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经颅磁治疗仪——经颅磁刺激治疗脑卒中后中枢神经痛研究

2022-01-19 15:46:09

经(jing)颅磁(ci)(ci)治(zhi)疗仪——经(jing)颅磁(ci)(ci)刺(ci)激治(zhi)疗脑卒中后(hou)中枢神经(jing)痛(tong)研究




经颅磁刺激技术


中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)性疼(teng)(teng)痛(tong)(tong)已(yi)被疼(teng)(teng)痛(tong)(tong)研究协(xie)会(hui)定义为,由于中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)神(shen)经(jing)(jing)系统病变或功能障碍引(yin)发的(de)疼(teng)(teng)痛(tong)(tong)。中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)性疼(teng)(teng)痛(tong)(tong)主要(yao)原因有(you)脑卒(zu)中(zhong)(zhong)(zhong)(zhong)、脊髓损(sun)伤(shang)、多发性硬(ying)化(hua)症等(deng)。脑卒(zu)中(zhong)(zhong)(zhong)(zhong)后中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)神(shen)经(jing)(jing)痛(tong)(tong)(central post stroke pain,CPSP)是(shi)比较常见的(de)一种中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)神(shen)经(jing)(jing)性疼(teng)(teng)痛(tong)(tong),是(shi)某些脑区血管损(sun)伤(shang)导致(zhi)相应躯体部位疼(teng)(teng)痛(tong)(tong)的(de)疼(teng)(teng)痛(tong)(tong)综合征。目前针对(dui)CPSP多采(cai)用(yong)综合治(zhi)疗,包括经(jing)(jing)颅磁刺(ci)激治(zhi)疗、药物治(zhi)疗、患者教育(yu)、认(ren)知行为治(zhi)疗等(deng),本文(wen)就经(jing)(jing)颅磁刺(ci)激治(zhi)疗脑卒(zu)中(zhong)(zhong)(zhong)(zhong)后中(zhong)(zhong)(zhong)(zhong)枢(shu)(shu)神(shen)经(jing)(jing)痛(tong)(tong)进(jin)行阐述。




