射频热凝腰交感神经节的临床应用

目的 探讨腰交感神经节射频热凝的方法与疗效。方法32例腰腿部血管性或交感反射性疼痛病人,腰交感神经节试验性阻滞阳性。随机分为两组:Ⅰ组(18例),X线透视引导穿刺针到位,注造影剂及用刺激电流确认,热凝85℃、90s;Ⅱ组(14例),根据术前X线照片测量值定位穿刺,电刺激和热凝参数同Ⅰ组。结果Ⅰ组和Ⅱ组治疗后,下肢变暖者分别为93.1％和78.3％(P<0.01);VAS评分降低分别为(3.4±2.2)和(3.2±2.4)分(P>0.05);显效分别为11.1％和7.1％(P<0.05),有效率44.4％和50。0％(P>0.05),部分有效率38.9％和35.7％(P<0.05),总有效率94.4％和92.9％(P>0.05)。治疗后下肢不适或穿刺点疼痛加用止痛药者Ⅰ组5.5％和Ⅱ组14.3％(P<0.01)。结论 射频热凝术能有效地毁损腰交感神经节。X线透视指引穿刺有助于提高成功率和减少并发症。     

腰交感神经节射频热凝毁损术的临床应用

目的探讨数字减影(ADS)引导下腰交感神经节射频消融术的疗效及安全性。方法 42例腰腿部血管性或交感性反射性疼痛病人,随机分为两组:均在ADS引导下,穿剌到位Ⅰ组(22例)行电剌激及局麻药阻滞试验确认后行射频热凝毁损,温度80℃,时间75s,两个周期,Ⅱ组(20例)行局麻药阻滞试验后以1%利多卡因10ml、维生素B12针0.5mg注射阻滞。结果Ⅰ组和Ⅱ组治疗后,下肢变暖者为94.7%和72.2%(P0.01)有极显著差异;VAS评分治疗后7d3.3±1.2和3.2±1.1分(P0.05)无显著性差异;3个月、6个月时有显著性差异(P0.05);显效、有效、部分有效均有显著性差异(P0.05),总有效率91.1%和80.0%有显著差异(P0.05)。结论腰交感神经节射频热凝毁损可有效长时间阻断腰交感性神经功能达到持续血管扩张,改善组织血液和营养供应、消除异感、减轻疼痛,是治疗腰腿部血管性或交感性反射性疼痛的安全有效、创伤小的微创治疗方法。     

腰交感神经节射频热凝对糖尿病痛性周围神经病变大鼠的镇痛作用及对背根神经节TTX-R钠电流的影响

目的 评价射频热凝毁损腰交感神经节对糖尿病痛性周围神经病变大鼠的镇痛作用及对背根神经节（DRG）细胞上河豚毒素不敏感（TTX-R）钠通道电流的影响。方法 腹腔注射链尿佐菌素诱导大鼠糖尿病痛性周围神经病变模型，取造模成功的大鼠20只，随机分为糖尿病对照组（D组）及交感神经节射频热凝组（R组），每组10只，另取10只同月龄大鼠为正常对照组（C组），R组大鼠行右侧L3，4椎旁射频热凝毁损腰交感神经节。于射频热凝前、射频热凝后1、2周采用von Frey纤维丝测定缩爪反应阈值（PWT）;射频热凝后2周，急性分离小DRG细胞，采用全细胞膜片钳记录方法，在电压钳制下记录TTX-R钠通道电流。结果 与C组比较，射频热凝前D组和R组PWT降低（P〈0．01），射频热凝后1、2周，R组PWT低于C组（P〈0．05），高于D组（P〈0．05）;射频热凝后2周，与C组比较， D组、R组I-V曲线向左移，R组电流密度高于C组（P〈0．01），低于D组（P〈0．05），与C组比较，D组、R组半激活电压及半失活电压升高（P〈0．01），D组和R组之间差异无统计学意义（P〉0．05）。结论 腰交感神经节射频热凝可有效缓解糖尿病痛性周围神经病变大鼠的痛觉过敏，抑制小DRG细胞TTX-R钠通道电流可能是其发挥镇痛作用机制之一。     

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1923年，Royle在治疗1例大脑皮质受伤的病人时。采用切除其一侧腰交感神经干的方法来缓解下肢肌痉挛术后不但肌痉挛得到缓解，同时还发现右腿毛细血管扩张，皮温升高。这就是首例腰交感神经切除术。腰交感神经切除术已有80年的历史，在血管外科技术不太成熟的当时，曾经是治疗下肢缺血性疾病的常规方法。开放性腰交感神经     

