疼痛治疗：介绍椎旁神经介入技术

介绍了介人技术的概念，范畴，临床范围和介入治疗学的分类。介人技术分类包括血管性介入治疗技术和非血管性介入治疗技术两种。介人治疗技术具有微创性、可重复性、定位准确、安全性强、并发症低和患容易接受的特点。在介绍椎旁介人技术的解剖学内容中包括了颈椎旁、胸椎旁和腰椎旁的解剖学特点，同时对上述3种介人治疗技术进行了规范化操作论述，并提出椎旁介入技术的临床应用范围。     

卵巢癌介入治疗的护理

血管性介入治疗为晚期卵巢癌及无法手术患者提供了治疗的机会，取得了较好的效果。介入治疗的术前、术中、术后护理是介入治疗的重要环节，其直接影响介入治疗能否顺利进行，防止和减少并发症的发生，对介入术后的疗效也很重要。现将卵巢癌介入治疗的护理介绍如下。１临床...     

神经外科介入治疗中的并发症的防治

神经介入治疗是随着近代神经影像技术及介入材料工程学的发展而建立和发展的一门新兴学科。由于脑血管病是神经内、外科发生率最高的疾病，神经介入治疗的应用范围非常广泛。目前，除北京、天津、上海、广州、武汉等大城市已经建立神经介入治疗中心外，许多中小城市也在纷纷开展神经介入工作。我国从事神经介入治疗的医生中。多数是神经外科医生，具有很好的解剖学知识和手术经验，     

血管性介入治疗的围手术期护理

介入放射学是一门集诊断、治疗于一体的新兴学科。行介入放射手术时,不仅需要有一套完整的医疗设备,还需要认真的术前准备、术中配合和术后护理,遵守同外科手术一样的无菌技术操作规程。我院近年来开展血管性介入治疗收到了满意的效果,现将护理配合体会介绍如下：     

介入放射学在临床医学本科教学中的分析及教学体会

目的:分析介入放射学在临床医学本科课程中的教学现状,为进一步改进介入放射学课堂形式提供依据。方法:2020年下半年,在我校临床医学五年制本科三年级学生中开展介入放射学相关课程教学。课程内容分为总论、血管性介入治疗(血管造影、血管成形术、栓塞术)、非血管介入治疗(穿刺引流术、经皮穿刺骨水泥椎体成形术)、肿瘤综合介入(肿瘤的消融治疗、粒子植入近程放疗技术等)四部分。在课程结束后对学生进行闭卷考核及问卷调查,评估学生对课程内容的掌握情况以及对课程改进的建议。结果:考核结果提示,学生对总论及非血管介入治疗相关内容的掌握程度较好;对血管性介入治疗内容掌握程度一般,主要体现在对人体血管解剖、出凝血功能异常的相关病理生理机制掌握不牢固。结论:在临床医学五年制学生三年级时开设介入放射学课程,并改革介入放射学的授课形式十分必要,能让更多临床专业本科生初识介入放射学,有助于其临床思维的拓展,促进这些未来医师的临床技能全面发展,适应现代医学工作的需要。     

《介入放射诊疗策略》

本书为《今日临床丛书》的一个临床专科分册。以疾病为线索,着重介绍相关疾病介入治疗的适应证、术前准备、操作技术、注意事项、并发症、预后评价及最新进展,同时对疾病的诊断思路与常规治疗作相应介绍,而对其他基础与理论知识只作简要叙述,甚至省略。第一至第五章以人体部位分类进行介入相关疾病的诊治介绍;第六章专门介绍一些特殊的介入技术;     

肿瘤介入治疗进展与研究方向

影像引导下的介入治疗具有"靶向、微创、安全、高效"的特点,因此日益得到广大患者和临床医师的认可和欢迎,在肿瘤的综合治疗中正发挥着越来越重要的作用.肿瘤的介入治疗包括血管内介入和非血管介入,前者主要指经动脉灌注化疗和栓塞术,后者主要指经皮穿刺行肿瘤消融术.现将近年来肿瘤介入治疗技术的主要进展综述如下,并提出进一步研究的重点方向.     

