Name: subcutaneous trigeminal nerve field stimulation for refractory facial pain
Uploaded: 2017-05-10T13:00:00.000+00:00
Duration: 9 min 35 s
Description: Watch this Scientific Journal Video about Subcutaneous Trigeminal Nerve Field Stimulation for Refractory Facial Pain at JoVE.com

这项工作得到DFG（Deutsche Forschungsgemeinschaft）资助的合作研究中心1158（SFB1158 From nociception to chronic pain:Structure-Function properties of neural pathways and their reorganization）的部分支持。

注意:所有程序都是作为单独的治疗尝试（"Individualueller Heilversuch"）执行的。并遵守当地的伦理委员会（Ethikkommission Heidelberg）以及关于个人治疗尝试的国家法律。患者被治疗医师广泛告知治疗的性质，程序，风险和益处。在开始手术之前，所有患者都提供书面知情同意书。个人治疗尝试需要得到患者医疗保健服务的报销。这必须由治疗医师在安排程序之前获得。 适应症<ol><li> 在一个或多个单侧三叉神经分支中诊断为慢性，治疗抗性，三叉神经痛感染和/或神经性疼痛。 <ol><li>包括符合以下标准的个体:至少6个月的疼痛持续时间，以及两个或更多个fa标准医疗和/或手术治疗的尝试。 </li><li>关于每日攻击的次数和持续时间以及疼痛药物的类型和剂量（用于永久性和阵发性疼痛）的文件信息。通过询问病人评估他/她现在的状态，通过SF-36问卷来评估生活质量。 注意:SF-36是一个问卷，由八个关于生命质量（ 例如活力，身体疼痛）的领域组成，评级范围从0到100。 </li><li>排除患有任何主要精神病（ 如抑郁症，精神分裂症），医疗禁忌症，手术和全身麻醉的严重医疗条件，钛过敏或局部麻醉剂（ 如 Mepivacain））的个体。 </li></ol></li></ol> 2.试验电极放置<ol><li>将患者置于仰卧位，并将头转向疼痛的对侧。 </li><li>完全disi使用无色皮肤消毒剂对面部区域进行处理。 </li><li>在外科手术区域周围涂抹无菌绒布，以尽量减少污染和感染的风险。 </li><li> 用无菌笔根据患者的信息标记疼痛区域，以计划电极位置和皮肤穿刺位置。 <ol><li>计划皮肤穿刺距离疼痛区域的内侧边界不超过9厘米（Tuhoy插管的长度）。 </li><li>对于第一个三叉神经分支，选择一个位置，在前额的外侧上穿刺皮肤，大约10厘米的外侧和眉头的内侧边界上方1厘米。 </li><li>对于第二个三叉神经分支，选择耳屏前方大约1厘米的位置。 </li><li>对于第三个三叉神经分支，选择位于前面约1厘米，耳屏下方4厘米处的位置进行皮肤穿刺。 </li><li>不要进行2 cm以上的皮肤穿刺耳屏使面神经纤维免受损伤。 </li><li>用无菌手术笔标记植入电极的期望方向以进行指导。 </li></ol></li><li>在计划的皮肤穿刺的每个部位，将1mL局部麻醉剂（ 例如 1％Mepivacain）用20G插管注入皮下组织，并等待几分钟以获得局部麻醉效果。疼痛的感觉不存在，但压力和运动仍然被感知。 </li><li> 在以前标记的位置用14 G Tuhoy针进行皮肤穿刺。将Tuhoy插管的尖端放置在皮肤表面下方约0.5厘米处，以保持在皮下组织内。 <ol><li>取出针头并重复步骤2.5，以防患者在皮肤穿刺部位感到疼痛。 </li></ol></li><li> 将Tuhoy插管按照先前标记的方向轻轻地穿过皮下组织，瞄准疼痛的内侧边界区。 <ol><li>对于第一个三叉神经分支，瞄准平行于眉毛的中线。对于第二个三叉神经分支，瞄准鼻翼。对于第三个三叉分支，瞄准下巴。 </li><li>确保保持0.5厘米的深度，并将Tuhoy针的锋利尖端远离皮肤，以防止任何意外的皮肤穿孔。 </li><li>手动轻轻地弯曲Tuhoy套管，以便在需要时考虑颅骨的曲率。 </li></ol></li><li>取出Tuhoy插管的探针，将测试电极插入Tuhoy针。一旦电极到达Tuhoy针的末端，便会检测到软电阻。 注意:电极长60厘米，直径为1.3毫米。用于刺激的八个触点（每个3mm长）在触头之间以6mm的距离排列成一行。电极通过内部可拆卸的管心针稳定。 </li><li>在保持电极的同时取下Tuhoy插管通过温和的压力朝向痛苦的地区的中间边界的位置。 </li><li>将电极的探针拔出约5厘米，并将触点插入连接到外部神经刺激器的屏蔽电缆的端口。 </li><li>对每个附加电极重复步骤2.6-2.10。 </li><li> 开始测试刺激。告知病人，一旦发生刺激感觉（感觉异常），疼痛区域就会被察觉。 <ol><li>使用医师程序员激活刺激。 </li><li>在30-40Hz的频率和120个脉冲宽度的触点（ 例如， 1+，2，3+，4，5+，6，7+，8）上施加交替的阳极和阴极的双极刺激-180μs。 </li></ol></li><li> 增加刺激幅度，直到患者能够轻松地察觉到刺激而不会痛苦。 注意:患者通常报告振幅0.5〜2V的刺激感知。 <ol><li> w ^atch用于直接肌肉刺激的迹象，如上睑下垂或面部肌肉收缩，表示电极植入太深。 </li><li>询问患者疼痛区域的百分比被感觉异常所覆盖。尝试达到至少80％的感觉异常覆盖率。 </li><li>增加刺激幅度和/或脉搏宽度与医生程序员扩大刺激的领域。 </li><li>在直接肌肉刺激和/或不足的感觉异常覆盖的情况下，停止刺激，将电极与屏蔽电缆断开，去除电极并重复步骤2.6-2.13。 </li></ol></li><li>停止刺激，从屏蔽电缆断开电极，并用镊子将电极保持在适当位置，并完全取下电极的探针。 </li><li> 使用涂抹器的固定装置将电极保持在皮肤穿刺部位的位置。使用不可吸收的3-0丝线缝合到皮肤。 </STRONG&gt; <ol><li>将涂抹器的固定装置一直移动到电极的远端，直到其接触皮肤表面。推动杆将固定片施加到电极上。取下涂抹器。 </li><li>用固定装置将电极缝合到患者的皮肤上，两个单针。 </li></ol></li><li>在皮肤穿刺部位进行无菌悬垂。 </li><li>将电极重新连接到屏蔽电缆。 </li></ol> 3.刺激试验和治疗评估<ol><li>计划刺激方案。 注意:调节活动触点，刺激频率，脉冲宽度和幅度以获得最佳的疼痛缓解。患者的刺激方案会有所不同。然而，双极刺激（电极中交替阴极和阳极）和低频刺激（30-40Hz）在大多数患者中是常见的。 </li><li> 指导患者使用手持式病人滚动打开和关闭刺激并增加或减少刺激。 <ol><li>要打开或关闭刺激并改变刺激幅度，请按下开/关按钮激活手持式病人控制器。将手持式病人控制器放在外部脉冲发生器上，然后按下患者控制器侧面的黑色"通讯"按钮。 </li><li>按下患者控制器侧面的灰色"刺激关闭"按钮，关闭刺激，将白色"刺激"按钮转向刺激。 </li><li>按病人控制器前面的"+"和" - "按钮增加或减少刺激幅度。 注意:患者控制器显示屏上提供有关刺激振幅，刺激状态和电池容量的信息。 </li><li>请病人不断刺激。指示每天关闭刺激1小时以比较pa在有和没有刺激。 </li></ol></li><li>放开患者进行12天的动态刺激试验。 </li><li> 评估在门诊诊所刺激的影响。 <ol><li>要求患者在VAS下用0和10之间的数字进行刺激评估疼痛 注意:视觉模拟量表（VAS）疼痛减少至少50％被认为是成功的试验刺激。 VAS是一个数字评分量表，从0"无疼痛"到10"最难以想象的"，并且是患者评估的主观。成功的进一步措施是:减少攻击频率在50％以上，减少药物和提高生活质量。比较数据与术前状态。 </li></ol></li><li>采取A / P（前后）和颅骨的横向x射线来记录第二步14的电极位置。 </li><li>去除悬垂，切断缝线并取出测试电极。在消毒和检查皮肤穿刺部位后应用新的覆盖物。 </li><li>在成功的试验刺激的情况下，计划植入电极和内部脉冲发生器（IPG）的程序。 注意:在试验电极被去除4-6周后，安排第二次手术，以实现良好的伤口愈合，以最大限度地减少感染的风险，并给予患者时间反映试验刺激期间减少疼痛的程度。 </li><li> 记录第二次手术后IPG的试验刺激期间的有效刺激方案。 <ol><li>将医师程序员天线与外部脉冲发生器连接</li><li>选择程序员显示屏上的"连接"选项</li><li>转到"刺激设置"部分，记录病人的刺激方案。 </li></ol></li></ol>永久性电极植入和IPG <ol><li>在全身麻醉下将患者置于仰卧位。把头转向对侧的疼痛。将枕头放在同侧肩下露出锁骨。 </li><li>在手术开始前20分钟，给予静脉注射单抗抗生素（ 如 2 g头孢唑啉）。 </li><li>刮伤面部痛苦的一面的耳朵周围的区域。去除任何松散的头发。如有必要，请将周围的头发带走，以防止他们进入手术区域。 </li><li>彻底消毒手术区域的面部区域，围绕耳朵向下移动至锁骨区域。 </li><li>使用在门诊预约期间获得的x射线和以前的皮肤穿刺的标记来指示永久电极的期望位置用于引导。 </li><li>在整个手术领域应用无菌悬垂。 </li><li>演出皮肤用14G Tuhoy插管穿刺，并且如先前针对第一试验程序描述的那样植入永久电极。 注意:电极的尺寸和长度与试验电极（长度60厘米，直径1.3毫米，8个触点）相同。 </li><li>在上眼睛区域做一个1厘米长的垂直切口，在那里形成一个小的皮下袋。 </li><li> 插入Tuhoy插管皮下隧道从上耳廓切口到皮肤穿刺部位。去除Tuhoy插管和电极的样式，并将电极的远端插入插管。 注意:第三个三叉神经分支需要两个Tuhoy插管的长度和一个额外的小皮肤切口在眼前区域以完全覆盖距离。 <ol><li>在用镊子将电极保持在适当位置的同时取下Tuhoy插管。 </li><li>使用3-0不可吸收的丝线缝合电极到肌肉筋膜防止电极脱位。 </li><li>如果患者戴眼镜，请将电极固定在位于眼镜框架上方的位置，以防止局部疼痛和皮肤侵蚀。 </li></ol></li><li>执行6厘米长的锁骨下切口，并手动形成皮下袋以容纳IPG。使用双极电钳将任何出血血液凝结。 </li><li> 在隧道内切口插入穿刺矛，并在耳后向皮下隧道穿过上耳切口。 <ol><li>做一个小的后视切口，用于长矛离开皮肤。然后使用第二条矛从上眼眶隧道切除至后视切口。 </li><li>取下长矛的风格并插入电极，直到埋在皮下组织中，没有任何环路或扭结。 </li><li>在将电极保持在位置的同时将其从锁骨下切口中拉出来取下矛用镊子</li><li>注意不要用隧道矛刺穿皮肤（特别是以前曾经接受手术治疗微血管减压术的患者，因为他们有一个后眼瘢痕）。 </li></ol></li><li>将电极连接到IPG上，并用扭矩螺丝固定。 </li><li> 用不可吸收的丝线缝线（3-0）将IPG缝合到胸大肌筋膜，以防止IPG脱位。 <ol><li>检查系统阻抗以检测任何有故障的连接或损坏的电极触点。 </li><li>将医师程序员的天线放在无菌悬垂中，并将其置于IPG上。使用IPG连接编程器，并转到"检查电极阻抗"部分。 注意:250欧姆以下的低阻抗指示开路。超过500 OHM的高阻抗表明电极与IPG或电极断裂的连接不足。 </li></ol></li><li>皮肤接触皮肤在面部区域可吸收3-0缝合线和不可吸收的3-0皮肤缝合线，并可在IPG现场吸收皮肤缝线。 </li><li>消毒所有伤口，用盐水清洁手术区域，并应用无菌悬垂。 </li></ol> 5.术后护理注意:将患者转移到病房，观察隔夜，并给予口服止痛药。 <ol><li> 使用试验刺激的刺激方案对IPG进行编程（见3.8）。 <ol><li>将医师程序员的天线放在IPG上的皮肤上，并选择"连接"选项与神经刺激器通信。 </li><li>在"刺激设置"部分插入试验刺激结束时记录的刺激方案。 </li><li>根据患者关于感觉异常覆盖的陈述调整刺激设置。增加幅度和/或pulse宽度实现更广泛的刺激。在直接肌肉刺激的痛苦刺激的情况下减小幅度和/或脉搏宽度。 </li><li>在试验刺激期间向患者提供个人患者控制器，以使他或她能够打开或关闭刺激或改变刺激幅度。 </li><li>如果植入可充电IPG，请指导患者如何使用手持设备检查电池容量以及如何执行充电过程。 注意:患者接受口服预防性术后抗生素（ 例如每日两次，每次两次，960mg三甲氧甲脒磺胺甲恶唑）5天。 </li></ol></li><li>手术后第二天放疗患者。 </li><li>在门诊诊所进行手术后7天取出缝合线。 </li><li>在手术后4周和12周进行随访，以评估刺激效果，并根据需要改变刺激设置。 </li></ol>

