CT引导下肛尾神经毁损技术及其在治疗癌性会阴痛中的应用

目的 介绍一种针对大小便改道术后的癌性会阴痛的治疗技术——CT引导下肛尾神经毁损技术，并评价其在某些癌性会阴痛中的镇痛效果。 方法 3例已行人工肛门并输尿管造瘘的晚期癌性会阴痛患者，就诊前均每天口服奥施康定200 mg以上，疼痛视觉模拟评分(VAS)仍大于5分。查无蛛网膜下腔穿刺禁忌证后，在CT引导下行肛尾神经毁损术:以层厚5 mm对腰4～骶1椎体进行冠状位平扫，选出最佳穿刺进针点，局麻后用7号腰麻穿刺针穿刺进入腰5骶1椎间隙对应的蛛网膜下腔，确认脑脊液回流通畅后，缓慢(1 ml/min)注入5%酚甘油1.2 ml(6%酚甘油1 ml+30%碘海醇0.2 ml)，再次CT扫描观察所注药液的分布并三维重建。拔出穿刺针后嘱患者保持坐姿半小时后移至病房，期间及随后6 h仍保持坐姿。治疗期间及随后12 h对患者进行生命体征监测，12 h后针刺测出患者无痛平面,并对患者的镇痛效果进行电话随访。 结果 3例患者术后三维重建示药液均位于终池，药液上界均在腰5椎体下缘水平，术后会阴区感觉完全麻木，针刺见血亦无痛感，会阴痛完全消失。所有患者双下肢肌力及感觉同术前，2例患者随访至病故(治疗后生存期分别为9、15个月)，另一例患者术后4个月仍存活，会阴痛无复发。 结论 CT引导下肛尾神经毁损技术是一种安全、有效的治疗癌性会阴痛的新方法，对大、小便改道的晚期肿瘤患者尤为适宜。 

CT guided anococcygeal nerves destruction technique and its application in treating malignancy associated perineal pain

Objective To report a new clinical therapeutic technique,anococcygeal nerves destruction under CT guidance,in treating malignancy associated perineal pain after fecal and urinary diversion surgery,and evaluate the analgesic efficacy of this technique. Methods Three cases of late stage of malignancy associated perineal pain with artificial anourethral fistula have been involved in this study.The pain scored higher than 5 for all the three patients even they took more than 200 mg OxyContin per day.CT guided anococcygeal nerves destruction was performed when no contraindication to cavitas subarachnoidealis penetration was found.Coronal CT scan was performed to L4-S1 vertebrae,5 mm thick.The best penetrating spot for needle puncture was determined.After Local anesthesia,a #7 lumbar puncture needle was used to enter the cavitas subarachnoidealis through the intervertebral space between L5 and S1.When good cerebrospinal fluid circulation was confirmed,1.2 ml 5% phenol glycerin (1 ml 6% phenol glycerin plus 0.2 ml 30% iohexol) was slowly injected at the rate of 1 ml/min.The distribution of the physic liquor has been confirmed from another CT scanning,and 3D reconstruction.The patients kept their position for another 30 min after the puncture needle was removed,and was then sent to the wards.During the transportation and the first 6 h after,the patients need to keep sitting posture.The patients were monitored for vital signs during the treatment and for the first 12 h.Then they were tested for analgesic area using needle punching,and receiving follow up calls after discharge. Results The 3D reconstruction after surgery showed in all 3 cases,that the injected physic liquor was located in the terminal cistern,and the upper bound of the physic liquor located below the L5 vertebrae.After surgery,all patients lost their sensation at perineal area,and felt no pain even punched to bleed.Perineal pain was all gone.All the patients had the same,not affected muscle strength and sensation of their two lower limbs as that before the surgery.2 cases were followed up until death (survival durations were 9 months and 15 months);another case is still going on(4 months after surgery),all with no recurrent perineal pain. Conclusion Anococcygeal nerves destruction under CT guidance is a novel,safe,efficacious strategy in treating malignancy associated perineal pain,especially for those patients with terminal cancer and received fecal and urinary diversion surgery.