CT引導(dǎo)射頻溫度及針尖裸露長度治療三叉神經(jīng)痛療效和并發(fā)癥關(guān)系

張志良　顧峰杰　孫愛軍　李志軍

?

·論著·

CT引導(dǎo)射頻溫度及針尖裸露長度治療三叉神經(jīng)痛療效和并發(fā)癥關(guān)系

張志良顧峰杰孫愛軍李志軍

066600河北省昌黎縣人民醫(yī)院疼痛科

【摘要】目的研究CT引導(dǎo)下不同射頻溫度以及針尖裸露長度對(duì)熱凝治療三叉神經(jīng)痛的治療效果和并發(fā)癥的影響。方法100例三叉神經(jīng)痛患者在CT引導(dǎo)下，均行半月神經(jīng)節(jié)穿刺，采用射頻溫控?zé)崮g(shù)治療?；颊唠S機(jī)分為4組，每組25例。A組應(yīng)用穿刺套管針針尖裸露端長為5 mm的射頻針進(jìn)行治療，持續(xù)熱凝溫度為80℃；B組針尖裸露端5 mm，溫度為75℃；C組針尖裸露端2 mm，溫度為80℃；D組針尖裸露端2 mm，溫度為75℃。射頻熱凝的時(shí)間均為120 s，2次。觀察治療前(T0)、治療后1 d(T1)、1周(T2)、1個(gè)月(T3)、2個(gè)月(T4)的視覺模擬評(píng)分(visual analogue scale,VAS)和睡眠評(píng)分以及不良反應(yīng)(麻木范圍及程度、咀嚼無力以及角膜炎等)。結(jié)果與治療前相比，4組均有顯著療效(P<0.05)，組間VAS和睡眠評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后所有患者出現(xiàn)不同程度的面部麻木感，并隨時(shí)間延長逐漸減輕。T2和T3時(shí)，4組患者中，A組麻木程度評(píng)分最高，C組程度評(píng)分明顯低于B組而高于D組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。T4時(shí)刻，A組的麻木范圍和咀嚼無力發(fā)生率明顯高于C組和D組(P<0．05)，B組明顯高于D組(P<0.05)，C組和D組無明顯差異(P>0.05)。無1例患者發(fā)生角膜炎。結(jié)論75℃下，同時(shí)應(yīng)用針尖裸露端為2 mm的穿刺套管針進(jìn)行CT引導(dǎo)下射頻治療三叉神經(jīng)痛可以達(dá)到滿意的治療效果，同時(shí)減少術(shù)后產(chǎn)生并發(fā)癥。

【關(guān)鍵詞】CT引導(dǎo)；半月神經(jīng)節(jié)；熱凝射頻；針尖裸露端長度；三叉神經(jīng)痛

三叉神經(jīng)痛系三叉神經(jīng)分布區(qū)內(nèi)反復(fù)發(fā)作陣發(fā)性劇痛的一種疾病，是常見的原因不明的疼痛性疾病，嚴(yán)重影響患者的生活質(zhì)量[1,2]。目前治療三叉神經(jīng)痛的方法比較多，如口服卡馬西平、伽馬刀三叉神經(jīng)根物理切除以及手術(shù)開路三叉神經(jīng)根減壓術(shù)等，但都存在療效不明顯或者各種不良反應(yīng)，導(dǎo)致患者不能耐受[3]。射頻熱凝療法是利用高溫作用于神經(jīng)節(jié)、神經(jīng)干和神經(jīng)根等部位，使其蛋白質(zhì)凝固變性，從而阻斷神經(jīng)沖動(dòng)的傳導(dǎo)的一種方法，臨床上已用于治療三叉神經(jīng)痛，且溫度一般控制在70℃～80℃[4,5]。如何使用射頻熱凝治療使患者具有良好的鎮(zhèn)痛療效又避免神經(jīng)過度損傷的并發(fā)癥，一直是本領(lǐng)域的研究熱點(diǎn)問題[6]。本文對(duì)CT引導(dǎo)下不同射頻溫度熱凝以及針尖裸露長度對(duì)三叉神經(jīng)痛的治療效果和并發(fā)癥關(guān)系論述如下。

