【晨读】脑桥前池吗啡泵植入术缓解头面部癌痛（一）

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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Zou D, Zhang W, Wang Y. Prepontine cistern intrathecal targeted drug delivery for cancer-related craniofacial pain [published online ahead of print, 2021 Feb 23]. Pain Med. 2021;pnab059. 本次学习由林小雯副主任医师主讲。

Dear Editor,

  Cancer-related craniofacial pain can severely affect a patient’s quality of life and is often difficult to control with regular analgesics. Intrathecal targeted drug delivery is a proven and accepted therapy in cancer patients for the treatment of uncontrolled refractory pain. The intrathecal catheter tip is generally placed near to the site of greatest pain. However, for craniofacial cancer pain, the catheter tip is usually placed far away from the root entry zone of the cranial nerves, which innervate head and face tissues, thus potentially leading to inadequate analgesia. Here, we describe a case of a terminal cancer patient with intractable pain who was successfully treated by intrathecal targeted drug delivery by placing the catheter tip near the prepontine cistern.

亲爱的编辑：

头面部癌痛严重影响患者的生活质量，通常很难通过常规镇痛药来控制。鞘内靶向药物输送是一种已被证实和接受的用以治疗顽固性癌痛的疗法。鞘内导管尖端通常放置在疼痛部位附近。然而，对于头面部癌痛，导管尖端通常放置在远离支配头面部的颅神经根的地方，因此可能导致镇痛效果不佳。在这里，我们描述了一例患有顽固性疼痛的晚期癌症患者，成功地通过将导管尖端放置在脑桥前池附近进行鞘内靶向药物输送成功控制疼痛。

Case

A 65-year-old female patient with metastatic lung cancer with a lesion to the frontal part of the skull (Figure 1, A and B), presented with severe head pain, which was refractory to oral medications, including oxycodone sustained-release tablets 80mg bid and gabapentin 300 mg tid. The pain was rated 6-7 on the numeric rating scale(NRS) at rest and 9-10 of breakthrough pain, which occurred frequently. Following this, an intrathecal catheter with an external port was implanted. For the insertion of the intrathecal catheter, the patient was placed in a left lateral decubitus position. A lumbar puncture was made with a Tuohy needle at the L2-L3 interspace and an intrathecal catheter (ZS2 Implantable Access Port, Linhwa, China) was inserted in the subarachnoid space in the cranial direction under fluoroscopic guidance. The tip of the catheter was carefully placed within the prepontine cistern (Figure 1, C and D). The end of the catheter was then tunneled subcutaneously and connected to a subcutaneous port in the right upper abdomen. An external electronic pump was connected to the port using a butterfly needle. The patient was given an external pump containing 0.03 mg/ml morphine, with a bolus of 0.1-ml each time and a 30-min lockout interval. No respiratory depression, sedation, nor confusion occurred. The dose of intrathecal morphine was started at 0.03 mg morphine daily, and gradually titrated up for improved pain control. The NRS was rated 1-2 at rest and 5-6 at worst during breakthrough pain, which was improved with administration of one bolus. The frequency of breakthrough pain episodes was also decreased. The oral oxycodone sustained-release tablets were stopped 1 week later. In the third month of this treatment, the patient’s continuous infusion rate was adjusted to deliver morphine 0.08 mg/day. The severe pain in the frontal part of the head was greatly reduced and she was satisfied with the results of intrathecal analgesic therapy.

病例

65岁女性，肺癌伴脑额部转移(图1、A、B)，表现为剧烈头痛，口服羟考酮缓释片80mg bid、加巴喷丁300mg tid镇痛效果不佳。静息痛的NRS评分为6-7分，爆发痛的NRS评分为9-10分，且发作频繁。随后，一个带外部端口的鞘内导管被植入。患者取左侧卧位，在x线透视下，用穿刺针在L2-L3间隙进行腰椎穿刺，并向头端将鞘内导管(ZS2 Implantable Access Port, Linhwa, China)置入蛛网膜下腔。导管尖端放置至脑桥前池。然后将导管的一端通过皮下隧道连接至右上腹皮下。外接电子泵用蝶形针连接到该端口。外接泵内的吗啡浓度为0.03 mg/ml，每小时0.1毫升，锁时30分钟。无明显呼吸抑制、镇静或意识障碍。吗啡鞘内注射剂量为每日0.03 mg，根据疼痛程度逐渐滴定。静息时NRS评分为1-2，爆发性疼痛时评分最差为5-6，初次给药疼痛即得到改善。爆发性疼痛发作的频率也降低了。口服羟考酮缓释片1周后停用。治疗后第3个月，鞘内吗啡的持续输注剂量调整为0.08 mg/天。患者头痛明显缓解，对治疗效果表示满意。