息态功能磁共振(f MRI)成像扫描,用SPM8中的多重回归分析,在控制被试年龄、性别、教育年限的影响下,将每个体素的ALFF值同每个被试的病程、视觉模拟评分(visual analog scale,VAS)进行相关分析.与健康志愿者相比,PHN组与VAS评分相关的ALFF值增高的脑区有:右侧小脑后叶、前额叶背外侧区域(BA11/46/47)、右侧顶叶(BA40)、右侧舌回(BA17/18/19);与VAS评分相关的ALFF值降低的脑区有:右侧颞中回(BA21)、左侧舌回(BA17/18)、右侧小脑前叶、左侧后扣带回(BA30/19)和右侧中央前回(BA3/4/6);PHN组与病程相关的ALFF值增高的脑区有:右侧小脑后叶、前额叶背外侧区域(BA9/10/11/47)、左侧颞上回(BA38)、右侧顶叶和右侧舌回(BA17/18/19);与病程相关ALFF值降低的脑区有:左侧海马旁回(BA28)、右侧小脑前叶、左侧扣带回(BA24)、右侧颞上回(BA13)、左侧中央前回和右侧顶下小叶(BA39/40).研究结果提示,涉及疼痛的情绪、警觉行为、注意的脑区在带状疱疹后遗痛慢性疼痛的产生和维持中发挥重要作用.     

膝周神经射频热凝治疗顽固性膝骨关节炎疼痛的临床效果

目的:探讨膝周神经射频热凝治疗顽固性膝骨关节炎疼痛的疗效。方法:收集2013年1月至2014年1月,我院收治的顽固性膝骨关节炎疼痛患者62例,随机分为观察组与对照组,各31例。观察组予以膝周神经射频热凝联合关节腔内注射玻璃酸钠治疗,对照组单纯行关节腔内玻璃酸钠注射治疗,比较两组的临床疗效。结果:观察组治疗后VAS评分及OKS评分均显著低于对照组(P0.05);两组均未见明显并发症。结论:膝周神经射频热凝辅助治疗顽固性膝关节炎疼痛疗效显著,创伤较小,可促进关节功能的康复,值得推广应用。     

The PINE study: rationale and design of a randomised comparison of epidural injection of local anaesthetics and steroids versus care-as-usual to prevent postherpetic neuralgia in the elderly [ISRCTN32866390]

BACKGROUND: Postherpetic neuralgia (PHN) is by far the most common complication of herpes zoster (HZ) and one of the most intractable pain disorders. Since PHN is seen most often in the elderly, the number of patients with this disorder is expected to increase in our ageing society. PHN may last for months to years and has a high impact on the quality of life. The results of PHN treatment are rather disappointing. Epidural injection of local anaesthetics and steroids in the acute phase of HZ is a promising therapy for the prevention of PHN. Since randomised trials on the effectiveness of this intervention are lacking, the PINE (Prevention by epidural Injection of postherpetic Neuralgia in the Elderly) study was set up. The PINE study compares the effectiveness and cost-effectiveness of a single epidural injection of local anaesthetics and steroids during the acute phase of HZ with that of care-as-usual (i.e. antivirals and analgesics) in preventing PHN in elderly patients. METHODS / DESIGN: The PINE study is an open, multicenter clinical trial in which 550 elderly (age >/= 50 yr.) patients who consult their general practitioner in the acute phase of HZ (rash < 7 days) are randomised to one of the treatment groups. The primary clinical endpoint is the presence of HZ-related pain one month after the onset of the rash. Secondary endpoints include duration and severity of pain, re-interventions aiming to treat the existing pain, side effects, quality of life, and cost-effectiveness. CONCLUSION: The PINE study is aimed to quantify the (cost-) effectiveness of a single epidural injection during the acute phase of HZ on the prevention of PHN.     

Allodynic skin in post-herpetic neuralgia: histological correlates

Most post-herpetic neuralgia (PHN) patients suffer from tactile allodynia (pain evoked by lightly touching the skin) and it is frequently the dominant clinical manifestation. The pathophysiology of tactile allodynia in PHN patients is poorly understood and this is one of the major limits to the development of appropriate therapies. Epidermal nerve fibres (ENFs) are free nerve endings of small-diameter A-delta and C primary afferents, which can easily be assessed by neurodiagnostic skin biopsy (NSB). The aim of this study was to establish the correlation between the residual epidermal innervation of the allodynic skin and the intensity of tactile allodynia in that area. Twenty-five patients (13 males and 12 females) with PHN were enrolled. Eighteen patients had PHN in the thoracic dermatome, four in the cervical, two in the trigeminal and one in the lumbar. The severity of allodynia evoked by a paintbrush was graded according to an eleven-point numerical scale. A skin biopsy was obtained from the maximal allodynia area and from the contralateral skin. Nerve fibres were labelled with indirect immunofluorescence. Results showed that epidermal innervation was lower in the allodynic skin than in the contralateral skin, although there was great variability among patients. There was no correlation between severity of allodynia and epidermal innervation of the PHN skin. In conclusion, the present study further indicates peripheral nervous system involvement in PHN but does not support a direct correlation between epidermal innervation changes and tactile allodynia.     