1資料與方法

1．1一般資料本研究已獲本院倫理委員會(huì)批準(zhǔn)，并與患者或家屬簽署知情同意書。河北省昌黎縣人民醫(yī)院疼痛科2015年1月1日至2015年12月1日收治的擇期三叉神經(jīng)痛患者100例，男40例，女60例;年齡42～70歲；體重59～85 kg；病程1～20年；左側(cè)疼痛48例，右側(cè)疼痛52例。第Ⅰ支30例，第Ⅱ支35例，第Ⅲ支15例，第Ⅱ+ Ⅲ 支 10例，第Ⅰ+ Ⅱ支 5 例，第Ⅰ+ Ⅱ+ Ⅲ支 5例。排除標(biāo)準(zhǔn)：(1) 神經(jīng)精神系統(tǒng)疾病史；(2)脊柱以及腦外傷史；(3)嚴(yán)重肝腎疾病和心血管病。所選患者隨機(jī)分為4組，4組患者年齡、性別比、體重、發(fā)病時(shí)間均無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。

表12組一般臨床資料

1.2治療方法患者入CT室后，予持續(xù)心電、血壓和血氧飽和度監(jiān)測(cè)，開放上肢靜脈通路，給予甲強(qiáng)龍40 mg入壺，常規(guī)消毒、鋪無菌巾。用長15 cm的射頻穿刺針在 引導(dǎo)下行卵圓孔穿刺，穿刺到位后行掃描，確定針尖進(jìn)入卵圓孔，并且在三叉神經(jīng)半月節(jié)壓跡的部位連接射頻儀，繼之熱凝治療，采用50 Hz神經(jīng)電刺激誘發(fā)患者的異感，調(diào)整針尖的位置，使刺激電壓保持在0.1～0.5 V，且可復(fù)制疼痛發(fā)生的區(qū)域和麻刺感，注入2%利多卡因0.2% ml，作為實(shí)驗(yàn)性阻滯，15 min后若患者疼痛消失，感覺喪失的范圍符合要求且無其他異常癥狀和體征。在CT引導(dǎo)下，A組應(yīng)用穿刺套管針針尖裸露端長為5 mm的射頻針進(jìn)行治療，持續(xù)熱凝溫度為80℃；B組針尖裸露端5 mm，溫度為75℃；C組針尖裸露端2 mm，溫度為80℃；D組針尖裸露端2 mm，溫度為75℃。射頻熱凝的時(shí)間均為120 s，2次。見圖1。

1.3評(píng)價(jià)指標(biāo)觀察治療前(T0)、治療后1 d(T1)、1周(T2)、1個(gè)月(T3)、2個(gè)月(T4)的視覺模擬評(píng)分(visual analogue scale,VAS)和睡眠評(píng)分以及不良反應(yīng)。VAS評(píng)分(無疼痛為0分，劇烈疼痛為10分)[7]。睡眠質(zhì)量評(píng)分標(biāo)準(zhǔn)[8]：1分：不能入睡，5分；睡眠很好。術(shù)后不良反應(yīng)包括麻木范圍及程度、咀嚼無力以及角膜炎等。麻木程度評(píng)分[6]：請(qǐng)患者對(duì)于治療后的病變皮膚麻木程度進(jìn)行評(píng)分，10分為最難以忍受的麻木，0分為無麻木；麻木的范圍：記錄術(shù)后麻木范圍分支是否超出術(shù)前三叉神經(jīng)病變支數(shù)。

2結(jié)果

2.14組患者VAS評(píng)分比較治療前4治療組VAS評(píng)分均較高，間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，與治療前比較，治療后4組患者疼痛均得到改善，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，但4組之間T1～T4時(shí)刻，VAS評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表2。

2.24組患者睡眠質(zhì)量評(píng)分比較治療前4組睡眠質(zhì)量評(píng)分較低，組間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，與治療前相比，治療后4組患者睡眠均得到改善，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，但4組之間T1～T4時(shí)刻，睡眠評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表3。

注：與T0比較，*P<0.05

注：與T0比較，*P<0.05

2.34組各時(shí)間點(diǎn)面部麻木評(píng)分比較所有患者穿刺成功，并成功熱凝。治療前4組患者均無面部麻木癥狀，T1～T4麻木癥狀逐漸減輕，有隨時(shí)間延長而麻木程度降低的趨勢(shì)。T1時(shí)刻麻木程度最重，T4時(shí)刻麻木程度最輕。T2和T3時(shí)刻，4組患者中，A組麻木程度評(píng)分最高，C組麻木評(píng)分低于B組但高于D組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，C組和D組比較無差異(P>0.05)。A組術(shù)后麻木范圍情況超過術(shù)前疼痛范圍的病例 (P<0.05)。見表4。