 经颅磁刺激仪






1.脑卒中(zhong)后中(zhong)枢(shu)神(shen)经痛的流行(xing)病(bing)学研(yan)究


从事一项缺血性(xing)(xing)和出血性(xing)(xing)中(zhong)(zhong)(zhong)风患(huan)者(zhe)(zhe)(zhe)297例(li)(li)的(de)(de)(de)(de)前瞻性(xing)(xing)研(yan)(yan)究(jiu)(jiu)(jiu)中(zhong)(zhong)(zhong),发现(xian)患(huan)者(zhe)(zhe)(zhe)在(zai)(zai)发病(bing)(bing)4个(ge)月时有(you)(you)(you)32%出现(xian)中(zhong)(zhong)(zhong)度(du)到重(zhong)度(du)脑(nao)卒(zu)中(zhong)(zhong)(zhong)后中(zhong)(zhong)(zhong)枢疼(teng)(teng)痛(tong)(tong),在(zai)(zai)发病(bing)(bing)16个(ge)月后中(zhong)(zhong)(zhong)度(du)到重(zhong)度(du)疼(teng)(teng)痛(tong)(tong)患(huan)者(zhe)(zhe)(zhe)的(de)(de)(de)(de)比例(li)(li)缩小(xiao)为(wei)(wei)21%,还(hai)得(de)出女性(xing)(xing)、抑郁量表评分高和糖化血红蛋(dan)白(bai)高的(de)(de)(de)(de)患(huan)者(zhe)(zhe)(zhe)CPSP发病(bing)(bing)率(lv)(lv)更高的(de)(de)(de)(de)结(jie)论。研(yan)(yan)究(jiu)(jiu)(jiu)脑(nao)卒(zu)中(zhong)(zhong)(zhong)患(huan)者(zhe)(zhe)(zhe)275例(li)(li),CPSP发病(bing)(bing)率(lv)(lv)为(wei)(wei)10.5%,研(yan)(yan)究(jiu)(jiu)(jiu)结(jie)论认为(wei)(wei)一半以上(shang)(shang)的(de)(de)(de)(de)患(huan)者(zhe)(zhe)(zhe)卒(zu)中(zhong)(zhong)(zhong)6个(ge)月以后发病(bing)(bing)。张晓玲(ling)等(deng)前瞻性(xing)(xing)研(yan)(yan)究(jiu)(jiu)(jiu)脑(nao)卒(zu)中(zhong)(zhong)(zhong)患(huan)者(zhe)(zhe)(zhe)1130例(li)(li),随(sui)访(fang)1个(ge)月,卒(zu)中(zhong)(zhong)(zhong)后疼(teng)(teng)痛(tong)(tong)547例(li)(li),其中(zhong)(zhong)(zhong)CPSP患(huan)者(zhe)(zhe)(zhe)80例(li)(li)。其研(yan)(yan)究(jiu)(jiu)(jiu)样本量较大但(dan)随(sui)访(fang)时间较短(duan),1个(ge)月以后可能(neng)会有(you)(you)(you)新发病(bing)(bing)的(de)(de)(de)(de)患(huan)者(zhe)(zhe)(zhe)没有(you)(you)(you)随(sui)访(fang)造成遗(yi)漏。以上(shang)(shang)研(yan)(yan)究(jiu)(jiu)(jiu)的(de)(de)(de)(de)CPSP的(de)(de)(de)(de)诊断均由神经科医师(shi)根据(ju)CPSP的(de)(de)(de)(de)诊断标准(zhun)确(que)定,均将外(wai)周神经病(bing)(bing)变、心理原因、褥疮(chuang)、肩关节周围炎(yan)、紧张性(xing)(xing)头(tou)痛(tong)(tong)、深静脉血栓等(deng)疼(teng)(teng)痛(tong)(tong)病(bing)(bing)因排除在(zai)(zai)外(wai)。可见要得(de)到CPSP的(de)(de)(de)(de)准(zhun)确(que)患(huan)病(bing)(bing)率(lv)(lv)需(xu)要长时间(1年以上(shang)(shang))的(de)(de)(de)(de)随(sui)访(fang)。目(mu)前关于(yu)(yu)国内CPSP发病(bing)(bing)率(lv)(lv)数据(ju)缺乏,有(you)(you)(you)待于(yu)(yu)进一步研(yan)(yan)究(jiu)(jiu)(jiu)统(tong)计。




 


经颅磁治疗仪




2.经颅(lu)磁刺激的工作原理(li)