心脏介入术并发血管迷走反射的研究进展

近年来,随着心导管技术的发展,心脏介入术的临床应用越来越广泛,在冠心病、心律失常、风心病及部分先天性心脏病的诊断、治疗方面,已成为必不可少、行之有效的诊断方法和治疗手段。心脏介入诊疗技术主要包括冠状动脉介入治疗（PCI）、先天性心脏病的介入治疗、风湿性心脏病的介入治疗、心律失常的谢频消融治疗以及心脏起搏器的安置等。股动脉穿刺并置入鞘管是心脏介入治疗中的一种常用方法,但介入治疗术中、术后存在一些并发症,血管迷走反射（vaso-vagal reactions,VVRS）就是其中一种较少见和严重的并发症,严重时甚至危及生命,发生率3％～5％。     

第二届全国非血管性与血管性介入诊疗新技术学术会议征文通知

由河南省肿瘤介入诊疗专业委员会及郑州大学第一附属医院联合主办的“第二届全国非血管性与血管性介入新技术学术研讨大会”拟定于2005年10月20日-23日在郑州市召开。本次学术会议将邀请国内外著名介入影像学专家作学术专题报告,重点议题有外科术后或放疗后气道瘘及消化道瘘的处理;布加综合征的综合治疗;阻塞性黄疸介入治疗;肿瘤介入治疗;急诊的介入处理等。现面向全国征集学术论文。1.征文内容:①非血管性介入新技术;②血管性介入新技术;③影像学与介入新进展;④介入病房管理与护理等。2.征文要求:①专题讲座与综述全文3000字,论著800字以…     

介入治疗患者的护理干预

介入放射学是新兴的边缘学科．介入治疗工作正在逐步发展，系统、规范化的治疗体系在许多地方尚未形成，护理工作才刚刚起步。本院于1996年成立了介入诊疗科，形成了一套专业的规范的介入治疗体系．为肿瘤患者开展了不同种类的介入治疗，介入治疗护理工作也随之逐渐发展起来。笔者从介入病房和介入手术室两个方面．介绍了介入护理工作的特点．同时总结了一些临床护理工作经验。介入病房和介入手术室的护理是介入护理工作的两个重要组成部分．通过两者紧密结合起来，介入护理工作会得到全面、健康、顺利的发展。     

DSA引导下选择性脊神经根阻滞治疗颈源性疼痛的临床研究

【目的】评价数字减影血管造影（DSA）引导下选择性颈脊神经根阻滞（SNRB）与颈椎旁神经阻滞（PVB）治疗颈源性疼痛（CP）的临床效果和安全性。【方法】70例CP患者,随机分为DSA引导下SNRB治疗组（A组）和PVB治疗组（B组）两组,观察比较两组治疗前、治疗后14d疼痛VAS评分;治疗后7d、14d临床效果和不良反应。【结果】A组治疗后7d、14d优良率均高于B组,且差异均有显著性（P〈0．05）,两组治疗后14d,A组与B组疼痛VAS评分比较差异有显著性（P〈0．01）。地塞米松、局麻药混合液用量B组是A组的2倍。治疗后不良反应A组少于B组,且差异有显著性（P〈0．05）。【结论】DSA引导下SNRB目标性强、准确性高、安全、临床效果好,值得临床推广,而PVB因盲目注药目标性不强、准确性差,存在药物注入血管和神经根袖内的潜在危险。     

Paravertebral Blocks for Same-Day Breast Surgery

Purpose of Review

Breast surgery, performed for medical or cosmetic reasons, remains one of the most frequently performed procedures, with over 500,000 cases performed annually in the USA alone. Historically, general anesthesia (GA) has been widely accepted as the gold-standard technique, while epidural anesthesia was largely considered too invasive and thus unnecessary for breast surgery. Over the past years, paravertebral block (PVB) has emerged as an alternative analgesic or even anesthetic technique. Substantial evidence supports the use of PVB for major breast surgery.

Recent Findings

In patients receiving PVB, immediate and long-term analgesia is superior to systemic analgesia while opioid use and typical adverse effects of systemic analgesia such as nausea and vomiting are decreased. The benefits may also include an improved oncological survival with PVB after mastectomy for malignancy.

Summary

PVB offers clinically significant benefits for perioperative care of patients undergoing breast surgery. The benefits of continuous PVB are most firmly supported for major breast surgery and include both effective short-term pain control and reduction in burden of chronic pain. On the other hand, minor breast surgery should be effectively manageable using multimodal analgesia in the majority of patients, with PVB reserved as analgesic rescue or for patients at high risk of excessive perioperative pain.

