摘要： 目的 对比分析单纯马尾神经损伤后慢性神经病理性疼痛的手术策略及其有效性和长期安全性。方法 回顾分析2011年9月至2020年12月首都医科大学宣武医院收治的24例单纯马尾神经损伤后慢性神经病理性疼痛患者的临床资料，根据损伤部位、损伤程度、疼痛分布行脊髓背根入髓区（DREZ）毁损术或脊髓电刺激术，采用视觉模拟评分评价疼痛程度，疼痛缓解率≥ 50% 判断为手术有效，并记录出院时及随访期间并发症发生率。结果 共24例患者，行脊髓电刺激术14例，9例疼痛缓解率60%~80%，植入永久脉冲发生器；2例疼痛缓解率为60%，但未达预期，拒绝植入永久脉冲发生器；3例疼痛缓解率 < 10%，改行DREZ毁损术，2例疼痛缓解、1例仍无效。行DREZ毁损术10例，7例疼痛消失；2例部分区域残留疼痛；1例无效，改行脊髓电刺激术，疼痛仍未缓解。行脊髓电刺激术植入永久脉冲发生器后，2例因植入部位反复积液取出脉冲发生器。行DREZ毁损术后，3例于疼痛区域上界出现新发疼痛，术后2周至1个月逐渐消失；1例术后2年疼痛复发，再次行DREZ毁损术后疼痛消失。两组手术有效率差异无统计学意义（9/13对11/15；Fisher确切概率法：P = 1.000），但DREZ毁损术的疼痛缓解率高于脊髓电刺激术[100%（0，100%）对25%（0，75%）；Z = 0.441，P = 0.030]。结论 病因明确的单纯马尾神经损伤后慢性神经病理性疼痛行脊髓电刺激术或DREZ毁损术均可获得较满意的长期疗效。存在一定下肢运动和大小便功能的患者首选脊髓电刺激术；疼痛区域广泛、下肢运动和大小便功能丧失的患者则首选DREZ毁损术。DREZ毁损术的疼痛缓解率优于脊髓电刺激术。

关键词: 神经痛, 马尾, 脊髓, 电刺激, 疼痛测定

Abstract: Objective To analyze the surgical strategy, efficacy and long-term safety of chronic neuropathic pain (NP) after simple cauda equina injury.Methods The clinical data of patients with chronic NP after cauda equina injury treated by dorsal root entry zone (DREZ) derogation and spinal cord stimulation (SCS) in Xuanwu Hospital, Capital Medical University from September 2011 to December 2020 were analyzed. The DREZ derogation or SCS was selected according to the lesion location, injury degree and pain distribution. The long-term effect was evaluated according to the preoperative and postoperative Visual Analog Scales (VAS) scores, pain relief rate ≥ 50% was considered as effective, and the complications related to the surgery were followed up.Results Among 24 cases, 14 cases were treated with SCS, 9 cases had pain relief rate 60%-80%, and permanent pulse generator (IPG) was implanted; the pain relief rate was more than 60% in 2 cases, but it did not meet expectation so that the IPG was not implanted; no pain relief in 3 cases, DREZ derogation was performed later, the pain was relieved in 2 cases, and one case was still ineffective. DREZ derogation was firstly performed in 10 cases, and the pain disappeared in 7 cases; 2 cases had residual pain in some areas; one case was ineffective, and the pain was still unrelieved after SCS. After long?term implantation of IPG, 2 cases had been taken out of the stimulator due to fluid accumulation at the implantation site. After DREZ derogation, 3 cases had pain at the upper boundary of the preoperative pain area, which gradually disappeared within 2 weeks to one month. In one patient, the pain disappeared in early stage, which recurred after 2 years, and disappeared after the second DREZ derogation. There was no significant difference in the effective rate between 2 groups (9/13 vs. 11/15, Fisher's exact probability: P = 1.000). However, DREZ derogation had high pain improvement rate than SCS [100% (0, 100%) vs. 25% (0, 75%); Z = 0.441, P = 0.030].Conclusions For chronic neuropathic pain after simple cauda equina injury with clear etiology, both SCS and DREZ derogation may receive satisfactory long-term effect. SCS is the first choice for patients with lower limb movement, urinary and bowel function in pain area. DREZ derogation is the first choize for patients without lower limb movement, urinary and bowel. The pain improvement rate of DREZ derogation was better than that of SCS.

Key words: Neuralgia, Cauda equina, Spinal cord, Electric stimulation, Pain measurement