脊髓背根入髓区毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素分析(附105例报告)

目的探讨脊髓背根入髓区(DREZ)毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素。方法回顾性分析2005年8月至2018年1月首都医科大学宣武医院功能神经外科收治的105例臂丛神经损伤后神经病理性疼痛患者的临床资料。根据患者疼痛及感觉缺失区对应的皮节,采用颈髓DREZ毁损术治疗。术后对所有患者行电话或门诊随访,随访内容为疼痛数字评分(NRS),以疼痛改善率[(术前NRS-术后NRS)/术前NRS×100%]评估患者疗效;其中改善率>75%为优秀,50%~75%为良好,≤50%为差。进一步采用单因素和多因素logistic回归分析法判断影响患者疗效的临床因素。结果105例患者的手术均成功。术后并发生症包括:手术同侧下肢麻木33例(31.4%)、下肢深感觉障碍20例(19.0%)、下肢无力9例(8.6%),手术对侧肢体麻木5例(4.8%),硬脊膜漏1例(1.0%);无一例出现切口愈合不良和感染。105例患者的随访时间为(47.3±25.5)个月(10~144个月)。至末次随访,105例患者疼痛的中位改善率(上、下四分位数)为100%(60%,100%);其中,74例(70.5%)为优秀,9例(8.6%)为良好,22例(20.9%)为差。单因素分析结果显示,性别、年龄、损伤原因、疼痛出现的时间、疼痛形式、性质及术后并发症对患者的疗效均无影响(均P>0.05),而病程和脊髓萎缩程度对疗效有影响(均P<0.05)。进一步多因素logistic回归分析结果显示,轻度脊髓萎缩是影响患者疗效的独立保护因素(OR=95.952,95%CI:4.171~2207.414,P=0.004)。结论DREZ毁损术治疗臂丛神经损伤后神经病理性疼痛疗效较好且多较持久;同时有轻度脊髓萎缩的患者手术疗效较好。

Therapeutic effect analysis of dorsal root entry zonectomy for neuropathic pain post brachial plexus injury:A report of 105 cases

Objective To evaluate the efficacy and influencing factors of dorsal root entry zonectomy(DREZ)in the treatment of neuropathic pain post brachial plexus injury.Methods A retrospective analysis was conducted on the clinical data of 105 patients with neuropathic pain post brachial plexus injury admitted to Department of Functional Neurosurgery,Xuanwu Hospital of Capital Medical University from August 2005 to January 2018.According to the corresponding dermatomes of the patient′s pain and sensory loss area,the operation of cervical DREZ was performed.After surgery,all patients were interviewed by telephone or outpatient clinic and followed up based on the pain numerical rating scale(NRS).The patient′s efficacy was assessed with a pain improvement rate[(preoperative NRS-postoperative NRS)/preoperative NRS×100%]:the improvement rate of>75%as excellent,50%-75%as good,and≤50%as poor.Further univariate and multivariate logistic regression analysis were used to determine the relevant factors affecting the efficacy of patients.Results The operations of all 105 patients were successful.Postoperative complications included 33 cases(31.4%)of numbness,20 cases(19.0%)of deep sensory disturbance,9 cases(8.6%)of muscle weakness in ipsilateral lower limb,5 cases(4.8%)of numbness in contralateral limb and 1 case(1.0%)of postoperative dural leakage.There was no poor wound healing or infection.The follow-up duration of 105 patients was 47.3±25.5 months(10-144 months).By the last follow-up,the median improvement rate(upper and lower quartiles)in 105 patients was 100%(60%,100%).Among them,the outcome was excellent in 74(70.5%)cases,good in 9(8.6%)and poor in 22(20.9%).The results of univariate analysis showed that sex,age,cause of injury,time of occurrence of pain after injury,form and nature of pain,number of dermatomes involved and postoperative complications had no effect on the therapeutic effect(all P>0.05),while the course of disease and the degree of spinal cord atrophy had influence on the outcome(both P<0.05).Further multivariate analysis showed that the mild degree of spinal cord atrophy was an independent protective factor affecting the efficacy of patients(OR=95.952,95%CI:4.171-2207.414,P=0.004).Conclusion DREZ demonstrates long-lasting effect in the treatment of neuropathic pain following brachial plexus injury,and the patients with mild cervical spinal cord atrophy before operation may have favorable surgical effect.