中國(guó)神經(jīng)病理性疼痛診療指南(2024版)率為3.0%～17.0%[1]。療指南》文獻(xiàn)檢索時(shí)限為2014年1月至2024年6月。中文檢索詞包括神經(jīng)病理性疼價(jià)(gradingofrecommendationsassessment,developmentandGRADE)分級(jí)系統(tǒng)證據(jù)質(zhì)量分級(jí)及推薦強(qiáng)度(表1[24])和共識(shí)會(huì)議法，經(jīng)過(guò)表1GRADE系統(tǒng)證據(jù)質(zhì)量分級(jí)及推薦強(qiáng)度說(shuō)明級(jí)別說(shuō)明高質(zhì)量(A)中等質(zhì)量(B)低質(zhì)量(C)實(shí)值有很大差別極低質(zhì)量(D)值極大可能有很大差別推薦強(qiáng)度強(qiáng)推薦(1)員贊成弱推薦(2)證據(jù)以及他們的價(jià)值觀和意愿進(jìn)行討無(wú)明確推薦意見(jiàn)(3)見(jiàn)的證據(jù)不足；50%以下專家組成員同意(1)概述病理機(jī)制調(diào)制通路和認(rèn)知與情感相關(guān)腦區(qū)的病理可塑性改變?cè)谄渲邪l(fā)揮重要作用[5]。和異位放電，導(dǎo)致痛覺(jué)超敏、痛覺(jué)過(guò)敏和自發(fā)性疼痛[6];在中樞神經(jīng)系統(tǒng)，表現(xiàn)為興奮性突觸傳遞效率增強(qiáng)，即長(zhǎng)時(shí)程增強(qiáng)(longtermpotentiation,LTP),在后期出現(xiàn)形態(tài)學(xué)改變，即興奮性突觸數(shù)量增多，而抑制性突觸神經(jīng)環(huán)路重塑[7];痛覺(jué)調(diào)制系統(tǒng)可塑性改變導(dǎo)致下行抑制系統(tǒng)功能減弱，而下行易化系統(tǒng)活動(dòng)增強(qiáng)[8];認(rèn)知和情感相關(guān)腦區(qū)(如海馬和前額葉等)的功增強(qiáng)痛覺(jué)感受[9]。研究表明，神經(jīng)炎癥，即神經(jīng)膠質(zhì)細(xì)胞活化和致炎細(xì)胞因?qū)е峦庵苊庖呒?xì)胞浸潤(rùn)到外周神經(jīng)和腦實(shí)質(zhì)是引起神經(jīng)炎癥的重要原因[10]。常見(jiàn)NP疾病臨床特點(diǎn)一、外周神經(jīng)病理性疼痛1.三叉神經(jīng)痛TN(未發(fā)現(xiàn)潛在原因)。繼發(fā)性TN(存在潛在病理),又稱癥狀性TN,是指由10萬(wàn)，年發(fā)病率為3～5/10萬(wàn)，多發(fā)生于成年及老年人[11]。(2)臨床特點(diǎn)(3)診斷①三叉神經(jīng)1支或多支發(fā)作，無(wú)三叉神經(jīng)外放射痛。②至少包含下列4項(xiàng)中的3項(xiàng)。A.發(fā)作性疼痛持續(xù)1s～2min。(4)鑒別診斷2.帶狀皰疹后神經(jīng)痛(1)概述老年人，隨年齡增加患病率增高[12]。(2)臨床特點(diǎn)(1)概述多神經(jīng)病變等。PDPN患病率為8.0%～26.0%[14],在2型糖尿病中更容易慢性痛性多神經(jīng)病變[16]。(2)臨床特點(diǎn)(3)診斷標(biāo)準(zhǔn)③其他(1)定義(2)臨床特點(diǎn)(3)診斷(1)定義起痛性神經(jīng)根病[13]。(2)臨床特點(diǎn)(3)診斷(1)定義(2)診斷標(biāo)準(zhǔn)(3)鑒別診斷(1)定義(2)臨床特點(diǎn)(3)診斷標(biāo)準(zhǔn)(1)定義疼痛、中樞性疼痛等[23]。(2)臨床特點(diǎn)(1)定義(3)診斷(1)概述(2)臨床特點(diǎn)(3)診斷Klit等[26]推薦的CPSP診斷標(biāo)準(zhǔn)。(2)臨床特點(diǎn)(3)診斷標(biāo)準(zhǔn)1.