腰交感神经节射频热凝对糖尿病周围神经病变大鼠外周神经功能和结构的影响

目的 建立糖尿病周围神经病变大鼠模型,采用射频热凝毁损腰交感神经节,观察大鼠外周神经功能和结构的变化.方法 腹腔注射链尿佐菌素诱导糖尿病周围神经病变大鼠模型,选择造模成功的大鼠20只,随机分为糖尿病对照组(Ⅱ组)及交感神经节射频热凝组(Ⅲ组),另选择10只同月龄健康大鼠为正常对照组(Ⅰ组).Ⅲ组大鼠在X光机介导下行右侧L3,L4椎旁腰交感神经节射频热凝毁损.分别于0周、4周时,测定大鼠坐骨神经外膜血流量和运动神经传导速度(motor nerve conductive velocity,MNCV),4周时采用透射电镜观察大鼠腓肠神经超微结构.结果 与Ⅰ组比较,0周时Ⅱ组和Ⅲ组MNCV降低(P＜0.01);射频热凝后4周Ⅲ组较Ⅱ组MNCV升高,但仍较Ⅰ组降低(P＜0.05).与Ⅰ组比较,0周时Ⅱ组Ⅲ组神经外膜血流量降低(P＜0.01);4周时Ⅲ组神经外膜血流量高于Ⅱ组(P＜0.01),与Ⅰ组比较无统计学差异(P＞0.05).Ⅰ组髓鞘排列均匀,轴突内可见形态正常的线粒体;Ⅱ组脱髓鞘明显,髓鞘板层排列紊乱、断裂、肿胀;Ⅲ组脱髓鞘程度明显减轻,髓鞘板层局部排列紊乱、空泡形成.结论 腰交感神经节射频热凝可显著增加糖尿病周围神经病变大鼠坐骨神经外膜血流量,促进受损外周神经超微结构和功能的恢复.     

超激光照射治疗下肢神经病理性疼痛

目的 观察直线偏光近红外线(超激光)照射腰交感神经节,治疗下肢神经病理性疼痛的疗效.方法 采用超激光治疗仪,以L_2为中心对腰交感神经节进行照射,每日1次,每次20 min,连续照射30 d.评价指标为下肢皮肤温度、VAS评分及痛阈.结果 照射后皮肤温度明显高于照射前(P<0.01),治疗后VAS评分明显低于治疗前(P<0.01),治疗后痛阈高于治疗前(P<0.01).结论 超激光照射对下肢神经病理性疼痛有较好的治疗效果.     

CT引导下经皮穿刺胸交感神经节毁损术治疗手汗症和雷诺综合征的效果

胸交感神经阻滞可用于治疗多种疼痛、非疼痛性疾病[1].但胸交感神经节的位置较深,徒手操作极易引起气胸,甚至损伤脊髓.手汗症与雷诺综合征的临床表现虽然炯然不同.但其发病机制均与胸交感神经功能紊乱有关[2-3].国内外已有C臂X线引导下胸交感神经节毁损术治疗手汗症和雷诺综合征的报道[4-5],但由于X线定位准确性较差,使其在临床疼痛治疗应用受限.本课题组近年来先后开展了"CT引导下双针会师法腹腔神经丛阻滞治疗顽固性上腹部癌痛[6]"和"CT引导下选择性脊神经背根节射频热凝治疗带状疱疹后遗神经痛[7]",发现CT引导的经皮穿刺不但定位准确.立体感强,且CI随机软件上的工具尺可辅助最佳穿刺层面的选择及穿刺路径设计,还可进行三维重建,更易于在术中及时发现并发症.因此,本研究拟评价CT引导下经皮穿刺胸交感神经节毁损术治疗手汗症和雷诺综合征的效果.     

连续腰交感神经阻滞治疗盘源性下腰痛的疗效观察

目的:观察CT引导下连续腰交感神经阻滞治疗盘源性下腰痛(Discogenin low back pain)的疗效.方法:选择盘源性下腰痛患者32例,患者在CT引导下行连续腰交感神经节阻滞.结果:患肢术后疼痛、发凉异常感觉有效率93.7%,治愈率75%.结论:CT引导下连续腰交感神经阻滞能有效缓解盘源性下腰痛的症状.     