注：與A組比較，*P<0.05；與B組比較，#P<0.05；與C組比較,△P<0.05

2.44組咀嚼無力情況比較A組術(shù)后咀嚼無力的發(fā)生率明顯高于C組和D組(P<0.05)，B組發(fā)生率明顯高于D組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表5。

注：與A組比較，*P<0.05；與B組比較，#P<0.05

2.5不良反應(yīng)發(fā)生結(jié)膜炎1例。

3討論

三叉神經(jīng)痛患者疼痛劇烈，且發(fā)病率隨著年齡上升而增加。20世紀(jì)70年代Sweet等將射頻電熱用于治療三叉神經(jīng)痛痛，并取得較好的療效，其機(jī)制為當(dāng)穿刺針抵達(dá)半月神經(jīng)節(jié)內(nèi)時(shí)，射頻電流產(chǎn)生大量的熱，這些熱量通過通過熱敏電阻反饋測(cè)量組織溫度或者調(diào)節(jié)溫度[5,9]。三叉神經(jīng)傳導(dǎo)痛覺的Aδ纖維和C纖維加熱后首先變性，而傳導(dǎo)觸覺的Aα和Bβ纖維能耐受較高溫度，通過溫控加熱可以選擇性破壞痛覺纖維而保留初級(jí)纖維，從而達(dá)到鎮(zhèn)痛的目的[5,9]。

眾所周知，射頻的溫度是治療三叉神經(jīng)痛療效的重要因素，一般認(rèn)為65℃～75℃為常用溫度，溫度過高，容易因溫度過高而導(dǎo)致神經(jīng)燙傷等各種并發(fā)癥；而溫度過低，雖然可以減少一定的并發(fā)癥，但是復(fù)發(fā)率又隨之增高，所以對(duì)于射頻治療三叉神經(jīng)痛，溫度的選擇是至關(guān)重要的[10,11]。射頻治療的原理是穿刺套管針針尖的裸露端在接觸面產(chǎn)生強(qiáng)烈的熱效應(yīng)，迅速升高局部組織溫度，使其發(fā)生脫水、變硬，甚至凝固性壞死，從而達(dá)到組織破壞的治療目的[12]。本研究通過對(duì)100例三叉神經(jīng)痛的患者，應(yīng)用不同的穿刺套管針(針尖裸露長度分別為5 mm、2 mm)及不同射頻溫度進(jìn)行射頻治療，旨在觀察不同射頻溫度以及不同針尖裸露長度對(duì)電凝后的治療效果以及并發(fā)癥的影響，尋找一種既安全有效，又可以減少并發(fā)癥的臨床方法。

本組研究的所有患者均在CT的引導(dǎo)下精確定位，行通過到達(dá)半月神經(jīng)節(jié)。研究發(fā)現(xiàn)，與治療前相比，三種方法均有療效，組間VAS和睡眠評(píng)分無顯著差異。Zhao等[13]甚至比較70℃和75℃熱凝射頻對(duì)三叉神經(jīng)痛的影響，發(fā)現(xiàn)兩種不同溫度的治療效果無明顯差異，這與本研究結(jié)果相似。Tang等[14]比較射頻治療三叉神經(jīng)痛后的長期效應(yīng)，所有的患者長期隨訪后發(fā)現(xiàn)術(shù)后即時(shí)疼痛緩解率可達(dá)98.4%，術(shù)后第1、3、5、7、9和11年后，第Ⅱ支的疼痛緩解率分別為89%、80%、72%、60%和54%，這與本研究類似。Tang等[14]羅列了長期隨訪中發(fā)現(xiàn)的不良反應(yīng)，發(fā)現(xiàn)咀嚼無力好發(fā)第Ⅲ支疼痛患者，而角膜炎以及復(fù)視好發(fā)第Ⅰ支疼痛患者，而第Ⅱ支患者治療效果好且無明顯并發(fā)癥。雖然本研究第Ⅰ支疼痛的患者有40例，但是本實(shí)驗(yàn)在CT的精確定位下，針尖裸露端嚴(yán)格控制在 5 mm，所以患者主要出現(xiàn)咀嚼無力和面部麻木的現(xiàn)象，而只有1例發(fā)生角膜炎。我們的研究發(fā)現(xiàn)術(shù)后所有患者均出現(xiàn)不同程度的面部麻木感，T2和T3時(shí)， A組麻木程度評(píng)分最高， D組最低，而T4時(shí)刻，A組的麻木范圍和咀嚼無力發(fā)生率明顯高于C、D組，說明CT引導(dǎo)下半月節(jié)射頻術(shù)治療原發(fā)性三叉神經(jīng)痛，是一種安全有效的治療方法，而在相同的射頻溫度下，應(yīng)用針尖裸露端為2 mm的穿刺套管針進(jìn)行射頻治療，術(shù)后所產(chǎn)生的麻木范圍、麻木程度以咀嚼無力明顯少于針尖裸露端為5 mm的穿刺套管針；Zhao等[13]也建議裸露針尖<3 mm為宜，同時(shí)Lai等[15]發(fā)現(xiàn)當(dāng)裸露針尖>5 mm時(shí)，不良反應(yīng)明顯增加。在應(yīng)用相同穿刺套管針下，研究發(fā)現(xiàn)80℃射頻熱凝，術(shù)后麻木程度評(píng)分明顯高于75℃組。

