冷冻肋间神经预防开胸术后胸痛

我们自１９９６年１月开始采用开胸手术中冷冻肋间神经的方法预防开胸术后的严重胸痛，取得较满意的效果。临床资料采用随机双盲法选择１００例常规标准后外侧切口开胸的手术病人，其中男７８例，女２２例；年龄１８～７２岁，平均５２．３岁。均分为冷冻止痛组及对照组。...     

肋间神经冷冻防治侧开胸手术后切口疼痛

目的 评价侧开胸手术后肋间神经冷冻镇痛效果及其安全性。方法 对138例开胸患者进行随机前瞻性研究。术前将患者随机平均分为3组：组1（46例）为肋间神经冷冻组；组2（46例）为硬膜外置管给药组；组3（46例）为肌注给药组。比较3组镇痛的效果、镇痛相关并发症及对呼吸系统并发症的影响。结果 组1的镇痛效果明显优于组2和组3（P〈0．05）；组1的镇痛相关并发症及呼吸系统并发症的发生也少于另两组（P〈0．05）。结论 肋间神经冷冻是一种安全有效的防治侧开胸手术后切口疼痛的方法。     

肋间神经冷冻术预防开胸术后切口疼痛的效果观察

目的 探讨术中肋间神经冷冻术对开胸手术后的镇痛效果。方法 将138例开胸术患者随机分为观察组（肋间神经冷冻组）、对照1组（硬膜外置管给药组）和对照2组（肌内注射给药组）各46例。比较三组镇痛效果及不良反应发生情况。结果 观察组的镇痛效果明显优于对照1组及对照2组（χ^2=33．6、27．6，均P〈0．01），术后咳嗽、咳痰评分优良率显著高于对照1，2组（均P〈0．01）；术后肺炎和肺不张发生率显著低于对照2组（P〈0．01）。结论 术中肋间神经冷冻预防开胸术后切口疼痛安全有效．有利于患者术后有效咳嗽、咳痰。减少并发症发生。     

开胸术后冷冻肋间神经镇痛的临床研究

目的观察肋间神经冷冻在开胸术后的镇痛效果。方法将208例开胸术后患者采用不同的镇痛方法分为3组,肋间神经冷冻镇痛组(冷冻镇痛组,n=80):采用JT-1型冷冻手术治疗机冷冻,每根肋间神经冷冻温度为-55℃左右,冷冻时间为90s;人自控镇痛组(PCA组,n=80):术后静脉应用镇痛泵实行人自控镇痛;对照组(n=48):采用临时肌肉注射度冷丁和口服曲马多缓释剂。以视觉模拟疼痛评分法评价疼痛程度,并比较各组术后肺部并发症发生率及第1秒用力呼气容积(FEV1.0)实测值。结果冷冻镇痛组患者疼痛程度显著弱于PCA组和对照组(χ2=74.93,15.04,P<0.05),肺部并发症的发生率也显著低于对照组(6.25%vs.31.25%,P<0.05);冷冻镇痛组的FEV1.0较对照组高(1.97±0.27L vs.1.39±0.14L,P<0.05)。结论冷冻肋间神经可以显著减轻接受开胸手术患者的术后疼痛,并减少肺部并发症的发生。     

肋间神经冷冻术预防开胸术后切口疼痛的效果观察

目的探讨术中肋间神经冷冻术对开胸手术后的镇痛效果.方法将138例开胸术患者随机分为观察组(肋间神经冷冻组)、对照1组(硬膜外置管给药组)和对照2组(肌内注射给药组)各46例.比较三组镇痛效果及不良反应发生情况.结果观察组的镇痛效果明显优于对照1组及对照2组(χ2=33.6、27.6,均P<0.01),术后咳嗽、咳痰评分优良率显著高于对照1、2组(均P<0.01);术后肺炎和肺不张发生率显著低于对照2组(P<0.01).结论术中肋间神经冷冻预防开胸术后切口疼痛安全有效,有利于患者术后有效咳嗽、咳痰,减少并发症发生.     