一般治療環(huán)境因素、情緒變化等均可加重NP,患者健康教育和自我管理很重要。教育患者要保持良好的生活習(xí)慣，避免熬夜和過(guò)度勞累，避免暴飲暴食、過(guò)度煙酒、過(guò)度辛辣食物等。指導(dǎo)患者自我調(diào)節(jié)情緒。堅(jiān)持適當(dāng)?shù)倪\(yùn)動(dòng)，參加各種有益的社交活動(dòng)，與醫(yī)師建立良好的醫(yī)患關(guān)系，加強(qiáng)醫(yī)患的信任和尊重，鼓勵(lì)患者參與治療決策，更好地理解和接受治療，使得治療的依從性更好，有助于提高治療效果。一般治療的循證醫(yī)學(xué)證據(jù)、質(zhì)量分級(jí)及推薦強(qiáng)度見(jiàn)表2[27-29]。表2一般治療的循證醫(yī)學(xué)證據(jù)質(zhì)量分級(jí)及推薦強(qiáng)度證據(jù)證據(jù)級(jí)別推薦強(qiáng)度健康教育[27]A1自我管理[28-29]A12.藥物治療藥物治療是基礎(chǔ)，應(yīng)使用有效劑量的推薦藥物[12]。聯(lián)合治療耐受性良好，可改善單藥治療疼痛控制欠佳患者的鎮(zhèn)痛效果[30]。藥物有效緩解疼痛后應(yīng)避免立即停藥，仍要維持治療至少2周[12]。(1)常見(jiàn)藥物分類①鈣離子通道藥物：主要代表藥物有普瑞巴林(pregabalin)、加巴噴丁(gabapentin)、克利加巴林(crisugabalin)、美洛加巴林(mirogabalin)②鈉離子通道藥物：主要代表藥物有卡馬西平(carbamazepine)、奧卡西平(oxcarbazepine)、利多卡因(lidocaine)、草烏甲素(bulleyaconitine③三環(huán)類抗抑郁藥：主要代表藥物有阿米替林(amitriptyline)、丙咪嗪、[32]及去甲替林[33]治療NP?；蚍瘩g嗎啡[34]、芬太尼[35]、氫嗎啡酮[36]對(duì)NP治療有效。⑦富血小板血漿(plateletrichDA受體拮抗劑(如氯胺酮、美金剛、美沙芬等)、大麻素(cannabinoids)、藥(如頸舒顆粒[39]等)、糖皮質(zhì)激素(glucocorticoids)、維生素、肌松藥(如巴氯芬等)等。(3)NP藥物治療推薦(表4[144-149])。(4)TN藥物治療推薦(表5[95,98])。(5)糖尿病性周圍神經(jīng)病理性疼痛藥物治療推薦[150](表6)。(6)中樞神經(jīng)病理性疼痛藥物治療推薦[151](表7)。表3常見(jiàn)神經(jīng)病理性疼痛藥物治療循證醫(yī)學(xué)證據(jù)質(zhì)量分中樞性神經(jīng)痛放療后SNRIs利多卡因A195,98.99,101-10B2[10B2196-97AI[106-107AI"8.47.450,76,104.10Ai's.B2,101.120-24B2124128B2/104.120.o注：PHN為帶狀皰疹后神經(jīng)痛；PDPN為痛性糖尿病周圍神經(jīng)病變；CIPN為化療后致周圍神經(jīng)病變；CPSP為卒中后中樞性疼痛；表4神經(jīng)病理性疼痛藥物治療推薦鈣離子通道藥物4、三環(huán)類抗抑郁藥144、5-羥色胺-去甲腎上腺素再攝取抑制劑+8、局部利多卡因[14利多卡因貼劑14146、辣椒素高濃度貼劑1441+6、曲馬多144147-48、肉毒桿菌毒素Al*5、強(qiáng)阿片類四線治療藥物美沙酮1、他噴他多1、外用利多卡因、肉治療推薦常用藥物一線治療藥物卡馬西平[95,98]、奧卡西平[95,98]表6糖尿病性周圍神經(jīng)病理性疼痛藥物治療推薦治療推薦常用藥物一線治療藥物度洛西汀、文拉法辛、阿米替林、普瑞巴林、加巴噴丁注：國(guó)家藥品監(jiān)督管理局2024年已經(jīng)批準(zhǔn)克利加巴林表7中樞神經(jīng)病理性疼痛藥物治療推薦治療推薦常用藥物一線治療藥物加巴噴丁、度洛西汀、三環(huán)類抗抑郁藥二線治療藥物文拉法辛、普瑞巴林、拉莫三嗪、曲馬多三線治療藥物美沙酮、羥考酮、大麻素3.