     

Parascapular Sub-Iliocostalis Plane Block: Comparative Description of a Novel Technique for Posterior Rib Fractures

We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateral-posterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. No complications were reported. The efficacy of the PSIP block may potentially depend on different mechanisms of action: (1) direct action in the fracture site by craniocaudal myofascial spread underneath the erector spinae muscle (ESM); (2) spread to deep layers through tissue disruption caused by trauma, to reach the proximal intercostal nerves; (3) further medial spread through deeper layers to the midline to block the posterior and ventral spinal nerves; (4) medial spread below the ESM, to reach the posterior spinal nerves (more reliably than rhomboid intercostal / sub-serratus [RISS] block); and (5) lateral spread in the sub-serratus (SS) plane to reach the lateral cutaneous branches of the intercostal nerves; while avoiding significant negative hemodynamic effects associated with techniques such as the paravertebral block (PVB), erector spinae plane (ESP) block or its variations, or thoracic epidural analgesia (TEA). A comparative comprehensive overview of the regional techniques described for posterior chest trauma is presented, including TEA, PVB, ESP block, retrolaminar block, mid-point to transverse process block, costotransverse foramen block, RISS, and serratus anterior plane (SAP) block.     

Temporary sympathectomy in the treatment of chronic refractory angina

The aim of this study was to investigate the safety and efficacy of the two most commonly practiced temporary sympathectomy techniques in the treatment of chronic refractory angina. Fifty-nine consecutive refractory angina patients commencing outpatient temporary sympathectomy from November 1, 2000 to November 1, 2002, were prospectively audited for duration of pain relief and procedural complications over a two-year period. A total of 227 stellate ganglion blockades (SGB) and 100 paravertebral blockades (PVB) were performed on 59 chronic refractory angina (CRA) patients na?ve to sympathectomy. The mean period of pain relief obtained following SGB was 3.48 weeks (SD 3.38) and the mean relief following PVB was 2.80 weeks (SD 2.00). Mild, fully reversible complications occurred in 3% of SGB and 3% of PVB procedures, with one patient requiring overnight hospitalization. This study demonstrates that temporary sympathectomy may provide a safe and effective outpatient procedure in refractory angina patients when applied as part of holistic care.     

CT-guided paravertebral block for microwave ablation of kidney tumors: a new technique

Purpose

In patients undergoing computed tomography (CT)-guided microwave ablation (MWA) for renal tumors, we developed a CT-guided anterior paravertebral block (PVB) associated with anesthesia of the kidney capsule and inhalation of an equimolar mixture of oxygen and nitrous oxide (EMONO). The primary objectives were to describe our technique and to study its efficacy in terms of procedural success. The secondary objective was to study the tolerance by evaluating patient pain scores and the number of complications.

Methods

Patients suffering from renal carcinoma classified T1a and considered to be poor candidates for surgery were included in this prospective, single-center pilot study. They underwent MWA under CT-guided loco-regional anesthesia: an anterior variant of the PVB at the level of T10, ipsilateral to the renal MWA associated with anesthesia of the kidney capsule and EMONO. Technical success was defined as total thermal ablation without additional sedation and no side effect during the procedure. Maximal pain score during the procedure was assessed using a visual analog score.

Results

Four patients were included. All procedures were technical success. No side effects were reported, either due to the procedure or anesthesia. The maximal pain score recorded immediately after procedure was 2 ± 2.4 on the visual analog score.

Conclusions

MWA of the kidney is feasible under CT-guided anterior paravertebral block. PVB is well tolerated and can be associated with anesthesia of the kidney capsule and EMONO. This new technique may be an alternative to general anesthetic or conscious sedation in clinical practice.

     

Thoracic Paravertebral Block for Postoperative Pain Management in Percutaneous Nephrolithotomy Patients: A Randomized Controlled Clinical Trial

Objective

To investigate the effect of thoracic paravertebral block (PVB) on pain control and morphine consumption in percutaneous nephrolithotomy operations.

Subjects and Methods

This randomized controlled clinical study was performed on 60 American Society of Anesthesiologists (ASA) I-II patients between the ages of 18 and 60 years who underwent percutaneous nephrolithotomy with approval of the ethical committee and written consent of the patients. Patients were randomly allocated into two groups: group P had 4 ml of 0.5% levobupivacaine injected at each of the T10, T11, and T12 paravertebral spaces and a standard PVB, and group C received 4 ml of 0.9% NaCl solution. All patients were given standard general anesthesia. The follow-up of saturation, heart rate, peripheral oxygen, and blood pressure values was recorded before induction, intraoperatively, and postoperatively. At postoperative 1, 2, 6, 12, and 24 h, the visual analog scale (VAS), Ramsey sedation score, respiratory rate, and 24-hour total morphine consumption were recorded. In addition, side effects and satisfaction of patients were recorded.

Results

VAS scores and total morphine consumption were lower in group P than in group C: 2.3 vs. 4.3 and 22.3 vs. 43.2 mg, respectively (p < 0.05). The level of satisfaction was higher in group P than group C. Differences between groups in other parameters were not significant.