三叉神經(jīng)是痛溫覺的纖維和觸覺的纖維組成的混合神經(jīng)[16]，所以在實(shí)際操作過程中，很難進(jìn)行高選擇性的只毀損傳導(dǎo)痛覺的纖維，而不損傷觸覺纖維，而這恰恰是術(shù)后導(dǎo)致麻木的主要原因。面部麻木成為射頻手術(shù)后最常見的并發(fā)癥。通過對(duì)4組的兩兩比較說明射頻溫度越高，麻木程度的評(píng)分也較高，而且應(yīng)用針尖裸露端為5 mm的射頻組術(shù)后麻木程度評(píng)分也明顯高于2 mm的治療組，表明熱凝溫度的增加及針尖裸露長度的增加可以加重術(shù)后麻木。

綜上所述，75℃下，同時(shí)應(yīng)用針尖裸露端為2 mm的穿刺套管針進(jìn)行射頻治療可以達(dá)到滿意的治療效果，同時(shí)減少術(shù)后產(chǎn)生并發(fā)癥。

參考文獻(xiàn)

1Tamburin S, Schweiger V, Magrinelli F, et al.Effect of 5% lidocaine medicated plaster on pain intensity and paroxysms in classical trigeminal neuralgia.Ann Pharmacother,2014,48:1521-1524.

2Abdallah K, Monconduit L, Artola A, et al.GABAAergic inhibition or dopamine denervation of the A11 hypothalamic nucleus induces trigeminal analgesia.Pain,2015,156:644-655.

3Yameen F, Shahbaz NN, Hasan Y, et al.Efficacy of transcutaneous electrical nerve stimulation and its different modes in patients with trigeminal neuralgia.J Pak Med Assoc,2011,61:437-439.

4Bescós A, Pascual V, Escosa-Bage M, et al.Treatment of trigeminal neuralgia: an update and future prospects of percutaneous techniques.Rev Neurol,2015,61:114-124.

5Du SB,Ma XL,Li XQ,et al.Ophthalmic branch radiofrequency thermocoagulation for atypical trigeminal neuralgia:a case report.Springerplus,2015,4: 80-83.

6Zhao WX, Wang Q, He MW, et al.Radiofrequency thermocoagulation combined with pulsed radiofrequency helps relieve postoperative complications of trigeminal neuralgia.Genet Mol Res,2015,14:7616-723.

7Taghavi R, Tabasi KT, Mogharabian N,et al.The effect of acupuncture on relieving pain after inguinal surgeries.Korean J Pain,2013,26:46-50.

8Yang PY, Ho KH, Chen HC, et al.Exercise training improves sleep quality in middle-aged and older adults with sleep roblems: a systematic review.J Physiother,2012,58:157-163.

9Mathews ES, Scrivani SJ.Percutaneous stereotactic radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.Mt Sinai J Med,2000,67:288-299.

10Huang Y, Ni J, Wu B, et al.Percutaneous radiofrequency thermocoagulation for the treatment of different types of trigeminal neuralgia: evaluation of quality of life and outcomes.J Huazhong Univ Sci Technolog Med Sci,2010,30:403-407.