物理治療物理治療是一種常見(jiàn)的非侵入性、非藥物性的治療手段，在NP治療中有廣強(qiáng)度激光療法(lowlevellasercutaneouselectricalnervtherapy,ST)、體外沖擊波療法(extracorporealshockwavetherapy,重復(fù)經(jīng)顱磁刺激(repetitivetranscranialmagneticstimulation,rTMS)[152-155]、經(jīng)顱直流電刺激(transcranialdirectelectricalstimulation,tDCS)[153-156]、冷療、全身振動(dòng)(wholebodyvibration,WBV)、瑜伽等[157158](表8[61,63,111,159-160,162-214])。STPDPNCIPN術(shù)后/創(chuàng)傷后疼痛痛性中樞性神經(jīng)痛Aj[s.193-199A2[200-Aj06-2071B2(202-200瑜伽B2[213]B2[注：PHN為帶狀皰疹后神經(jīng)痛；PDPN為痛性糖尿病周圍神經(jīng)病變；CIPN為化療后致周圍神經(jīng)病變；CPSP為卒中后中樞性疼痛；4.微創(chuàng)介入治療微創(chuàng)介入治療是指應(yīng)用CT、超聲、數(shù)字減影血管造影(DSA)、C形臂等影像設(shè)備引導(dǎo)，以最小的切口路徑和最少的組織損傷，實(shí)現(xiàn)對(duì)體內(nèi)病灶的觀察、診斷及治療的技術(shù)，主要包括神經(jīng)阻滯、神經(jīng)毀損(化學(xué)性毀損和物理性毀損)、神經(jīng)調(diào)控等，具體治療方法有星狀神經(jīng)節(jié)阻滯(stellateganglionblock,SGB)、連續(xù)射頻(continuousradiofrequency,CRF)、脈沖射頻(pulsedradiofrequency,PRF)、脈沖聯(lián)合連續(xù)射頻(pulsedcombinedcontinuousradiofrequency,PCRF)、球囊壓迫(percutaneousballooncompression,PBC)、脊髓電刺激(spinalcordstimulation,SCS)[215-216]、腦深部電刺激(deepbrainstimulation,DBS)[217-218]、運(yùn)動(dòng)皮層電刺激(motorcortexstimulation,MCS)、周圍神經(jīng)刺激(peripheralnervestimulation,PNS)、背根神經(jīng)節(jié)電刺激(dorsalrootganglionstimulation,DRGS)、鞘內(nèi)藥物輸注系統(tǒng)(intrathecaldrugdeliverysystem,IDDS)等(表9[125,145,168,表9微創(chuàng)介入治療循證醫(yī)學(xué)證據(jù)質(zhì)量分級(jí)及推薦強(qiáng)度中樞性神經(jīng)痛A2205-236B2[22A1[234,207.2wA1[235.20A1[244247注：PHN為帶狀皰疹后神經(jīng)痛；PDPN為痛性糖尿病周圍神經(jīng)病變；CIPN為化療后致周圍神經(jīng)病變；CPSP為卒中后中樞5.外科手術(shù)針對(duì)NP的外科治療方法主要為神經(jīng)減壓和神經(jīng)毀損(表10[98,238,280-2疾病名稱治療方法三叉神經(jīng)痛MVD[98,238,280-285]舌咽神經(jīng)痛MVD[290]注：MVD為顱神經(jīng)顯微血管減壓術(shù)；SRS為立體定向放射外科；PDPN為痛性糖尿病周圍神經(jīng)病變6.中醫(yī)治療 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