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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trigeminal+branch+stimulation+for+the+treatment+of+intractable+craniofacial+pain.">Trigeminal branch stimulation for the treatment of intractable craniofacial pain.</a> J Neurosurg. 123 (1), 283-288 (2015).</li><li>Verrills, P., Rose, R., Mitchell, B., Vivian, D., Barnard, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peripheral+nerve+field+stimulation+for+chronic+headache:+60+cases+and+long-term+follow-up.">Peripheral nerve field stimulation for chronic headache: 60 cases and long-term follow-up.</a> Neuromodulation. 17 (1), 54-59 (2014).</li><li>Slotty, P. J., Bara, G., Vesper, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+surgical+technique+of+occipital+nerve+stimulation.">The surgical technique of occipital nerve stimulation.</a> Acta Neurochir. (Wien). 157 (1), 105-108 (2015).</li><li>Boccard, S. G., Pereira, E. A., Moir, L., Aziz, T. Z., Green, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcomes+of+deep+brain+stimulation+for+neuropathic+pain.">Long-term outcomes of deep brain stimulation for neuropathic pain.</a> Neurosurgery. 72 (2), 221-230 (2013).</li><li>Rasche, D., Ruppolt, M., Stippich, C., Unterberg, A., Tronnier, V. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motor+cortex+stimulation+for+long-term+relief+of+chronic+neuropathic+pain:+a+10+year+experience.">Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience.</a> Pain. (1-2), 43-52 (2006).</li><li>Merhkens, J. H., Steude, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Chronic+electrostimulation+of+the+trigeminal+ganglion+in+trigeminal+neuropathy:+current+state+and+future+prospects.">Chronic electrostimulation of the trigeminal ganglion in trigeminal neuropathy: current state and future prospects.</a> Acta Neurochir Suppl. 97 (Pt 2), 91-97 (2007).</li><li>Slavin, K. V., Colpan, M. E., Munawar, N., Wess, C., Nersesyan, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trigeminal+an+occipital+peripheral+nerve+stimulation+for+craniofacial+pain:+a+single-institution+experience+and+review+of+the+literature.">Trigeminal an occipital peripheral nerve stimulation for craniofacial pain: a single-institution experience and review of the literature.</a> Neurosurg Focus. 21 (6), E5 (2006).</li><li>Cheng, J. S., Lim, D. A., Chang, E. F., Barbaro, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Review+of+percutaneous+treatments+for+trigeminal+neuralgia.">A Review of percutaneous treatments for trigeminal neuralgia.</a> Neurosurgery. 10, 25-33 (2014).</li></ol>