背根神经节Nav1.8磷酸化在大鼠糖尿病痛性周围神经病变中的作用

目的 本研究采用射频热凝毁损腰交感神经节,探讨背根神经节（DRG）Nav1．8磷酸化在大鼠糖尿病痛性周围神经病变中的作用。方法 采用腹腔注射链尿佐菌素诱导糖尿病痛性周围神经病变大鼠模型,取造模成功的大鼠20只,随机分为糖尿病对照组（D组）及交感神经节射频热凝组（R组）,每组10只,另取10只同月龄大鼠为正常对照组（C组）。R组大鼠在X光机介导下行右侧L3,4椎旁腰交感神经节射频热凝毁损。分别于射频热凝前、射频热凝后1、2周时,采用von Frey纤维丝测定大鼠右侧后爪对机械性刺激缩足反应的阈值（PWT）;射频热凝后2周,采用Western-blotting方法测定DRG细胞Nav1．8蛋白和苏氨酸磷酸化Nav1．8蛋白表达,并采用透射电镜观察大鼠腓肠神经超微病理结构。结果 与C组比较,射频热凝前D组和R组PWT降低（P＜0．01）。射频热凝后1～2周,R组较D组PWT升高,但仍较C组降低（P＜0．05）。C组髓鞘排列均匀,轴突内可见形态正常的线粒体;D组脱髓鞘明显,髓鞘板层排列紊乱、断裂、肿胀;R组脱髓鞘程度明显减轻,髓鞘板层局部排列紊乱、空泡形成。与C组比较,D组和R组Nav1．8蛋白表达降低（P＜0．05）,而苏氨酸磷酸化Nav1．8蛋白表达增高（P＜0．01）;R组苏氨酸磷酸化Nav1．8蛋白表达低于D组（P＜0．05）。结论 DRG细胞Nav1．8的磷酸化可能是糖尿病痛性周围神经病变大鼠痛觉过敏形成的机制之一。     

腹腔镜辅助下原发性肝癌和肝转移癌的射频消融术治疗

目的 :探讨腹腔镜辅助下肝癌射频消融术治疗的优势。方法 :全麻下联合腹腔镜技术对原发性肝癌和多发的肝转移癌灶行射频消融术治疗。结果 :1 0例患者 32个瘤体 ,其中直径 5cm的 2 0个瘤体均一次手术热凝损毁 ,CT和MRI提示肿瘤坏死 ,其中 ,1 5个瘤体完全缓解 (CR)占 75 % ,5个瘤体部分缓解 (PR)占2 5 % ,近期疗效CR +PR为 1 0 0 %。随访 2～ 1 4个月无复发。直径 >5cm的 1 2个瘤体亦予以一次性热凝损毁 ,术后 1～ 8周内AFP、CEA、CA1 9 9肿瘤指标均转阴或下降 ,CT或MRI提示肿瘤热凝损毁 ,近期疗效CR +PR为 83 3%。患者均能耐受射频消融治疗 ,无并发症发生。 1例原发性肝癌术后 1 3个月死于肿瘤扩散。结论 :腹腔镜辅助下肝癌射频消融术治疗直径 5cm的瘤体效果显著 ,对直径 >5cm的瘤体部分有效。此法为腹腔镜辅助下结直肠癌手术中多发肝转移癌灶的处理提供了一种创伤小、时间短、见效快、安全方便的治疗方法。     

高龄患者下肢静脉曲张日间手术的安全性及可行性探讨

目的 探讨高龄患者下肢静脉曲张日间手术的安全性及可行性.方法 收集2016年1月至2019年9月浙江大学医学院附属邵逸夫医院收治的186例行下肢静脉曲张射频消融日间手术高龄患者的临床资料,对所有患者均于术后3 d、1个月、3个月及1年进行随访,评估其手术成功率、手术时间、术中出血量及麻醉肿胀液使用量.统计并发症发生情况...     