肋间神经冷冻用于开胸术后镇痛的研究

目的 探讨肋间神经最佳冷冻时间和最佳镇痛方式。方法在-70℃不同时间下对家犬行肋间神经冷冻,于当天、术后10d、60d分别取材,行病理检查。选择150例患者,随机分为5组,即对照组（肌肉注射镇痛药物镇痛）,静脉镇痛泵镇痛组（PCIA）,肋间神经冷冻60 s组,肋间神经冷冻90 s组和肋间神经冷冻90 s＋PCIA组。记录心率、血压、SO2、疼痛评分、杜冷丁用量及术后并发症和副反应。结果动物实验中,冷冻时间〉90 s出现褐色印记及明显的神经变性、坏死和纤维断裂;术后10d,超过90 s神经变细,术后60d神经基本恢复正常。临床研究中,90 s组和90 s ＋PCIA组VAS疼痛评分优于PCIA组和60 s组,90 s＋PCIA组VAS疼痛评分最好。结论 肋间神经冷冻术是安全有效的,-70℃时应超过90s,术后联合镇痛泵效果最好,但有较多副反应。     

肋间神经冷冻止痛术预防开胸术后胸痛疗效分析

开胸手术后病人常因切口疼痛而影响呼吸功能、术后恢复及生活质量。我们自2003年3月开始采用开胸手术中冷冻肋间神经的方法预防开胸术后胸痛，取得满意的效果，现报告如下。     

肋间神经冷冻止痛术和PCIA在开胸术后镇痛效果的比较

目的:对开胸术后肋间神经冷冻止痛与静脉自控镇痛(PCIA)临床效果及安全性进行对比研究。方法:40例开胸手术病人随机分为A组(肋间神经冷冻止痛术组)和B组(病人静脉自控镇痛组,PCIA),每组20(n=20);所选两组病人ASA分级、年龄、体重、手术时间及麻醉过程中镇痛药用量无统计学差异。A组在关胸前分别游离出切口部位及切口上、下各一个肋间和胸腔引流管所在肋间的肋间神经进行冷冻处理(采用北京库蓝医疗设备有限公司生产的IT-1冷冻手术治疗机,在-50℃低温下冷冻神经90s)。B组术后静脉连接一次性微量镇痛泵行PCIA,镇痛液的配制为:芬太尼0.5mg+格拉司琼3mg+生理盐水稀释至100ml(背景剂量2ml h~-1,PCA0.5ml/次,锁定时间15min)。分别于手术后8、12、24、48h进行术后随访,同时记录Prince Henry镇痛评分、平均动脉压(MAP)、心率(HR)、和呼吸频率(RR),并对病人术后48h两种镇痛方法的整体满意度进行评级。结果:①两组病人在术后各时段的MAP、HR和RR组间无统计学差异(P>0.05);②术后Prince Henry镇痛评分均<3,A组在术后8h、12h的Prince Henry评分高于B组(P<0.05),其余时段的Prince Henry评分无显著性差异(P>0.05);③病人对术后镇痛总体满意度评估:优秀者B组高于A组,良好者A组与B组基本接近。结论:两种开胸术后的镇痛方?     

肋间神经冷冻止痛在开胸术中的应用

20 0 2年 4月～ 2 0 0 2年 8月 ,我们为6 0例患者在开胸术后实施了肋间神经冷冻止痛治疗 ,作为预防术后胸痛的方法 ,效果满意 ,报告如下。一、临床资料1.一般临床资料及方法 :本组男 4 5例 ,女 15例 ;年龄 34～ 77岁 ,平均 5 7岁 ;手术方式包括食管癌切除弓下、弓上或经胸颈部吻合术 ,贲门癌根治术 ,肺叶切除 ,纵隔肿瘤切除等。所有患者术前各脏器功能基本正常 ,无手术禁忌证。本组患者均于开胸术后关胸前 ,分别将切口、切口上下各一肋间及放置胸腔引流管部位的肋间神经于根部游离出来 ,置于冷冻探头上 ,在 - 30℃～ - 5 0℃下进行冷冻约 90…     

胸部微创切口联合肋间神经冷冻的临床应用

开胸被认为是术后疼痛最重，需要止痛药剂量最大的手术；可引起咳嗽无力，呼吸道分泌物潴留，严重者导致肺炎、肺不张甚至呼吸衰竭；减轻疼痛必能促进恢复。我们应用胸部微创切口联合肋间神经冷冻显著减轻了术后疼痛，结果报道如下。     

Surgical aspects of chronic post-thoracotomy pain

Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.     