作者没有什么可以披露的。

通过皮下三叉神经域刺激（sTNFS），我们提出了一种手术技术，用于对不同病因的三叉神经的慢性难治性疼痛进行微创神经调节。 减少并发症彻底消毒整个手术领域至关重要。任何不必要的皮肤穿孔可能会随着系统的连续损失而增加设备感染的风险。医生应始终注意电极的植入深度，因为当植入距离皮肤表面0.5厘米以下时，它们会侵蚀皮肤。使用固定装置固定电极应彻底执行...

用于治疗三叉神经痛的神经外科手术与潜在病因相同大小多样。在三叉神经微血管减压（MVD） 1脑干根进入区动脉压缩造成的经典三叉神经痛（TN）的情况下，高度有效。 加速器神经节的经皮破坏性技术（如射频热凝，甘油注射或气囊压缩2 ）和三叉神经痛立体定向放射外科手术可应用于无神经血管疾病或无明显外科手术禁忌症的情况。然而，所有技术都与某些疼痛复发率相关。此外，治疗本身具有导致神经性疼痛或甚至疼痛的创伤后三叉神经病变的神经损伤的风险。最后，三叉神经痛来源于中心（例如脑卒中后疼痛）将不会对Gasser神经节的MVD或破坏性技术作出反应，但需要通过神经调节治疗，如深部脑刺激（DBS）或运动皮层刺激（MCS）。 神经调节是用于外科技术的术语，其似乎改变神经活动而不引起不可逆的组织损伤。神经调节治疗是可逆的，适应性的，通常可以间断或连续地将电流施加到外周或中枢神经系统的部分。有几种认证（CE和/或FDA批准）治疗可用于治疗躯干和四肢的慢性和/或神经性疼痛，如硬膜外脊髓刺激（SCS），周围神经区域刺激（PNFS）或背根神经节刺激（DRG） 4 。然而，目前没有CE或FDA批准的治疗可用于慢性神经性面部和三叉神经痛/ P&gt; 针对不同来源的慢性面部疼痛患者，深部脑刺激（DBS）和运动皮层刺激（MCS）已被应用于多种病例系列。然而，这两种技术都具有高度的复杂性，并且需要特殊的医师专长。当保守治疗失败并且需要避免破坏性技术时，需要简单，成本效益和有效的慢性三叉神经和面部疼痛的神经调节。 除外科手术外，一系列非侵入性或临时形式的神经调节可用于治疗慢性疼痛（ 例如 PENS:经皮电神经刺激，TENS:经皮电神经刺激，TMS:经颅磁刺激）。 皮下周围神经域刺激（sPNFS）是神经调节的最小侵入形式。一个或多个电极a重新置于疼痛区域的皮下组织中。应用持续的电刺激来产生令人愉悦的感觉异常，涵盖痛苦的区域。确切的行动机制是未知的。然而，尽管存在所有缺点，但类似的机制，如门控制理论，或其变化，假设抑制性纤维的伤害性输入的调制是最常用的。另外，讨论了周围神经纤维的局部去极化阻滞，其兴奋性降低以及关于炎性蛋白质的微环境变化。 如在大多数神经调节程序中，执行连接到脉冲发生器的外部电极的测试试验以评估在完全植入式脉冲发生器（IPG）被放置在皮下组织中并连接到电极之前的有效性，作为用于刺激的电源治疗情况CCESS。没有一个积极的测试试验的一般定义，但在视觉模拟量表（VAS）上减少50％或更多的疼痛通常被认为是标志性标准。此外，减少口服止痛药物或提高生活质量可能是有利于植入永久性系统的因素。 外周神经域刺激被认证用于慢性腰痛8 ，并已被用于局部慢性疼痛综合征（ 例如 ，发作后疼痛）。它也用作枕骨神经刺激（ONS）治疗慢性偏头痛和丛集性头痛9 。几项非随机研究表明，三叉神经根皮瘤中sPNFS用于不同来源的慢性和神经性难治性疼痛（经典TN，非典型TN，疱疹后三叉神经病，MS相关性三叉神经病，持续性特发性面部疼痛） 10 </sup&gt; ， 11，12 。 皮下三叉神经区域刺激（sTNFS）容易且快速。与DBS或MCS相反，sTNFS可以作为门诊手术（如果报销）执行。没有颅内或硬膜外出血的风险。癫痫发作不发生。试验刺激是在动态的环境下进行的，以便病人能够在执行他的日常生活中评估刺激效果，而不是绑在医院病床上。无需广泛的术前或术前成像来确定电极的正确位置。在考虑神经病理或中枢性疼痛患者的MCS或DBS之前，sTNFS可以被认为是在应用经皮破坏性手术或作为较少侵入性类型的神经调节之前调节疼痛感知和加工的治疗选择。