11Nguyen M, Wilkes D.Pulsed radiofrequency V2 treatment and intranasal sphenopalatine ganglion block: a combination therapy for atypical trigeminal neuralgia.Pain Pract,2010,10: 370-374.

12Li X, Ni J, Yang L, et al.A prospective study of Gasserian ganglion pulsed radiofrequency combined with continuous radiofrequency for the treatment of trigeminal neuralgia.J Clin Neurosci,2012,19:824-828.

13Zhao WX, Wang Q, He MW, et al.Radiofrequency thermocoagulation combined with pulsed radiofrequency helps relieve postoperative complications of trigeminal neuralgia.Genet Mol Res,2015,14:7616-7623.

14Tang YZ, Wu BS, Yang LQ, et al.The Long-Term Effective Rate of Different Branches of Idiopathic Trigeminal Neuralgia After Single Radiofrequency Thermocoagulation: A Cohort Study.Medicine (Baltimore),2015,94:e1994.

15Lai GH, Tang YZ, Wang XP, et al.CT-Guided Percutaneous Radiofrequency Thermocoagulation for Recurrent Trigeminal Neuralgia After Microvascular Decompression: A Cohort Study.Medicine (Baltimore),2015,94:e1176.

16Al-Quliti KW.Update on neuropathic pain treatment for trigeminal neuralgia. The pharmacological and surgical options.Neurosciences (Riyadh),2015,20:107-114.

The therapeutic effects and complications of CT-guided different radio frequency temperature and the exposed length of needle point in treatment of trigeminal neuralgia

ZHANGZhiliang,GUFengjie,SUNAijun,etal.

DepartmentofPain,People’sHispitalofChangliCounty,Hebei,Changli066600,China

【Key words】CT-guidance;semilunar ganglion;thermocoagulation radio frequency;exposed length of needle tip;trigeminal neuralgia

【Abstract】ObjectiveTo investigate the therapeutic effects and complications of CT-guided different radio frequency (RF) temperature and the exposed length of needle point in treatment of trigeminal neuralgia.MethodsOne hundred patients with trigeminal neuralgia who were admitted and treated in our hospital received semilunar ganglion percutaneous puncture under CT guidance,who were treated by radiofrequency temperature-controlled thermocoagulation.The patients were randomly divided into four groups,with 25 patients in each group.The patients in group A were treated by RF needle with the exposed length of needle point being 5mm and continuous thermocoagulation temperature being 80℃.In group B, the exposed length of needle point was 5mm and thermocoagulation temperature was 75℃;In group C,the exposed length of needle point was 2mm and thermocoagulation temperature was 80℃;In group D, the exposed length of needle point was 2mm and thermocoagulation temperature was 75℃,with the time of RF thermocoagulation for 120s,the application of two times in the four groups.The visual analogue scale (VAS),sleep quality score as well as the adverse reactions after treatment including the range and severity of facial numbness,inability to chew, keratitis were observed and recorded before treatment (T0).ResultsAs compared aftertreatment 1 day (T1),1 week (T2),1 month (T3),and 2 months(T4) for the four groups.withthose before treatment,the therapeutic effects in the four groups were quite significant (P<0.05).There were no significant differences in VAS and sleep quality score among four groups (P>0.05).The facial numbness feeling appeared in all the patients after treatment at different extent,however, which was gradually relieved with the time going on. Among the four groups, the scores of facial numbness degree in group A at T2,T3 were the highest,which in group C were significantly lower than those in group B and higher than those in group D (P<0.05). The range of facial numbness and incidence of atonia masticatoria at T4 in group A were significantly higher than those in group C and group D (P<0.05),which in group B were significantly higher than those in group D (P<0.05),however,there were no significant differences between group C and group D (P>0.05). Besides keratitis was not found in all the patients.ConclusionThe therapeutic effects of CT-guided radiofrequency thermocoagulation in 75℃ combined with puncture trocar of 2mm exposed length of needle point on trigeminal neuralgia are satisfactory,with few postoperative complications.

doi:10.3969/j.issn.1002-7386.2016.12.014

通訊作者：李志軍,066600河北省昌黎縣人民醫(yī)院疼痛科；

【中圖分類號(hào)】R 745.11

【文獻(xiàn)標(biāo)識(shí)碼】A

【文章編號(hào)】1002-7386(2016)12-1809-04

(收稿日期：2016-02-08)

E-mail：13803384444@163.com