经(jing)颅(lu)(lu)(lu)磁刺(ci)(ci)(ci)激(ji)(ji)(ji)技术是(shi)一种利用(yong)(yong)脉冲(chong)磁场作用(yong)(yong)于中(zhong)(zhong)枢神经(jing)系统(主要是(shi)大脑),改(gai)变皮(pi)层(ceng)神经(jing)细胞的(de)(de)膜电位(wei),使之产生感应电流,影响脑内代谢和神经(jing)电活动(dong),从(cong)而引(yin)起(qi)一系列(lie)生理生化反应的(de)(de)磁刺(ci)(ci)(ci)激(ji)(ji)(ji)技术。临(lin)床上已经(jing)证实重复(fu)经(jing)颅(lu)(lu)(lu)磁刺(ci)(ci)(ci)激(ji)(ji)(ji)能够改(gai)善脑卒(zu)中(zhong)(zhong)运(yun)动(dong)障碍、偏侧空间忽略,在脑卒(zu)中(zhong)(zhong)言(yan)语功(gong)能、吞咽功(gong)能的(de)(de)治(zhi)疗同(tong)样(yang)有明(ming)确的(de)(de)效果。将健康受(shou)(shou)试(shi)者14位(wei)纳入(ru)研究,首先应用(yong)(yong)辣椒辣素(su)(su)刺(ci)(ci)(ci)激(ji)(ji)(ji)受(shou)(shou)试(shi)者引(yin)起(qi)疼(teng)(teng)(teng)痛(tong),然后(hou)应用(yong)(yong)经(jing)颅(lu)(lu)(lu)磁刺(ci)(ci)(ci)激(ji)(ji)(ji)(10 Hz,共2000脉冲(chong))刺(ci)(ci)(ci)激(ji)(ji)(ji)大脑初级运(yun)动(dong)区、左背外侧前额叶及枕部中(zhong)(zhong)线,使用(yong)(yong)MPQ疼(teng)(teng)(teng)痛(tong)量表(McGill Pain Questionnaire,MPQ)对(dui)辣椒辣素(su)(su)应用(yong)(yong)之前、辣椒辣素(su)(su)后(hou)30 min和经(jing)颅(lu)(lu)(lu)磁刺(ci)(ci)(ci)激(ji)(ji)(ji)后(hou)进行疼(teng)(teng)(teng)痛(tong)评估,只(zhi)有刺(ci)(ci)(ci)激(ji)(ji)(ji)大脑初级运(yun)动(dong)区的(de)(de)受(shou)(shou)试(shi)者疼(teng)(teng)(teng)痛(tong)减轻(qing)。








由此(ci)可见,经颅磁刺(ci)激不仅能改善脑(nao)(nao)卒(zu)中患者各种功能障碍,且(qie)经颅磁刺(ci)激大脑(nao)(nao)的特定部位具(ju)有(you)明显(xian)的镇痛效果(guo)。




 






3.经(jing)颅磁刺激治疗(liao)脑卒中后中枢神经(jing)痛原理


目前对于中(zhong)(zhong)枢(shu)(shu)性生理(li)疼痛(tong)了解(jie)甚少(shao),脑(nao)(nao)卒中(zhong)(zhong)后中(zhong)(zhong)枢(shu)(shu)神经(jing)(jing)(jing)痛(tong)病理(li)生理(li)机制(zhi)尚未完全研究清楚(chu),已经(jing)(jing)(jing)提出有(you)中(zhong)(zhong)枢(shu)(shu)敏化、异位电活动(dong)增加、丘(qiu)脑(nao)(nao)血流(liu)动(dong)力(li)学改(gai)变,神经(jing)(jing)(jing)系统脱(tuo)抑制(zhi)状态(tai)、中(zhong)(zhong)枢(shu)(shu)的可(ke)塑性改(gai)变理(li)论,并(bing)被广泛接受。研究证实经(jing)(jing)(jing)颅(lu)磁刺激能够影响患者内分泌系统、免疫系统、自主神经(jing)(jing)(jing)功能系统。研究从机制(zhi)说(shuo)明经(jing)(jing)(jing)颅(lu)磁刺激治疗脑(nao)(nao)卒中(zhong)(zhong)后中(zhong)(zhong)枢(shu)(shu)神经(jing)(jing)(jing)痛(tong)原理(li),由以下(xia)几个方(fang)面阐述。




 