<table><tbody><tr><td>myStim Patient Programmer</td><td>Medtronic</td><td>97740</td><td>enables the patient to turn off and on stimulation</td></tr><tr><td>Prime Advanced</td><td>Medtronic</td><td>97702</td><td>non-rechargeable IPG as powersource for stimulation</td></tr><tr><td>Restore Ultra</td><td>Medtronic</td><td>97712</td><td>rechargeable IPG as powersource for stimulation</td></tr><tr><td>Charging System</td><td>Medtronic</td><td>97754</td><td>used by the patient to recharge the Restore Ultra IPG</td></tr><tr><td>N&#039;Vision Programmer</td><td>Medtronic</td><td>8840</td><td>used by the physician to program the IPG and define stimulation parameters</td></tr><tr><td>External Neurostimulator</td><td>Medtronic</td><td>37022</td><td>external IPG as powersource for trial stimulation with externalized electrodes</td></tr><tr><td>Advanced Screening Cable</td><td>Medtronic</td><td>355531</td><td>connects externalized electrodes to the external neurostimulator during trial stimulation</td></tr><tr><td>Tunnelling Spear 60 cm</td><td>Medtronic</td><td>3655-60</td><td>used to subcutaneously tunnel the permanent electrodes to an infraclavicular pocket that houses the IPG</td></tr><tr><td>Tunnelling Spear 38 cm</td><td>Medtronic</td><td>3655-38</td><td>used to subcutaneously tunnel the permanent electrodes to an infraclavicular pocket that houses the IPG</td></tr><tr><td>Tuhoy Cannula</td><td>Medtronic</td><td>3550-32</td><td>14 G Epidural Tuhoy cannula (length 9 cm) to subcutaneously implant the electrodes</td></tr><tr><td>InjexFixation Device</td><td>Medtronic</td><td>97791 / 97792</td><td>used to fixate the electrodes on the skin or on the muscle fascia</td></tr><tr><td>Octad Compact</td><td>Medtronic</td><td>3878-60</td><td>permanent electrode (length 60 cm) implanted in the subcutaneous tissue with 8 contacts</td></tr><tr><td>Vectris Trial Lead</td><td>Medtronic</td><td>977D260</td><td>externalized electrode (length 60 cm) used during the stimulation trial</td></tr><tr><td>Ethilon*II 3-0</td><td>Ethicon</td><td>EH7933H</td><td>non-absorbable suture for skin closure</td></tr><tr><td>Seide 2-0</td><td>Resorba</td><td>40221</td><td>non-absorbable silk suture to fixate electrodes and IPG</td></tr><tr><td>Resolon DS21</td><td>Resorba</td><td>881413</td><td>absorbable suture for subcutaneous wound closure</td></tr><tr><td>Feather disposable scalpel</td><td>Feather</td><td>5205052</td><td>single use scalpel for skin incision and suture cutting</td></tr><tr><td>Scandicain 1%</td><td>Astra Zeneca</td><td>23186</td><td>1% Mepivacain solution for local anesthesia</td></tr><tr><td>Cosmopor E steril 10 x 6</td><td>Hartmann</td><td>900871</td><td>Sterile draping for IPG wound</td></tr><tr><td>Cosmopor E steril 7, 2 x 5</td><td>Hartmann</td><td>900870</td><td>Sterile draping for skin punctures and small incisions</td></tr><tr><td>Foliodrape Comfort 50 x 50</td><td>Hartmann</td><td>252302</td><td>Sterile draping for the surgical field</td></tr><tr><td>Cephazolin</td><td>Fresenius</td><td>6062403.00.00</td><td>Single shot perioperative antibiotic</td></tr><tr><td>Kepinol forte 800 mg/160 mg</td><td>Dr. R. Pfleger Chemische Fabrik</td><td>2485177</td><td>Postoperative prophylactic oral antibiotic</td></tr><tr><td>Poly-Alcohol</td><td>Antiseptica</td><td>UN1219</td><td>Coloured skin disinfectant used during the permanent implantation</td></tr><tr><td>Cutasept F</td><td>Bode</td><td>976800</td><td>Un-colored skin disinfectant used during the trial implantation</td></tr></tbody></table>

