侧卧位CT引导下C8T1脊神经根射频治疗带状疱疹后神经痛1例

2020-01-06 林慧丹 谢道奋 应永干 中国疼痛医学杂志

病人贺某,男,79岁。因“右胸背腋、右上肢尺侧皮肤疱疹后剧烈疼痛49天”就诊。病人49天前出现右胸背部、右腋下、右上肢尺侧阵发性烧灼样刺痛,2天后疼痛相应部位出现成簇疱疹,入住皮肤科对症治疗。14天后疱疹结痂脱落,但仍有剧烈的阵发性疼痛,药物治疗效果欠佳,视觉模拟评分(visual analogue scale,VAS)5~8分。本次以“带状疱疹后神经痛(post herpetic neuralg

1.病例资料
 
病人贺某,男,79岁。因“右胸背腋、右上肢尺侧皮肤疱疹后剧烈疼痛49天”就诊。病人49天前出现右胸背部、右腋下、右上肢尺侧阵发性烧灼样刺痛,2天后疼痛相应部位出现成簇疱疹,入住皮肤科对症治疗。14天后疱疹结痂脱落,但仍有剧烈的阵发性疼痛,药物治疗效果欠佳,视觉模拟评分(visual analogue scale,VAS)5~8分。本次以“带状疱疹后神经痛(post herpetic neuralgia,PHN)”收住院。
 
查体:神清,精神差,原疱疹区(右C8T1T2脊神经支配区)皮肤色素沉着(见图1),触诱发痛明显,自主爆发痛10~15次/小时,VAS6~8分。辅助检查:出凝血时间及凝血酶原时间正常。鉴于病人疼痛发作频繁而剧烈,决定先行超声引导下行C8T1椎旁阻滞(0.25%罗哌卡因共5ml),疼痛立即缓解,但6小时后疼痛依然。遂与家属商量,决定行“CT引导下右侧C8T1脊神经根射频”治疗。报请医院伦理委员会批准并与病人家属签署知情同意书,术前禁食4h,静脉留置套管针备用,更换无菌手术衣后嘱病人健侧卧于CT台上,肩下垫枕,使头颈部垂向健侧,用宽胶布将患侧肩部向足侧牵拉固定于CT台上。


图1 皮损后色素沉着区位于右胸背、右腋下、右上肢尺侧(右C8T1T2脊神经支配区)皮肤
 
安置无创血压、脉搏氧饱和度及心电监测,鼻导管吸氧4L/min。颈肩部放置定位栅,CT扫描颈胸部定位像后以第1肋为中心,层厚3mm垂直扫描C7T1椎间孔,并在相应层面上设计穿刺路径(测量穿刺深度并确定进针点),随后于局麻下按设计的穿刺路径进针,直至射频针抵达C7T1椎间孔(见图2、3),进行高(50Hz)、低(2Hz)频电生理测试,刺激电流仅0.5mA前者即可诱发出原疼痛区麻刺异感,后者可诱发出原疼痛区肌肉抽动后,经静脉注入丙泊酚50mg,病人入睡后先对T1脊神经根进行射频热凝毁损(95℃,300s),随后对C8脊神经根(位于C7椎间孔内)进行长时程脉冲射频(42℃,600s)。期间监测显示病人生命体征正常,术毕病人苏醒后针刺腋下及胸前皮损区感觉减退,触诱发痛消失,自诉疼痛减轻80%,VAS1~2分。停用加巴喷丁及普瑞巴林,观察3天疼痛无加重。出院随访3月,病人无需服用任何镇痛药,对本次射频治疗感觉非常满意。
 

图2 C8脊神经根射频


图3 T1脊神经根射频


图4 T1椎间孔因被椎板和肋-横突关节阻挡,使经典的俯卧位椎旁侧入路操作非常困难,使用弯针技术才能勉强完成射频治疗
 
2.讨论
 
带状疱疹后神经痛是中老年带状疱疹病人常见的后遗症。目前认为其发生原因为水痘-带状疱疹病毒破坏了神经包膜,从而形成外周敏化而出现痛觉过敏,加之神经中枢可塑性改变导致中枢敏化而形成自发痛。在疱疹急性期时神经阻滞不仅可有效镇痛,而且可有效减少后遗神经痛的发生。我们早期的研究发现,CT引导下脊神经背根节射频热凝可有效治疗顽固性带状疱疹后神经痛,我们也描述了胸段脊神经背根节射频热凝时具体的CT定位引导穿刺技术-俯卧位椎旁侧入路。
 
但对于T1脊神经背根节,因椎体小而椎板大,椎间孔因被椎板和肋-横突关节阻挡,使经典的俯卧位椎旁侧入路操作非常困难,使用弯针技术才能勉强完成(见图4),十分费时费力。而本例病人的病变同时累及颈胸脊神经,如果采用经典的穿刺操作技术,需仰卧位完成颈脊神经根射频后改俯卧位再行胸脊神经根射频,使操作更加繁烦。
 
为此,我们设想采用侧卧位下操作:通过肩下垫枕使头颈垂向健侧,另外用宽胶布将患侧肩部拉向足侧固定在CT台上,这样手术野得以有良好暴露,而且患侧胸膜顶也随之下移,使穿刺路径无需经过胸膜腔,为避免穿刺造成气胸提供了基本保证。本例病人疼痛区主要位于右C8T1,为避免损伤C8脊神经造成相应的运动功能受损,我们对C8采取了长时程脉冲射频,而对无上肢运动功能的T1脊神经根,则采用射频热凝毁损,符合带状疱疹后神经痛的序贯治疗策略。从本例病人的射频治疗经过和结果看,对于同时累及颈、胸脊神经的带状疱疹后顽固性神经痛病人,采用健侧卧位CT引导下脊神经根射频治疗的确是个不错的选择。
 
原始出处:

林慧丹,谢道奋,应永干,许周亮,黄冰.侧卧位CT引导下C_8T_1脊神经根射频治疗带状疱疹后神经痛1例[J].中国疼痛医学杂志,2019(01):76-77.

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    2020-01-08 14803194m12暂无昵称

    怎么没有啊

    0

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    2020-01-08 贵阳
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