Intercostal nerve loop as an original treatment for long-term post-thoracotomy pain

Up to now, the treatment for long-term post-thoracotomy pain has been problematic. Conservative methods, surgical, or percutaneous rhizotomies or implantation of a permanent nerve stimulator have failed in many patients, and were not without risk. Because of this, we looked for a fundamental physiologically based approach to manage this pain problem with minimal risks but long lasting effect. As most patients obtained complete temporary pain relief after an intercostal nerve block of serial dermatomes bordering the thoracotomy, nerve ischemia, nerve entrapment in scar tissue, nerve compression due to abnormal bone formation and neuroma function may all have been mechanisms resulting in pain. Subsequently, three intercostal nerve loops between the six intercostal nerves, belonging to the three ribs above and below the thoracotomy, were performed. This technique creates permanent anesthetic dermatomes, thus avoiding nociceptive afferent stimuli and preventing recurrence of aberrant nerve regeneration responsible for chronic pain. This technique was applied successfully in five cases with a mean follow-up of 13 months. As nerve regeneration has stopped at that time, neuroma formation is prevented and pain recurrence is not to be expected. We, therefore, propose that if an anatomical pain distribution pattern along the thoracotomy scar is found in patients with long-term post-thoracotomy pain, serial intercostal nerve loops might be indicated as primary treatment. Received: 28 June 1996 / Accepted: 25 February 1997     

利用腹腔镜戳孔局部注射布比卡因术后镇痛研究

目的 评价腹腔镜术后戳孔局部注射布比卡因的镇痛效果.方法 选用腹腔镜胆囊切除术后90例患者,随机分为3组,每组30例.布比卡因组:于戳孔局部注射0.25%布比卡因20 ml(50 mg);生理盐水组:于戳孔局部注射生理盐水加ml;镇痛泵组:于术后使用静脉镇痛泵(patientcontrolled intravenous analgesia,PCIA).在麻醉苏醒后2、6、12、24 h分别记录患者安静状态下的镇痛模拟评分(按视觉模拟评分法 visual analogue scale,VAS),同时记录3组患者术后排气时间.结果 3组患者术后均无并发症,布比卡因组患者无相应毒副作用,12 h内镇痛效果优于生理盐水组,尤以6 h内明显(t2h=8.475;t6h=5.356;t12h=3.496,均P＜0.05),与镇痛泵组相比,镇痛效果差异无统计学意义(t2h=1.361;t6h=1.720;t12h=1.682;t24h=1.721,均P＞0.05),镇痛泵组患者的术后排气时间晚于其他两组患者(x224h=5.406,P＜0.05).结论 腹腔镜胆囊切除术后,患者戳孔局部应用布比卡因镇痛效果明显,尤其在术后12 h内,可以降低使用其他镇痛药物的用量,并且不影响术后肠道功能的恢复.

Abstract：

Objective To evaluate analgesic effect of bupivacaine infiltration in trocar incision after laparoscopic surgery.Methods 90 patients were randomly divided into 3 groups after laparoscopic cholecystectomy.In group 10.25% bupivacaine 20 ml(50 mg) injection, in group 2 sterile NS 20 ml infiltrated in the muscular fasciae of the trocars, in group 3 patient-controlled intravenous analgesia(PCIA) was used.In 2, 6, 12 and 24 hours after the intervention, the pain intensity was recorded with the use of a Visual Analogue Scale ( VAS), time of flatus passing was recorded as well.Results Patients with bupivacaine or PCIA had statistically significant in pain score compared with patients with NS especially within 12 hours after the surgery (t2h = 8.475; t6h = 5.356; t12h = 3.496, P ＜ 0.05) while the difference was not statistically significant between the 3 groups at 24 hours.The time of passing flatus in group 1 patients with bupivacaine was earlier than with PCIA ( x224h = 5.406, P ＜ 0.05 ) .Conclusions Bupivacaine infiltrated in trocar incision after laparoscopic surgery reduced postoperative pain, and did not disturb peristalsis reflex recovery of the intestines.     