subcutaneous trigeminal nerve field stimulation for refractory facial pain

慢性或神经性三叉神经面痛可能是具有挑战性的治疗。当保守治疗失败时，应适用神经外科手术。慢性面部疼痛的神经调节技术包括深层脑刺激和运动皮层刺激，这些复杂的表现。皮下神经域刺激被认证为慢性背痛，是神经调节的最小侵入形式。我们应用这种技术治疗慢性和神经性三叉神经痛作为个体治疗概念。首先，进行试验刺激。在局部麻醉下将皮下引线置于疼痛的三叉神经皮肤。引线连接到应用恒定刺激的外部神经刺激器。患者接受12天门诊试验以评估刺激的效果。试验后电极被去除。如果患者报告疼痛减轻至少50％的强度和/或攻击频率，则减少用药或提高生活质量，定期进行永久植入。在全身麻醉下植入新电极，并皮下隧道穿入锁骨内部脉冲发生器。患者能够根据需要打开和关闭刺激并增加或减少刺激幅度。 这种技术代表了三叉神经痛的其他更具侵入性的神经调节手段，如运动皮层刺激或深部脑刺激的最小侵入性替代方法。

<html>由于皮下三叉神经域刺激（sTNFS）不是标准治疗，与其他疾病相比，潜在受益的患者数量相当小，所以只有较小的病例系列表现出sTNFS的结果。在一个系列中，10例患者接受了sTNFS的检测刺激。八名患者对治疗作出反应，并接受电极和IPG 11的永久植入。患者患有三叉神经痛，与多发性硬化有关的三叉神经病变，疱疹后三叉神经病，放射性三叉神经病和?...

Watch this Scientific Journal Video about Subcutaneous Trigeminal Nerve Field Stimulation for Refractory Facial Pain at JoVE.com

Subcutaneous Trigeminal Nerve Field Stimulation for Refractory Facial Pain

当医疗或标准治疗失败时，治疗慢性或神经性面部疼痛可能具有挑战性。皮下神经域刺激是神经调节的最小侵入形式，用于慢性背痛。我们应用这项技术治疗慢性和神经性三叉神经面部疼痛。

皮下三叉神经场刺激难治性面部疼痛

Chronic or neuropathic trigeminal facial pain can be challenging to treat. Neurosurgical procedures should be applied when conservative treatment fails. ...

subcutaneous-trigeminal-nerve-field-stimulation-for-refractory-facial

Research

JoVE Journal

Medicine

18.6K 次观看.  University Hospital Heidelberg. 当医疗或标准治疗失败时，治疗慢性或神经性面部疼痛可能具有挑战性。皮下神经域刺激是神经调节的最小侵入形式，用于慢性背痛。我们应用这项技术治疗慢性和神经性三叉神经面部疼痛。 

视频: Subcutaneous Trigeminal Nerve Field Stimulation for Refractory Facial Pain

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

微血管减压：突出的手术原则和技术的细微差别

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

科研

医学

Electrode Positioning and Montage in Transcranial Direct Current Stimulation

Transcranial direct current stimulation (tDCS) is a technique that has been intensively investigated in the past decade as this method offers a non-invasive and safe alternative to change cortical excitability2. The effects of one session of tDCS can last for several minutes, and its effects depend on polarity of stimulation, such as that cathodal stimulation induces a decrease in cortical excitability, and anodal stimulation induces an increase in cortical excitability that may last beyond the duration of stimulation6. These effects have been explored in cognitive neuroscience and also clinically in a variety of neuropsychiatric disorders &#x2013; especially when applied over several consecutive sessions4. One area that has been attracting attention of neuroscientists and clinicians is the use of tDCS for modulation of pain-related neural networks3,5. Modulation of two main cortical areas in pain research has been explored: primary motor cortex and dorsolateral prefrontal cortex7. Due to the critical role of electrode montage, in this article, we show different alternatives for electrode placement for tDCS clinical trials on pain; discussing advantages and disadvantages of each method of stimulation.

Transcranial direct current stimulation (tDCS) is an established technique to modulate cortical excitability1,2. It has been used as an investigative tool in neuroscience due to its effects on cortical plasticity, easy operation, and safe profile. One area that tDCS has been showing encouraging results is pain alleviation 3-5.

经颅直接电流刺激电极定位和蒙太奇

Transcranial direct current stimulation (tDCS) is a technique that has been intensively investigated in the past decade as this method offers a ...