(1)脱抑制理论




Dejerine在1911年提出了脱(tuo)抑(yi)制(zhi)理(li)论(lun),正常情况下中(zhong)(zhong)枢系统(tong)各(ge)个核(he)团(tuan)、脊(ji)髓(sui)(sui)、皮层间相互(hu)平衡,CPSP患(huan)者(zhe)(zhe)在丘脑(nao)脊(ji)髓(sui)(sui)传导通路损(sun)伤后导致外侧丘脑(nao)解除(chu)抑(yi)制(zhi),神经兴奋性明显(xian)(xian)增(zeng)高,神经过度活跃引(yin)起自发性疼痛或痛觉过敏。对CPSP患(huan)者(zhe)(zhe)行经颅磁刺激治疗后,结果显(xian)(xian)示患(huan)者(zhe)(zhe)大脑(nao)静息(xi)阈值和运(yun)动诱发电(dian)位(wei)振幅(反(fan)映大脑(nao)皮质(zhi)兴奋性的(de)指标)均降低(di)。大脑(nao)皮质(zhi)兴奋性降低(di)和中(zhong)(zhong)枢神经系统(tong)脱(tuo)抑(yi)制(zhi)状(zhuang)态得(de)到缓解,患(huan)者(zhe)(zhe)疼痛减轻(qing)。此研究(jiu)结论(lun)符合脱(tuo)抑(yi)制(zhi)理(li)论(lun)的(de)机制(zhi)。




 




(2)中(zhong)枢(shu)神经系统可塑性改变(bian)




脑(nao)(nao)(nao)卒(zu)(zu)中后(hou)受损区(qu)域大脑(nao)(nao)(nao)皮(pi)层内神(shen)(shen)经(jing)(jing)元细(xi)胞异(yi)常(chang)放电(dian),持(chi)续(xu)异(yi)常(chang)的(de)(de)(de)病(bing)理生(sheng)理状态(tai)使(shi)中枢神(shen)(shen)经(jing)(jing)系统(tong)发生(sheng)可(ke)塑(su)性改变。目前(qian)治(zhi)疗CPSP患者(zhe)的(de)(de)(de)慢(man)性疼(teng)(teng)(teng)痛(tong)药物作(zuo)用(yong)(yong)机(ji)制就是(shi)(shi)(shi)利用(yong)(yong)降低神(shen)(shen)经(jing)(jing)兴奋性缓解疼(teng)(teng)(teng)痛(tong)。用(yong)(yong)神(shen)(shen)经(jing)(jing)系统(tong)可(ke)塑(su)性改变理论(lun)来解释CPSP发病(bing)机(ji)制是(shi)(shi)(shi)不完(wan)整的(de)(de)(de),提(ti)出了脑(nao)(nao)(nao)网络重组障(zhang)碍学说,影像学已经(jing)(jing)证(zheng)(zheng)实没有单一的(de)(de)(de)“疼(teng)(teng)(teng)痛(tong)皮(pi)质(zhi)”的(de)(de)(de)存(cun)在(zai)(zai),疼(teng)(teng)(teng)痛(tong)的(de)(de)(de)感知(zhi)由多个(ge)皮(pi)层区(qu)域共同参与,典型(xing)CPSP是(shi)(shi)(shi)多维度神(shen)(shen)经(jing)(jing)网络模(mo)型(xing),包(bao)括感官、情感和认知(zhi)多个(ge)区(qu)域平行(xing)处理产(chan)生(sheng)的(de)(de)(de)。研究发现高达50%的(de)(de)(de)CPSP患者(zhe)在(zai)(zai)6个(ge)月以后(hou)逐渐开始发病(bing),而(er)不是(shi)(shi)(shi)卒(zu)(zu)中发病(bing)后(hou)立(li)即(ji)出现,证(zheng)(zheng)明CPSP是(shi)(shi)(shi)一个(ge)渐进地、自我适应的(de)(de)(de)可(ke)塑(su)的(de)(de)(de)疼(teng)(teng)(teng)痛(tong)网络重组过(guo)程。对CPSP患者(zhe)进行(xing)经(jing)(jing)颅(lu)磁刺激(ji)治(zhi)疗后(hou),除使(shi)用(yong)(yong)视觉模(mo)拟评分(fen)(VAs)评估患者(zhe)疼(teng)(teng)(teng)痛(tong)之外,还应用(yong)(yong)了弥(mi)散(san)张(zhang)量(liang)成(cheng)像和功(gong)能性磁共振成(cheng)像等技术测量(liang)来观(guan)察(cha)患者(zhe)大脑(nao)(nao)(nao)兴奋性变化,检(jian)测指标包(bao)括大脑(nao)(nao)(nao)静(jing)息阈值、运动(dong)诱发电(dian)位振幅、皮(pi)质(zhi)缄默期(qi)的(de)(de)(de)持(chi)续(xu)时间,得出结论(lun):经(jing)(jing)颅(lu)磁刺激(ji)治(zhi)疗是(shi)(shi)(shi)通过(guo)作(zuo)用(yong)(yong)于丘脑(nao)(nao)(nao)皮(pi)质(zhi)束调整疼(teng)(teng)(teng)痛(tong)网络发挥镇痛(tong)作(zuo)用(yong)(yong)。