超声引导下血管腔内射频消融联合局部点式剥脱治疗下肢静脉曲张

目的 观察超声引导下血管腔内射频消融联合点式剥脱治疗下肢静脉曲张的效果。方法 回顾性分析接受腔内射频消融联合点式剥脱治疗下肢静脉曲张的373例患者共397条下肢静脉(单侧349例、双侧24例),包括大隐静脉384条、小隐静脉13条,观察治疗中及治疗后不良反应;记录治疗后随访复查静脉彩色多普勒超声所见,评估静脉闭合率。结果 对373例397条静脉均顺利完成治疗,技术成功率100%(397/397)。治疗中不良反应主要包括穿刺及肿胀麻醉过程中轻度疼痛;治疗后6例切口明显渗血、3例局部血肿、2例切口局部感染,经相应治疗后均好转;治疗后1个月1例发生肺栓塞,予抗凝治疗后缓解。治疗后1、6、12个月,经治下肢曲张静脉闭合率分别为99.24%(394/397)、100%(307/307)及100%(217/217);治疗后随访2~5年,期间6例下肢局部新发曲张静脉,予以剥脱处理,1例溃疡愈合后再次复发,予局部换药。结论 血管腔内射频消融联合点式剥脱治疗下肢静脉曲张安全、有效。     

Effects of lumbar sympathetic ganglion block in a patient with acquired lymphangioma]

A 70-year-old woman developed lymphangioma following surgery for cervical cancer and subsequent radiotherapy. The operation was performed 12 years ago, and a swelling of lower extremities was recognized 8 years ago. Her lower extremities became greatly edematous, and leakage of lymph to the groin was observed. We performed bilateral lumbar sympathetic ganglion block. After the block, lymphedema was relieved dramatically, and the leakage of the lymph to the groin was gradually reduced. We conclude that lumbar sympathetic ganglion block may be very effective in some patients with acquired lymphangioma.     

椎间盘源性痛——射频消融术和椎间孔镜下椎间盘摘除术的疗效对比

目的比较射频消融术和椎间孔镜下椎间盘摘除术治疗椎间盘源性痛的临床疗效。方法回顾2010年8月～2012年5月收治的腰椎椎间盘源性痛患者16例,其中男9例,女7例,平均年龄37.5岁(26～49岁)。均采用C形臂X线机引导下椎间盘穿刺。10例采用射频消融术治疗,6例采用椎间孔镜下椎间盘摘除术的方法。观察手术时间、疼痛改善情况以及术后疼痛复发情况。疼痛改善采用视觉模拟量表(visual analog scale,VAS)评分法评估。结果射频消融术的手术时间平均为34 min,VAS评分由术前的7.5分降至术后的0.8分,有3例术后半年内再次出现疼痛。椎间孔镜下椎间盘摘除术的手术时间平均为78.8 min,VAS评分由术前的7.7分降至术后的1.2分,术后有1例出现椎间盘突出复发。结论射频消融术和椎间孔镜下椎间盘摘除术均可有效缓解椎间盘源性腰痛,前者的损伤小,但有一定的复发率,后者手术时间长,复发率较低。     

Pedal bypass with deep venous arterialization: the therapeutic option in critical limb ischemia and unreconstructable distal arteries

Heavily calcified and severely stenotic distal arteries defined as unreconstructable, precludes the possibility of revascularization, resulting in major amputation in patients with critical limb ischemia. However, providing blood supply to the ischemic foot through the venous system instead of the arterial system may improve the circulation adequately for the healing process in the vascular compromised distal tissue. This study aimed to assess the safety and efficacy of pedal bypass with deep venous arterialization, one of the possible procedures to improve the circulation through the venous system in critically ischemic limbs and unreconstructable distal arteries. Twenty-six patients with critical limb ischemia and an unreconstructable distal artery of the lower extremities were included for the surgical procedure. Arterial bypass with distal anastomosis at the paramalleolar deep vein was carried out through a composite graft combined with adequate destruction of valve competency in the distal vein. The primary endpoint was complete healing of ischemic ulcer with amelioration of rest pain within six months. The secondary endpoints were the outcomes of survival, limb salvage and primary graft patency rate at six-month intervals to 24 months. Nineteen patients (73.1%) had complete healing of ischemic ulcer and disappearance of rest pain within six months. Six patients (23.1%) underwent major amputation. Perioperative mortality was 3.8%. After 24 months of follow-up study, the survival rate was 87.5%, whereas the limb salvage and graft patency rates were 76.02 and 49.17%, respectively. Pedal bypass with deep venous arterialization may be another therapeutic option to enhance the healing of ischemic ulcer and limb salvageability in patients with critical limb ischemia and unreconstructable distal artery.     

Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS)

A 59-year-old man with amyotrophic lateral sclerosis (ALS) received lumbar epidural and sympathetic ganglion blocks to increase regional blood flow and improve his clinical symptoms. After a lumbar epidural block (0.5% mepivacaine), the skin temperature of his affected lower extremities rose by 7.0°C and became close to that of the intact side, and the distance he was able to walk with his cane increased from 2 to 8 m. The clinical effects produced by the lumbar sympathetic ganglion block (99.5% alcohol) were sustained for approximately 8 weeks after the first block and for approximately 6 weeks after the second block. There were no particular adverse effects or complications associated with these nerve block procedures. Epidural and sympathetic ganglion blocks for an ALS patient, albeit their effects are of a transient nature, may improve related clinical symptoms, and were thought to play a contributory role in improving our patient's quality of life.     

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis

OBJECTIVE: This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. METHODS: Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. RESULTS: Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). CONCLUSIONS: Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.     

Complex regional pain syndrome in a patient with spinal cord injury: management with pulsed radiofrequency lumbar sympatholysis

STUDY DESIGN: Short communication. OBJECTIVES: To report a case with bilateral lower extremity complex regional pain syndrome (CRPS) in a patient with paraplegia occurring following spinal disc herniation surgery, who was treated successfully with pulse radiofrequency (PRF) lumbar sympatholysis. SETTING: Departments of Physical Medicine and Rehabilitation, Algology Department of Anaesthesiology and Nuclear Medicine, Medical Faculty of Ege University, Izmir, Turkey. METHODS: A 55-year-old woman had neuropathic pain in her lower extremities after T12-L1 disc herniation surgery. The pain decreased to a tolerable level with conservative treatment and her condition remained stable for the following 6 months; then she developed swelling, redness and severe burning pain in both feet. Physical examination showed edema and redness in the feet. On the basis of clinical findings and Tc-99m methylene diphosphonate (MDP) three-phase bone scintigraphy, she was diagnosed to have CRPS. RESULTS: The patient underwent a diagnostic sympathetic ganglion blockade with bupivacaine, which resulted in a marked decrease in the pain and edema of the feet. Consequently, PRF lumbar sympatholysis was performed with a successful outcome in pain, edema and color changes in the feet. CONCLUSION: When treatment of CRPS fails with conventional modalities, PRF sympatholysis may be used for control of pain and other symptoms in such patients.     

Comparison of lower extremity cutaneous temperature changes in patients receiving lumbar sympathetic ganglion blocks versus epidural anesthesia

STUDY OBJECTIVE: To investigate if paravertebral lumbar sympathetic ganglion block and lumbar epidural anesthesia result in comparable cutaneous temperature changes in the lower extremity. DESIGN: Nonrandomized comparison study. SETTING: Operating rooms and pain clinic procedure rooms in a tertiary care hospital. PATIENTS AND INTERVENTIONS: 18 patients undergoing lumbar sympathetic ganglion blocks for the diagnosis and/or treatment of chronic pain, and 13 patients undergoing lumbar epidural anesthesia for radical prostatectomy. MEASUREMENTS: Cutaneous temperatures were measured over the great toe, calf, and thigh in all patients. Mean maximum temperature (Tmax), rate of change of skin temperature (from 5% to 95% of maximum temperature change), and mean time to 1 degrees C increase, and 50% and 95% of maximum temperature change for each group were compared. Temperature changes for the epidural and lumbar sympathetic block patients were compared. MAIN RESULTS: Epidural and lumbar sympathetic block resulted in similar Tmax (34.1 +/- 0.2 and 33.8 +/- 0.9 degrees C, respectively, mean +/- SEM; p = 0.18) and rate of temperature change (0.64 +/- 0.09 and 0.49 +/- 0.07 degrees C/min; p = 0.2) in the great toe. The onset of cutaneous temperature change after lumbar sympathetic block was slower than after epidural anesthesia (1 degrees C increase: 17 and 11 min, respectively, 50% of Tmax: 25 and 17 min, respectively, and 95% of Tmax: 40 and 31 min, respectively; p < 0.05 for each). CONCLUSIONS: The similar rate and magnitude of cutaneous temperature change in the distal lower extremity suggests the degree of sympathetic blockade is similar with lumbar sympathetic blockade and epidural anesthesia. Either technique should provide adequate sympathectomy for treating sympathetically maintained pain once the diagnosis has been confirmed using selective sympathetic blockade.