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脊髓刺激：植入和管理

Author
Anne Marie McKenzie-Brown, MD
Section Editor
Stephanie B Jones, MD
Deputy Editor
Marianna Crowley, MD
Translators
李金宝, 副主任医师，副教授

引言

脊髓刺激(spinal cord stimulation, SCS)是一种神经调制技术，可用于治疗神经病性和交感神经介导的慢性疼痛。SCS采用经皮或外科手术的方式将电极植入硬膜外隙，并通过植入电池来供能。

本专题将讨论脊髓刺激器的植入、脊髓刺激器植入时的麻醉管理，以及接受其他外科手术患者的SCS管理。本专题不介绍椎板切除术和手术植入刺激电极的技术。慢性疼痛的评估、治疗慢性疼痛的其他方法，以及特定疾病的SCS治疗将单独介绍。 (参见“成人慢性疼痛的评估”和“慢性疼痛的治疗概述”和“治疗下肢外周动脉疾病症状的试验性疗法”，关于‘脊髓刺激’一节和“成人复杂性局部疼痛综合征的预防和治疗”)

作用机制

SCS复杂的作用机制尚未被完全阐明，可能有多因素的参与。SCS对神经病理性疼痛的镇痛机制似乎与缓解缺血性疼痛的机制不同[1]。

●减轻神经病理性疼痛–最初认为，SCS通过脊髓灰质后角中的门控机制发挥作用。因此，脊髓刺激器也被称为脊髓背柱刺激器。根据门控理论，脊髓后角中的胶状质即是功能性的闸门系统，疼痛在此处调制。细神经纤维(痛觉Aδ和C类纤维)和粗神经纤维(Aβ纤维)会在闸门处形成突触。粗神经纤维激活会抑制痛觉细神经纤维，关闭闸门，缓解疼痛[2]。

现已知SCS缓解疼痛的机制实际上更为复杂。SCS对神经病理性疼痛的缓解在部分程度上是由抑制脊髓后角的广动力范围(wide dynamic range, WDR，也称广动力域)神经元抑制介导的。这涉及了脊髓γ-氨基丁酸(gamma-aminobutyric acid, GABA)系统及其对兴奋性氨基酸(excitatory amino acid, EAA)活性的影响[3-5]。此外，SCS似乎至少在部分程度上通过对脑的影响来发挥作用。SCS引起的疼痛缓解通常可在关闭刺激器后持续数日甚至数周，这表明SCS有更多中枢性的作用机制[3,6]。一项对下肢慢性神经病性疼痛患者进行的脑电图(electroencephalography, EEG)研究发现，长期SCS会影响疼痛阈值和皮质信号传递，进一步证实了更为中枢性的镇痛机制[7]。

                     

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Literature review current through: 2017-06 . | This topic last updated: 2016-11-01.
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