神经科学

Assessment of Nerve Injury-Induced Mechanical Hypersensitivity in Rats Using an Orofacial Operant Pain Assay

Pain has sensory and affective components. Unlike traditional, reflex-based pain assays, operant pain assays can produce more clinically relevant results by addressing the cognitive and motivational aspects of pain in rodents. This paper presents a protocol for assessing mechanical hypersensitivity following chronic constriction injury of the infraorbital nerves (CCI-ION) in rats using an orofacial operant pain system. Before CCI-ION surgery, rats were trained in an orofacial pain assessment device (OPAD) to drink sweetened condensed milk while making facial contact with the metal spiked bars and lick-tube.
In this assay, rats can choose between receiving milk as a positive reinforcer or escaping an aversive mechanical stimulus that is produced by a vertical row of small pyramid-shaped spikes on each side of the reward access hole. Following 2 weeks of training in the OPAD and before the CCI-ION surgery, baseline mechanical sensitivity data were recorded for 5 days for each rat during a 10 min testing session. During a session, the operant system automatically records the number of reward bottle activations (licks) and facial contacts, contact duration, and latency to the first lick, among other measures.
Following baseline measurements, rats underwent either CCI-ION or sham surgery. In this protocol, mechanical hypersensitivity was quantified by measuring the number of licks, latency to the first lick, the number of contacts, and the ratio of licks to facial contacts (L/F). The data showed that CCI-ION resulted in a significant decrease in the number of licks and the L/F ratio and an increase in the latency to the first lick, indicating mechanical hypersensitivity. These data support the use of operant-based pain assays to assess mechanical pain sensitivity in preclinical pain research.

This protocol describes the assessment of mechanical hypersensitivity in a rat model of neuropathic orofacial pain using an operant-based orofacial pain assessment device.

使用口面部操作性疼痛测定法评估大鼠神经损伤诱导的机械超敏反应

Pain has sensory and affective components. Unlike traditional, reflex-based pain assays, operant pain assays can produce more clinically relevant results ...

行为学

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell&#8217;s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.
The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.
Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

在不可逆面瘫的微笑通过免费功能肌肉交接单级动态Reanimation来

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic ...

Chronic Constriction Injury of the Rat's Infraorbital Nerve (IoN-CCI) to Study Trigeminal Neuropathic Pain

Animal models are important tools to study the pathophysiology and pharmacology of neuropathic pain. This manuscript describes the surgical and behavioral procedures to study trigeminal neuropathic pain in rats. To meet the specificity of trigeminal neuropathic pain syndromes, the infraorbital nerve (IoN) is subjected to a chronic constriction injury (CCI) by loosely ligating the nerve. An intra-orbital approach is presented here to expose and ligate the IoN in the orbital cavity. After IoN ligation, rats exhibit changes in spontaneous behavior and in response to von Frey hair stimulation that are indicative of persistent pain and mechanical allodynia. Two phases can be defined in the development of the behavioral changes. During the first week following IoN-CCI (phase 1), rats show an increased and asymmetric face grooming activity, i.e., with face wash strokes primarily directed to the nerve-injured IoN territory. A distinction is made between face grooming behavior that is part of a more general body grooming behavior, which remains largely unaffected by IoN-CCI, and face grooming that is neither preceded nor followed by body grooming, which is significantly increased after IoN-CCI. During this period, responsiveness to mechanical stimulation of the IoN territory is reduced. This hyporesponsiveness is abruptly replaced by an extreme hyperresponsiveness whereby even very weak stimulus intensities provoke nocifensive behavior (phase 2). The phenomenological similarities between these behavioral alterations and reported signs of facial pain (i.e., responses to noxious stimulation of the face) suggest the presence of dysesthesia/paresthesia and mechanical allodynia in the ligated IoN territory.

Chronic Constriction Injury of the Rat's Infraorbital Nerve IoN-CCI to Study Trigeminal Neuropathic Pain

This manuscript describes a rodent model to study trigeminal neuropathic pain. The methods described include surgical procedures to perform a chronic constriction injury of the rat&#8217;s infraorbital nerve and the post-surgical behavioral tests to measure the changes in spontaneous and evoked behavior that are indicative of persistent pain and allodynia.

老鼠的眶下神经（ION-CCI）研究三叉神经性疼痛性损伤

Animal models are important tools to study the pathophysiology and pharmacology of neuropathic pain. This manuscript describes the surgical and behavioral ...

Laboratory Administration of Transcutaneous Auricular Vagus Nerve Stimulation (taVNS): Technique, Targeting, and Considerations

Non-invasive vagus nerve stimulation (VNS) may be administered via a novel, emerging neuromodulatory technique known as transcutaneous auricular vagus nerve stimulation (taVNS). Unlike cervically-implanted VNS, taVNS is an inexpensive and non-surgical method used to modulate the vagus system. taVNS is appealing as it allows for rapid translation of basic VNS research and serves as a safe, inexpensive, and portable neurostimulation system for the future treatment of central and peripheral disease. The background and rationale for taVNS is described, along with electrical and parametric considerations, proper ear targeting and attachment of stimulation electrodes, individual dosing via determination of perception threshold (PT), and safe administration of taVNS.