 




(3)丘(qiu)脑(nao)血流动(dong)力学病变




CPSP就是(shi)在丘脑损伤患者中发(fa)现,研究(jiu)(jiu)用(yong)正电子发(fa)射(she)断(duan)层扫(sao)描(positron emission computed tomography,PET)证实CPSP患者丘脑局部(bu)脑血流(liu)(liu)(liu)量(liang)降(jiang)低(di),丘脑处于低(di)代(dai)谢状态,丘脑的(de)(de)(de)病(bing)变与CPSP密切(qie)相关。将志愿者36位纳入研究(jiu)(jiu),采用(yong)l Hz的(de)(de)(de)经(jing)颅磁刺(ci)(ci)激(ji)颞皮层连续5 d,然后(hou)PET显示双(shuang)侧听觉皮层灰(hui)质(zhi)的(de)(de)(de)厚(hou)(hou)度增加。从方法(fa)论的(de)(de)(de)角度来看,灰(hui)质(zhi)的(de)(de)(de)厚(hou)(hou)度增加代(dai)表细(xi)胞(bao)外液和血流(liu)(liu)(liu)量(liang)的(de)(de)(de)扩张,从而认(ren)为(wei)经(jing)颅磁刺(ci)(ci)激(ji)具(ju)有改(gai)善患者局部(bu)脑血流(liu)(liu)(liu)量(liang)的(de)(de)(de)作用(yong)。




 




(4)调节神经递质的表达




将(jiang)(jiang)受试(shi)者(zhe)20位(wei)(wei)分为两组(zu),实验组(zu)给予左(zuo)背外(wai)侧前额叶皮(pi)(pi)层经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)(20 Hz,20 min/d),对照组(zu)给予假刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji),连续刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)5 d后(hou)(hou)实验组(zu)受试(shi)者(zhe)的皮(pi)(pi)质(zhi)(zhi)谷氨酸(suan)/谷氨酰(xian)胺(an)(an)比例会增加,而对照组(zu)无(wu)明(ming)显改变,研究证实了(le)经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)能(neng)够(gou)调节患者(zhe)的神经(jing)(jing)递质(zhi)(zhi)。除此(ci)之(zhi)外(wai),设(she)计研究先用冷(leng)痛(tong)刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)患者(zhe)左(zuo)鱼际诱(you)发疼痛(tong),然后(hou)(hou)将(jiang)(jiang)健康志愿者(zhe)12位(wei)(wei)分为3组(zu),分别给予氯胺(an)(an)酮(tong)、安慰(wei)剂、经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)(10 Hz,80%静息(xi)(xi)运(yun)动阈(yu)值(zhi),每日共1 500脉冲)刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)右侧初级运(yun)动区(qu)(primary motor area,M1),记录受试(shi)者(zhe)治疗前后(hou)(hou)静息(xi)(xi)疼痛(tong)刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)运(yun)动阈(yu)值(zhi)、阈(yu)上运(yun)动诱(you)发电位(wei)(wei)、短(duan)期内(nei)抑制(zhi)反应(ying)(脑皮(pi)(pi)质(zhi)(zhi)兴奋性参数),只有氯胺(an)(an)酮(tong)和经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)组(zu)疼痛(tong)评分下降,但经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)组(zu)疼痛(tong)静息(xi)(xi)运(yun)动阈(yu)值(zhi)、阈(yu)上运(yun)动诱(you)发电位(wei)(wei)、短(duan)期内(nei)抑制(zhi)无(wu)明(ming)显变化,间接(jie)得出(chu)经(jing)(jing)颅(lu)磁刺(ci)(ci)(ci)(ci)(ci)激(ji)(ji)的镇痛(tong)作用与天冬氨酸(suan)谷氨酸(suan)受体有关(guan)。




