 英语晨读 · 山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。 本次文献选自Raghu ALB, Parker T, Aziz TZ, et al. Invasive Electrical Neuromodulation for the Treatment of Painful Diabetic Neuropathy: Systematic Review and Meta-Analysis. Neuromodulation, 2021; 24: 13–21。本次学习由谢珺田副主任医师主讲。 The appropriate timing of treatment with neuromodulation is a long-standing question in pain management. Surgical treatments are usually reserved for the most refractory patients, who have been suffering the longest. However, it is recognized that the more longstanding pain syndromes are, the more psychological morbidity accumulates as well as plastic changes in the brain that ultimately make pain more difficult to treat. As invasive neuromodulation has demonstrated superiority to continued medical treatment in poorly responding cases, it may be prudent to offer surgical treatments as soon as it becomes clear that medical treatments are not working satisfactorily, with cessation of nonbeneficial medications as soon as possible. It is increasingly clear that opioids do not provide effective long-term symptom control in chronic neuropathic pain syndromes. The opioid epidemic has brought into focus the need for more judicious prescribing and the dangers of insidiously escalating doses, which are far greater than risks from surgery. 神经调节治疗的适当时机是疼痛管理中一个长期存在的问题。手术治疗通常用于最难治的疼痛患者，他们往往经历了漫长的痛苦。然而，大家逐渐认识到，慢性疼痛综合征越多，心理疾患发病率越高，同时伴发大脑的可塑性变化，最终使疼痛更难治疗。由于有创神经调节已证明在药物反应不佳的病例中优于继续药物治疗，因此，在明确药物治疗效果不理想时，尽快停用相关药物治疗改用有创治疗是有益的。阿片类药物不能有效地控制慢性神经病理性疼痛综合征的长期症状。阿片类药物的普遍应用使人们关注到需要更明智的处方，以及潜在地增加剂量的危险，这些危险远远大于手术的风险。 LIMITATIONS AND RECOMMENDATIONS Treatment with t-SCS has level 1 evidence, accumulated in two trials, across multiple centers, showing superiority to BMT. However, these were necessarily unblinded and performance bias is important to acknowledge. The treatment effect calculated in this meta-analysis is likely to include a placebo effect. However, such effects can be long lasting, and the aim in highly refractory patients with severe pain is simply to leverage pain relief. On these grounds, t-SCS can be recommended. There is only level 4 evidence for longer term benefit, so the clinician must be cautious with a patient’s expectations on duration of effect, while acknowledging the increasing possibility of complications over time. 推荐意见 t-SCS治疗具有1级证据，有两项多中心协作研究结果支持，显示优于BMT。然而，需要认识到这些研究都存在明显的非盲法偏倚和完成偏倚。此荟萃分析中计算的治疗效果可能包括安慰剂效应。然而，这样的效果可能是持久的，对顽固性重度疼痛患者的目的只是用以缓解疼痛。基于这些理由，可以推荐t-SCS。只有4级证据表明长期受益，因此临床医生必须谨慎对待患者对疗效持续时间的期望，同时认识到随着时间的推移，并发症的风险逐渐增加。 For b-SCS, HF-SCS, and DRGS, only a small amount of level 4 evidence is available, insufficient for routine recommendation for PDN. These can only be recommended on a research or exceptional basis. However, SCS devices can operate with multiple programs interchangeably, allowing the patient to select programs based on observed relief and side effects. In this setting, devices providing b-SCS or HF-SCS can be recommended provided that they have a tonic program as default, and other optional programs used at patient’s preference. 对于b-SCS、HF-SCS和DRGS，只有少量的4级证据可用，不足以提出作为PDN的常规建议。这些建议只能在另外的研究基础上提出。然而，SCS设备可以与多个程序互换操作，允许患者根据观察到的缓解效果和副作用选择刺激模式。在此情形下，可以推荐提供b-SCS或HF-SCS的设备，前提是它们具有默认的t-SCS模式，也可以根据患者的喜好使用其他可选程序。 CONCLUSION As a leading cause of neuropathic pain worldwide, the effective treatment of PDN is of high societal and economic importance. Meta-analysis of the existing evidence provided by two randomized controlled trials supports the use of t-SCS in the treatment of medication refractory severe PDN. Other newer stimulation modalities such as high-frequency SCS, burst SCS, and DRGS show promise but require formal trial evaluation. We suggest that the available evidence should encourage healthcare professionals to consider neuromodulation in any case where there is severe pain unresponsive to anticonvulsant and antidepressant medications, and before prescription of strong opioids, certainly well before such drugs reach guideline dose limits. 结论 作为世界范围内引起神经病理性疼痛的主要原因，PDN的有效治疗具有重要的社会和经济意义。两项随机对照试验提供的现有证据的荟萃分析支持t-SCS在药物难治性重度PDN治疗中的应用。其他较新的刺激方式，如高频SCS、爆发SCS和DRGS有望取得独到的效果，但需要正式的研究评估。我们建议，现有的证据应鼓励医护人员在以下情况下考虑神经调制技术：在出现对抗惊厥药和抗抑郁药无效的剧烈疼痛时，在处方强阿片类药物之前，以及在此类药物达到指南剂量限值之前。 |
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