Laboratory Administration of Transcutaneous Auricular Vagus Nerve Stimulation taVNS: Technique, Targeting, and Considerations

A methodological description of the technique, potential targets, and proper administration of transcutaneous auricular vagus nerve stimulation (taVNS) on the human ear is described.

经皮耳穴神经刺激实验室管理 (tavns): 技术、定位和考虑

Non-invasive vagus nerve stimulation (VNS) may be administered via a novel, emerging neuromodulatory technique known as transcutaneous auricular vagus ...

Dural Stimulation and Periorbital von Frey Testing in Mice As a Preclinical Model of Headache

The cranial meninges, comprised of the dura mater, arachnoid, and pia mater, are thought to primarily serve structural functions for the nervous system. For example, they protect the brain from the skull and anchor/organize the vascular and neuronal supply of the cortex. However, the meninges are also implicated in nervous system disorders such as migraine, where the pain experienced during a migraine is attributed to local sterile inflammation and subsequent activation of local nociceptive afferents. Of the layers in the meninges, the dura mater is of particular interest in the pathophysiology of migraines. It is highly vascularized, harbors local nociceptive neurons, and is home to a diverse array of resident cells such as immune cells. Subtle changes in the local meningeal microenvironment may lead to activation and sensitization of dural perivascular nociceptors, thus leading to migraine pain. Studies have sought to address how dural afferents become activated/sensitized by using either in vivo electrophysiology, imaging techniques, or behavioral models, but these commonly require very invasive surgeries. This protocol presents a method for comparatively non-invasive application of compounds on the dura mater in mice and a suitable method for measuring headache-like tactile sensitivity using periorbital von Frey testing following dural stimulation. This method maintains the integrity of the dura and skull and reduces confounding effects from invasive techniques by injecting substances through a 0.65 mm modified cannula at the junction of unfused sagittal and lambdoid sutures. This preclinical model will allow researchers to investigate a wide range of dural stimuli and their role in the pathological progression of migraine, such as nociceptor activation, immune cell activation, vascular changes, and pain behaviors, all while maintaining injury-free conditions to the skull and meninges.

The most notable symptom of migraine is severe head pain, and it is hypothesized that this is mediated by sensory neurons innervating the meninges. Here, we present a method to locally apply substances to the dura in a minimally invasive manner while using facial hypersensitivity as an output.

小鼠硬脑膜刺激和眶周冯弗雷测试作为头痛的临床前模型

The cranial meninges, comprised of the dura mater, arachnoid, and pia mater, are thought to primarily serve structural functions for the nervous system.  ...

通过远程经颅直流电刺激治疗幻肢痛

Using Home-based, Remotely Supervised, Transcranial Direct Current Stimulation for Phantom Limb Pain

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that uses low-amplitude direct currents to alter cortical excitability. Previous trials have established the safety and tolerability of tDCS, and its potential to mitigate symptoms. However, the effects are cumulative, making it more difficult to have adherence to the treatment since frequent visits to the clinic or outpatient center are required. Moreover, the time needed for transportation to the center and the related expenses limit the accessibility of the treatment for many participants.
Following guidelines for remotely supervised transcranial direct current stimulation (RS-tDCS) implementation, we propose a protocol designed for remotely supervised and home-based participation that uses specific devices and materials modified for patient use, with real-time monitoring by researchers through an encrypted video conferencing platform. We have developed detailed instructional materials and structured training procedures to allow for self- or proxy-administration while supervised remotely in real time. This protocol has a specific design to have a series of checkpoints during training and execution of the visit. This protocol is currently in use in a large pragmatic study of RS-tDCS for phantom limb pain (PLP). In this article, we will discuss the operational challenges of conducting a home-based RS-tDCS session and show methods to enhance its efficacy with supervised sessions.

作者聚焦:对幻肢痛的远程监督神经调控程序的见解

The goal of this study is to describe a protocol for the home-based delivery of remotely supervised transcranial direct current stimulation (RS-tDCS) conserving the standard procedures of in-clinic practice, including safety, reproducibility, and tolerability. The participants included will be patients with phantom limb pain (PLP).

使用基于家庭的、远程监督的经颅直流电刺激治疗幻肢痛

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that uses low-amplitude direct currents to alter cortical ...

皮下三叉神经场刺激难治性面部疼痛

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此视频中的章节

微血管减压：突出的手术原则和技术的细微差别

经颅直接电流刺激电极定位和蒙太奇

使用口面部操作性疼痛测定法评估大鼠神经损伤诱导的机械超敏反应

在不可逆面瘫的微笑通过免费功能肌肉交接单级动态Reanimation来

老鼠的眶下神经（ION-CCI）研究三叉神经性疼痛性损伤

经皮耳穴神经刺激实验室管理 (tavns): 技术、定位和考虑

小鼠硬脑膜刺激和眶周冯弗雷测试作为头痛的临床前模型

使用基于家庭的、远程监督的经颅直流电刺激治疗幻肢痛

使用基于家庭的、远程监督的经颅直流电刺激治疗幻肢痛

使用基于家庭的、远程监督的经颅直流电刺激治疗幻肢痛