 




除此(ci)之外,对伴(ban)有感觉异常的CPSP患者(zhe)行(xing)经(jing)颅磁(ci)刺(ci)激治疗,发(fa)现不仅患者(zhe)疼(teng)痛减轻且(qie)温度(du)感知觉改善(shan),证(zheng)明重复经(jing)颅磁(ci)刺(ci)激在治疗中枢性疼(teng)痛和(he)温度(du)觉有显著交互(hu)作用。以上研(yan)究说明CPSP患者(zhe)的疼(teng)痛和(he)温度(du)觉异常存在关联。




 






4.经(jing)颅磁刺激的临床应(ying)用


(1)刺激部位




将难治性中枢神经(jing)(jing)痛(tong)患(huan)者20例纳入研究(jiu),在导航系统(tong)引(yin)导下行经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激治疗(liao),选择10 Hz的经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激刺(ci)(ci)(ci)激患(huan)者中央后回(hui)、运(yun)(yun)(yun)动(dong)(dong)前(qian)区(qu)(qu)(qu)(qu)和辅助运(yun)(yun)(yun)动(dong)(dong)区(qu)(qu)(qu)(qu),治疗(liao)后应用(yong)(yong)(yong)VAS疼(teng)(teng)(teng)痛(tong)评分评价患(huan)者疼(teng)(teng)(teng)痛(tong)。刺(ci)(ci)(ci)激M1区(qu)(qu)(qu)(qu)部位患(huan)者50%出现疼(teng)(teng)(teng)痛(tong)减(jian)轻,持续时间约3 h,其他部位疼(teng)(teng)(teng)痛(tong)评分差异(yi)较(jiao)(jiao)前(qian)无统(tong)计学意义。研究(jiu)结论认为(wei),M1部位是经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激治疗(liao)CPSP有(you)效(xiao)的作(zuo)用(yong)(yong)(yong)靶点(dian)。明研究(jiu)针对(dui)左(zuo)(zuo)侧(ce)运(yun)(yun)(yun)动(dong)(dong)前(qian)区(qu)(qu)(qu)(qu)/前(qian)额叶背(bei)外侧(ce)皮层,并得出结论刺(ci)(ci)(ci)激该区(qu)(qu)(qu)(qu)域并没有(you)减(jian)轻CPSP患(huan)者疼(teng)(teng)(teng)痛(tong)的作(zuo)用(yong)(yong)(yong)。受试者先用(yong)(yong)(yong)辣(la)椒辣(la)素引(yin)起疼(teng)(teng)(teng)痛(tong)对(dui),后经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激大(da)脑初级运(yun)(yun)(yun)动(dong)(dong)区(qu)(qu)(qu)(qu)、左(zuo)(zuo)背(bei)外侧(ce)前(qian)额叶和枕部中线(xian),研究(jiu)结果同样是大(da)脑初级运(yun)(yun)(yun)动(dong)(dong)区(qu)(qu)(qu)(qu)经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激后受试者疼(teng)(teng)(teng)痛(tong)较(jiao)(jiao)前(qian)减(jian)轻。目前(qian)在经(jing)(jing)颅磁(ci)(ci)刺(ci)(ci)(ci)激治疗(liao)CPSP作(zuo)用(yong)(yong)(yong)靶点(dian)的研究(jiu)中,只有(you)M1区(qu)(qu)(qu)(qu)作(zuo)用(yong)(yong)(yong)靶点(dian)作(zuo)用(yong)(yong)(yong)得到了证(zheng)实。