Percutaneous radiofrequency lumbar rhizolysis (rhizotomy).

Low back pain may arise from degenerative changes in the posterior joints of the lumbar spine. These joints are innervated by a branch of the posterior primary ramus, which follows an anatomically constant course. Pain impulses from these joints can be interrupted by coagulating this nerve with a radiofrequency wave, the probe having been placed in the area of the nerve percutaneously. Percutaneous lumbar rhizolysis was carried out under local anesthesia on an outpatient basis in 82 patients, most of whom had multiple level rhizolysis. Rhizolysis was successful in 67% of patients with mechanical low back pain without evidence of disc herniation and nerve-root compression or psychogenic pain, who had not previously undergone an operation for relief of the pain.     

Local and Systemic Cytokine Expression in Patients with Postherpetic Neuralgia

Background

Postherpetic neuralgia (PHN) is the painful complication of a varicella zoster virus reactivation. We investigated the systemic and local gene expression of pro- and anti-inflammatory cytokine expression in patients with PHN.

Methods

Thirteen patients with PHN at the torso (Th4-S1) were recruited. Skin punch biopsies were obtained from the painful and the contralateral painless body area for intraepidermal nerve fiber density (IENFD) and cytokine profiling. Additionally, blood was withdrawn for systemic cytokine expression and compared to blood values of healthy controls. We analyzed the gene expression of selected pro- and anti-inflammatory cytokines (tumor necrosis factor-alpha [TNF] and interleukins [IL]-1β, IL-2, and IL-8).

Results

IENFD was lower in affected skin compared to unaffected skin (p<0.05), while local gene expression of pro- and anti-inflammatory cytokines did not differ except for two patients who had 7fold higher IL-6 and 10fold higher IL-10 gene expression in the affected skin compared to the contralateral unaffected skin sample. Also, the systemic expression of cytokines in patients with PHN and in healthy controls was similar.

Conclusion

While the systemic and local expression of the investigated pro- and anti-inflammatory cytokines was not different from controls, this may have been influenced by study limitations like the low number of patients and different disease durations. Furthermore, other cytokines or pain mediators need to be considered.     

Sensory symptom profiles and co-morbidities in painful radiculopathy

Painful radiculopathies (RAD) and classical neuropathic pain syndromes (painful diabetic polyneuropathy, postherpetic neuralgia) show differences how the patients express their sensory perceptions. Furthermore, several clinical trials with neuropathic pain medications failed in painful radiculopathy. Epidemiological and clinical data of 2094 patients with painful radiculopathy were collected within a cross sectional survey (painDETECT) to describe demographic data and co-morbidities and to detect characteristic sensory abnormalities in patients with RAD and compare them with other neuropathic pain syndromes. Common co-morbidities in neuropathic pain (depression, sleep disturbance, anxiety) do not differ considerably between the three conditions. Compared to other neuropathic pain syndromes touch-evoked allodynia and thermal hyperalgesia are relatively uncommon in RAD. One distinct sensory symptom pattern (sensory profile), i.e., severe painful attacks and pressure induced pain in combination with mild spontaneous pain, mild mechanical allodynia and thermal hyperalgesia, was found to be characteristic for RAD. Despite similarities in sensory symptoms there are two important differences between RAD and other neuropathic pain disorders: (1) The paucity of mechanical allodynia and thermal hyperalgesia might be explained by the fact that the site of the nerve lesion in RAD is often located proximal to the dorsal root ganglion. (2) The distinct sensory profile found in RAD might be explained by compression-induced ectopic discharges from a dorsal root and not necessarily by nerve damage. These differences in pathogenesis might explain why medications effective in DPN and PHN failed to demonstrate efficacy in RAD.     

Spinal astrocytic activation is involved in a virally-induced rat model of neuropathic pain

Postherpetic neuralgia (PHN), the most common complication of herpes zoster (HZ), plays a major role in decreased life quality of HZ patients. However, the neural mechanisms underlying PHN remain unclear. Here, using a PHN rat model at 2 weeks after varicella zoster virus infection, we found that spinal astrocytes were dramatically activated. The mechanical allodynia and spinal central sensitization were significantly attenuated by intrathecally injected L-α-aminoadipate (astrocytic specific inhibitor) whereas minocycline (microglial specific inhibitor) had no effect, which indicated that spinal astrocyte but not microglia contributed to the chronic pain in PHN rat. Further study was taken to investigate the molecular mechanism of astrocyte-incudced allodynia in PHN rat at post-infection 2 weeks. Results showed that nitric oxide (NO) produced by inducible nitric oxide synthase mediated the development of spinal astrocytic activation, and activated astrocytes dramatically increased interleukin-1β expression which induced N-methyl-D-aspartic acid receptor (NMDAR) phosphorylation in spinal dorsal horn neurons to strengthen pain transmission. Taken together, these results suggest that spinal activated astrocytes may be one of the most important factors in the pathophysiology of PHN and "NO-Astrocyte-Cytokine-NMDAR-Neuron" pathway may be the detailed neural mechanisms underlying PHN. Thus, inhibiting spinal astrocytic activation may represent a novel therapeutic strategy for clinical management of PHN.