Conclusions

Thoracic PVB with levobupivacaine provided a good postoperative analgesia and increased patient satisfaction for those who underwent percutaneous nephrolithotomy.Key Words: Pain management, Postoperative pain, Paravertebral block, Levobupivacaine, Morphine consumption     

Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen

Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after “minor” surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.     

Occipital nerve block is effective in craniofacial neuralgias but not in idiopathic persistent facial pain

Occipital nerve block (ONB) has been used in several primary headache syndromes with good results. Information on its effects in facial pain is sparse. In this chart review, the efficacy of ONB using lidocaine and dexamethasone was evaluated in 20 patients with craniofacial pain syndromes comprising 8 patients with trigeminal neuralgia, 6 with trigeminal neuropathic pain, 5 with persistent idiopathic facial pain and 1 with occipital neuralgia. Response was defined as an at least 50% reduction of original pain. Mean response rate was 55% with greatest efficacy in trigeminal (75%) and occipital neuralgia (100%) and less efficacy in trigeminal neuropathic pain (50%) and persistent idiopathic facial pain (20%). The effects lasted for an average of 27 days with sustained benefits for 69, 77 and 107 days in three patients. Side effects were reported in 50%, albeit transient and mild in nature. ONBs are effective in trigeminal pain involving the second and third branch and seem to be most effective in craniofacial neuralgias. They should be considered in facial pain before more invasive approaches, such as thermocoagulation or vascular decompression, are performed, given that side effects are mild and the procedure is minimally invasive.     

Ultrasound and chronic pain

Ultrasound (US) is an increasingly used imaging technique in interventional pain management. It allows the identification of soft tissues, vessels and nerves, without exposing patients and personnel to radiation. Imaging can be performed continuously and the fluid injected is visualized in a real time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal and paravertebral nerve blocks, inguinal nerve blocks, occipital nerve blocks, blocks of painful stump neuromas, caudal epidural injections and injections of trigger/tender points. Due to direct nerve visualization, US has a potential application for destructive procedures, such as cryoanalgesia, radiofrequency lesions or chemical neurolysis. Limitations are the poor resolution of narrow-gauge needles, the loss of resolution with increasing working depth and possible interference of echoes from overlying structures with the image of the target area. US opens new perspectives in interventional pain management. However, there is a need for more clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are completed, US can not replace fluoroscopy or computed tomography in most interventional pain procedures and remains the domain of well-trained and experienced physicians. The limited evidence supporting the clinical utility of nerve blocks remains a problem, irrespective of the imaging technique employed.     

超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用

目的探讨超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用价值。方法选择ASA I~II级,年龄18~60岁择期行开胸手术肺结核患者90例,随机分为单纯全麻组（G组）、全麻复合超声引导下胸椎旁神经阻滞组（P组）和全麻复合硬膜外阻滞组（E组）,每组各30例。P组患者麻醉诱导前在超声引导下行单次胸椎旁神经阻滞,E组患者麻醉诱导前行胸段硬膜外穿刺并留置硬膜外导管。3组患者均采用静吸复合全麻维持麻醉,术毕行静脉自控镇痛。记录患者入手术室时（T0）、诱导插管前（T1）、切皮前（T2）、切皮后5 min（T3）、拔管后（T4）及术后2 h (T5)的MAP及HR;记录患者术中舒芬太尼用量、手术时间及多巴胺使用例数;记录患者术后2、6、12、24、48、72 h安静状态下和咳嗽时VAS评分及镇痛泵的按压次数。结果P组患者MAP在T3、T4时间点较G组患者有下降（P<0.05）,HR在T3、T4、T5时间点较G组患者有下降（P<0.05）;E组患者MAP、HR在T1、T2、T3、T4、T5时间点较G组、P组患者均有下降（P<0.05）;P组及E组患者术中舒芬太尼用量较G组患者少（P<0.05）;E组患者多巴胺使用例数多于G组、P组患者（P<0.05）,而P组患者多巴胺使用例数多于G组患者（P<0.05）;在安静和咳嗽状态下,P组患者在术后2、6、12 h评分低于G组患者（P<0.05）,E组患者在术后2、6 h评分低于G组患者（P<0.05）;P组、E组患者术后镇痛泵按压次数少于G组患者（P<0.05）。结论超声引导下胸椎旁神经阻滞操作成功率高,镇痛效果确切,围术期血流动力学平稳,可减少肺结核患者开胸手术术中阿片类药物用量,增强术后早期镇痛效果,可安全有效地应用于肺结核患者开胸手术麻醉。