 




(2)刺激频率




刺(ci)(ci)激频(pin)(pin)(pin)率(lv)(lv)是(shi)经颅磁刺(ci)(ci)激的(de)重要参数,高(gao)频(pin)(pin)(pin)TMS刺(ci)(ci)激(>1 Hz)可以增强(qiang)皮质(zhi)兴(xing)奋(fen)(fen)性(xing),低(di)频(pin)(pin)(pin)TMS刺(ci)(ci)激(≤1 Hz)会抑制(zhi)皮质(zhi)兴(xing)奋(fen)(fen)性(xing)。目前(qian)应用经颅磁刺(ci)(ci)激治疗CPSP刺(ci)(ci)激频(pin)(pin)(pin)率(lv)(lv)多采用5 Hz或者(zhe)10 Hz,只有采用1 Hz,但是(shi)他在经颅磁刺(ci)(ci)激治疗后没有起(qi)到镇痛(tong)效(xiao)果(guo)。鉴于以上(shang)研究(jiu),高(gao)频(pin)(pin)(pin)刺(ci)(ci)激可以有效(xiao)治疗CPSP患者(zhe)的(de)疼痛(tong),而低(di)频(pin)(pin)(pin)刺(ci)(ci)激起(qi)不到镇痛(tong)的(de)效(xiao)果(guo)。




 




(3)靶点(dian)定位(wei)和(he)导航系统




运用(yong)脑磁共振数据进行三维(wei)重建,利(li)用(yong)重建数据来帮助(zhu)确定(ding)(ding)(ding)经颅磁刺(ci)(ci)激(ji)靶点位(wei)(wei)(wei)置(zhi)(zhi)。为了(le)比较该方法(fa)比其他(ta)传统(tong)确定(ding)(ding)(ding)靶点位(wei)(wei)(wei)置(zhi)(zhi)方法(fa)定(ding)(ding)(ding)位(wei)(wei)(wei)的(de)准确性,试验设(she)计(ji)分多种测量(liang)志愿者(zhe)50位(wei)(wei)(wei)双侧(ce)背外侧(ce)前额叶皮质(zhi)和(he)M1区(qu)(qu)的(de)坐标(biao)(biao)。结(jie)果显示用(yong)其他(ta)传统(tong)标(biao)(biao)准化程序(xu)定(ding)(ding)(ding)位(wei)(wei)(wei)的(de)坐标(biao)(biao)多在(zai)M1区(qu)(qu)(靶目(mu)标(biao)(biao))后缘,而行三维(wei)重建的(de)坐标(biao)(biao)位(wei)(wei)(wei)于M1区(qu)(qu)(靶目(mu)标(biao)(biao))。结(jie)论是,利(li)用(yong)磁共振导(dao)航系(xi)(xi)统(tong)定(ding)(ding)(ding)位(wei)(wei)(wei)靶点比其他(ta)传统(tong)确定(ding)(ding)(ding)靶点位(wei)(wei)(wei)置(zhi)(zhi)方法(fa)更(geng)加精(jing)准。除了(le)在(zai)定(ding)(ding)(ding)位(wei)(wei)(wei)上的(de)技术发(fa)展,目(mu)前已有同时检(jian)测头(tou)部(bu)作(zuo)用(yong)靶点和(he)经颅磁刺(ci)(ci)激(ji)的(de)线圈(quan)系(xi)(xi)统(tong)。




 