The effects of cryoanalgesia combined with thoracic epidural analgesia in patients undergoing thoracotomy

This study was performed to evaluate the effects of cryoanalgesia combined with thoracic epidural analgesia on pain and respiratory complications in patients undergoing thoracotomy. Ninety patients were prospectively randomised to epidural analgesia alone (n = 45) or epidural analgesia and cryoanalgesia combined (n = 45). We monitored the use of rescue pain medication and changes in forced vital capacity and forced expired volume in 1 s, and recorded pain and opioid-related side-effects during the immediate postoperative period. The incidence of post-thoracotomy pain and numbness were also assessed up to the sixth month after surgery. Cryoanalgesia combined with thoracic epidural analgesia was associated with earlier recovery in pulmonary function, less pain during movement and a lower daily requirement for rescue analgesia one week after surgery. However, the combination of cryoanalgesia and epidural analgesia failed to decrease the incidence of long-term pain and numbness. In view of its associated long-term morbidity, cryoanalgesia combined with thoracic epidural analgesia is not recommended for patients undergoing thoracotomy.     

肋间神经移位腋神经的解剖学研究

目的 为利用肋间神经移位腋神经恢复肩外展功能提供解剖学依据.方法对30侧成人尸体标本中第三至第六肋间神经自腋中线至锁骨中线的长度和相应肋间神经自腋中线起点处穿过皮下隧道至四边孔腋神经缝合口处的距离(在肩外展45°和90°两种情况下)进行比较.结果 在肩外展45°时第三肋间至第六肋间自腋中线到锁骨中线的选取长度与相应肋间自腋中线自皮下隧道至四边孔距离差值分别为(3.89±0.85) cm、(4.14± 1.15)cm、(2.99± 1.33) cm和(0.25±1.49)cm.在肩外展90°时,差值分别为(2.54±0.87) cm、(2.37± 1.51)cm、(1.04± 1.74) cm和(-1.59± 1.95)cm.结论 第三、第四、第五、第六肋间选取自腋中线至锁骨中线经皮下隧道至四边孔与腋神经直接缝合是可行的.其中若选用第六肋间神经作为移位神经直接修复腋神经,可适度增加肋间神经或腋神经游离长度,以实现肩外展90°情况下的无张力缝合.     

开胸术后慢性痛大鼠脊髓背角神经元ATP敏感型钾通道表达的变化

目的 评价开胸术后慢性痛大鼠脊髓背角神经元ATP敏感型钾通道(KATP通道)表达的变化.方法 雄性SD大鼠20只,体重250～350 g,采用随机数字表法,将其随机分为假手术组和开胸术后慢性痛组,每组10只.于术前1 d、术后1、5、10、15、20、25、30 d时分别测定机械痛阈,并行冷丙酮实验,记录1 min内大鼠后爪抓挠皮区次数;于术后30d时处死大鼠,取颈至上胸段脊髓,免疫组化法检测KATP通道的表达水平.结果 与假手术组比较,开胸术后慢性痛组大鼠术后5～如d时机械痛阈降低,术后20～30d时后爪抓挠皮区次数增加,术后30 d时胸段脊髓背角神经元KATP通道表达下调(P＜0.05).结论 开胸术后慢性痛大鼠脊髓背角神经元KATP通道表达下调,该变化可能参与了开胸术后慢性痛的病理生理机制.

Abstract：

Objective To evaluate the change in the expression of ATP-sensitive potassium (KATP) channels in spinal dorsal horn neurons in rats with chronic post-thoracotomy pain (CPTP). Methods Twenty male SD rats, weighing 250-350 g, were randomly divided into 2 groups ( n = 10 each): sham operation group and CPTP group. The animals were anesthetized with 10% chloral hydrate 300 mg/kg, tracheostomized and mechanically ventilated. At 1 d before operation, and at 1, 5, 10, 15, 20, 25 and 30 d after operation, paw withdrawal threshold to yon Frey filament stimulation was measured and the acetone test was performed. The responses of the hindpaw to the acetone test within 1 min were recorded. The rats were sacrificed at 30 d after operation, and the cervical and upper thoracic segments of the spinal cord were removed to detect the expression of KATP channels in spinal dorsal horn neurons by immuno-histochemistry. Results Compared with sham operation group, mechanical pain threshold was significantly decreased at 5-30 d after operation, the response frequency was significantly increased at 20-30 d after operstion, and the expression of KATP channels in spinal dorsal horn neurons in the thoracic segments was down-regulsted at 30 d after operation in CPTP group ( P ＜ 0.05). Conclusion The expression of KATP channels in spinal dorsal horn neurons is down-regulated in rots with CPTP,which may be involved in the pathophsiology mechanism of CPTP.     