设计试(shi)验研(yan)究导(dao)(dao)航程序能否提(ti)高经颅(lu)(lu)磁(ci)刺(ci)激镇痛(tong)效果,研(yan)究将各种原因引起的(de)神经性疼(teng)痛(tong)患者66例分(fen)为(wei)假刺(ci)激组(zu)、有导(dao)(dao)航经颅(lu)(lu)磁(ci)刺(ci)激组(zu)和无(wu)导(dao)(dao)航的(de)经颅(lu)(lu)磁(ci)刺(ci)激组(zu)。导(dao)(dao)航组(zu)利用(yong)芬兰(lan)Nexstim导(dao)(dao)航系统,采(cai)用(yong)磁(ci)共振成像(xiang)立体(ti)定位(wei)技术,借助(zhu)于红外摄像(xiang)系统监测头颅(lu)(lu)的(de)坐(zuo)标,患者的(de)头部和刺(ci)激线圈在同一个(ge)(ge)坐(zuo)标配准系统,线圈的(de)位(wei)置和方向(xiang)实时可视、可控;非导(dao)(dao)航组(zu)使用(yong)10~20脑电系统定位(wei)。两组(zu)采(cai)用(yong)10Hz经颅(lu)(lu)磁(ci)刺(ci)激持续刺(ci)激M1区,每日共计3 000个(ge)(ge)脉(mai)冲,应用(yong)VAS疼(teng)痛(tong)评分(fen)评估疼(teng)痛(tong)程度。








经颅磁刺(ci)激如何准确地定位作用靶(ba)点,直接影(ying)响着经颅磁刺(ci)激的效果(guo),在先进(jin)的影(ying)像学(xue)技术(shu)进(jin)行(xing)精准定位帮助(zhu)下,经颅磁刺(ci)激的效果(guo)会得到提升。




 




在临床应用(yong)(yong)中(zhong),对CPSP患者研究在药(yao)(yao)物(wu)(硫喷妥钠、吗啡)治疗(liao)(liao)基础(chu)上(shang)加用(yong)(yong)经颅(lu)磁(ci)刺激治疗(liao)(liao),药(yao)(yao)物(wu)治疗(liao)(liao)和经颅(lu)磁(ci)刺激治疗(liao)(liao)并(bing)非同(tong)时进行(xing),试验设计是(shi)先使用(yong)(yong)药(yao)(yao)物(wu)评估后再应用(yong)(yong)经颅(lu)磁(ci)刺激治疗(liao)(liao),研究结果(guo)(guo)显示药(yao)(yao)物(wu)治疗(liao)(liao)基础(chu)上(shang)使用(yong)(yong)经颅(lu)磁(ci)刺激治疗(liao)(liao)CPSP效果(guo)(guo)更好。这一(yi)研究结果(guo)(guo)在临床中(zhong)具有指(zhi)导(dao)意义。




 




5.总结




经颅(lu)(lu)磁(ci)刺(ci)(ci)激(ji)作(zuo)为(wei)一(yi)种CPSP无创(chuang)性治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)方法,有(you)(you)明确的(de)效果,同(tong)药物相比没有(you)(you)明显副作(zuo)用。经颅(lu)(lu)磁(ci)刺(ci)(ci)激(ji)治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)后(hou)后(hou)续镇痛时(shi)(shi)间较长,缺点是只能在有(you)(you)治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)仪(yi)器的(de)场所进行,患(huan)者必(bi)须在医院(yuan)或(huo)康(kang)复中心接受治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)。目前经颅(lu)(lu)磁(ci)刺(ci)(ci)激(ji)在CPSP治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)过程中仍然(ran)存(cun)在一(yi)些问题,CPSP患(huan)者个体之(zhi)间受损的(de)部位不同(tong),疼痛的(de)临床表现不同(tong),如何权衡(heng)经颅(lu)(lu)磁(ci)刺(ci)(ci)激(ji)治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)中的(de)部位、频率、治(zhi)(zhi)(zhi)(zhi)疗(liao)(liao)(liao)(liao)时(shi)(shi)间,这将(jiang)有(you)(you)待(dai)于(yu)进一(yi)步研究(jiu)。


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