不同浓度罗哌卡因肋间神经阻滞在开胸手术后早期镇痛中的应用

目的探讨不同浓度罗哌卡因肋间神经阻滞在开胸手术后早期的镇痛效果。方法120例择期开胸手术患者,男90例,女30例,年龄22~81岁,随机均分为四组,分别为0.25%(L25组)、0.50%(L50组)、0.75%(L75组)罗哌卡因肋间神经阻滞组和空白对照组(C组),关胸前分别行肋间神经阻滞,每一肋间给药4ml,拔出气管导管后行PCIA镇痛。记录拔管后即刻(T0)、2h(T1)、6h(T2)及24h(T3)的VAS疼痛评分,以及PCIA用量和不良反应。结果与C组比较,T1~T3时L25组、L50组和L75组静息VAS评分均明显降低(P0.05);T1时L25组、L50组和L75组,T2时L50组和L75组以及T3时L75组咳嗽VAS评分明显降低(P0.05)。与L25组比较,T2、T3时L75组咳嗽VAS评分明显降低(P0.05);与L50组比较,T3时L75组咳嗽VAS评分明显降低(P0.05)。T1时,L25、L50和L75组PCIA泵使用量明显少于C组(P0.05),且L50和L75组明显少于L25组(P0.05);T2时,L50和L75组PCIA泵使用量明显少于C组和L25组(P0.05);T3时,L75组PCIA泵使用量明显少于其他三组(P0.05)。结论 0.75%罗哌卡因肋间神经阻滞可在拔管后24h内为开胸手术患者提供良好的镇痛效果。     

Implantation of an intercostal nerve stimulator for chronic abdominal pain

Chronic abdominal pain is not uncommon and can be difficult to manage. We present the case of a 17-year-old man with a 4-year history of chronic abdominal pain. The patient had previously undergone abdominal surgery by way of laparoscopic appendicectomy and right nephrectomy for a mal-rotated kidney. The patient continued to suffer right-sided abdominal pain which was not controlled by analgesia. We report the successful implantation of a right D11 intercostal nerve stimulator to control the patient’s pain. This is the first report of an implantable intercostal nerve stimulator to control intractable chronic abdominal pain.     

超声引导下椎旁神经阻滞与肋间神经阻滞用于胸腔镜肺部术后镇痛效果的比较

目的 探讨超声引导下椎旁神经阻滞与肋间神经阻滞对胸腔镜术后镇痛效果的影响。方法 选取2016年1月至2018年12月择期行胸外科手术患者1 190例,男516例,女674例,年龄18~75岁,BMI 15~35 kg/m²,ASA Ⅰ—Ⅲ级。根据接受神经阻滞的类型分为两组：椎旁神经阻滞组（P组,n=327例）和肋间神经阻滞组（I组,n=863例）。P组术前行T3-4和T6-7椎旁神经阻滞;I组于手术结束时在胸腔镜监测下在切口及其相邻上下两个肋间实施肋间神经阻滞。记录患者性别、年龄、身高、体重,既往合并症,术后第1、2和3天舒芬太尼用量和镇痛泵有效按压次数,术后第1、2和3天静息和活动时疼痛数字（NRS）评分、恶心呕吐,记录术后头晕发生率和术后住院时间。结果 与I组比较,P组术后第1和2天舒芬太尼用量明显减少（P<0.05）,术后第1天镇痛泵有效按压次数明显减少（P<0.05）,术后第1天活动时NRS评分、恶心呕吐发生率明显降低（P<0.05）,术后头晕发生率明显降低(P<0.05),术后住院时间明显缩短（P<0.05 ）。术后第2和3天两组静息和运动时NRS评分、恶心呕吐发生率差异无统计学意义。结论 与肋间神经阻滞比较,椎旁神经阻滞可以减少胸腔镜肺部术后阿片类药物的用量,减少术后不良反应,缩短术后住院时间。