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Medicine

选择性化学腰椎交感神经切除术中灰色拉米关节的靶向性

Published: January 10, 2019 doi: 10.3791/58894

Summary

我们提出了一个选择性化学腰椎交感神经切除术 (cls) 的方案, 它只停用灰色的拉米沟通, 而不是交感神经的躯干。选择性 cls 可帮助实现治疗效果的血管扩张, 汗液减少, 疼痛缓解, 可与传统的 cls, 严重的并发症, 特别是输尿管损伤, 可以减少。

Abstract

化学腰椎交感神经切除术 (cls) 是一种常用的微创手术, 用于治疗包括下肢缺血性疾病、多汗症在内的疾病。通常练习将穿刺针尖放置在腰大肌前筋膜前, 并在交感神经干周围注射激活剂, 这就是传统的 cls。输尿管损伤虽然比较罕见, 但却是常规 cls 最常见的并发症, 可对患者造成严重伤害。我们发现, 在前筋膜后面注射灭活剂, 只针对灰拉米通病, 有助于在血管扩张、汗液减少和止痛方面达到治疗效果, 与传统的 cls 相当, 而且很严重。并发症在很大程度上得到了减少。我们将此过程定义为选择性 cls。在这里, 我们提出了一个选择性 cls 协议。精确的针道和准确的评估的传播造影剂是至关重要的, 以确保药物注射后的前筋膜的前筋膜的腰大肌肉。针尖大约是腰椎 x 线外侧视图中椎体分界线的三分之一。对比主要局限在针尖周围, 沿腰肌纤维向外和向下扩散。这样, 前筋膜为输尿管区提供了天然屏障, 而腰肌为腰神经根提供了天然屏障。本文有几个亮点, 包括 1) 选择性 cls 过程的详细描述, 2) 对实施选择性 cls 的解剖基础的解释, 3) 选择性 cls 和传统的 cls。

Introduction

化学腰椎交感神经切除术 (cls) 已被证明是一种有效的治疗缺血性疾病1,2,3,4, 5包括血栓闭塞症 (有时称为 buerger 病), 缺血性糖尿病足, 雷诺氏病, 足底多汗症6, 红血球痛7,8,9, 和生活网状 10.由于一些优点, 它取代了开放手术。它是微创和经济上有吸引力, 它不需要全身麻醉和住院, 它可以反复进行。然而, 精致的精度是至关重要的。例如, 在 cls 中使用盲技术11 报告了截瘫。通过放射线引导, 通过使用造影剂显示治疗区域, 极大地提高了手术的精度, 从而控制了穿刺针尖的准确位置以及穿刺路径和深度。然而, 即使有放射引导, 对邻近器官, 特别是输尿管器官的损害 12,13,14,15, 16, 1 71 81 9岁仍有报道。

它是通常练习定位针尖以外的前筋膜的腰主要肌肉和注射药物周围的交感神经树干8,12,13,14, 15,我们将其定义为传统的 cls。然而, 由于交感神经干和输尿管的位置都在前筋膜前面, 失活剂可能会扩散到输尿管, 造成损伤。在显示影像学图像12、131415的输尿管损伤报告中, 根据对比扩散情况, 药物被注射到前筋膜前。

根据我们以前执行 cls 程序的经验, 我们发现, 与针对交感神经主干相比, 瞄准灰色的 rami 通信器是非常有效和安全的。灰色 rami 通信是位于交感神经主干后面和在腰椎神经根前面的神经节后交感神经纤维, 沿着椎体的外侧边缘运行, 主要在腰大肌内。因此, 前筋膜为输尿管区提供了良好的屏障, 而腰肌为腰神经根提供了良好的屏障。我们将此过程定义为选择性 cls, 并在本协议中描述了选择性 cls 的技术细节。

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Protocol

该议定书已得到当地医疗和道德委员会的批准。该程序持续约 15分钟, 每侧。

1. 适应症

  1. 确保患者有以下提示 cls: 血栓闭塞症 (buerger 病), 缺血性糖尿病足, 雷诺氏病, 足底多汗症, 红斑痛, 血栓形成, 幻肢疼痛, 或下角的生活网肌四肢。

2. 禁忌症

  1. 如果满足以下任何禁忌症, 则排除患者: 脊柱畸形、出血倾向、过程中涉及的区域中的任何感染、不稳定的生命体征、怀孕或任何能够符合程序。

3. 术前准备

  1. 根据临床和实验室结果确认适应症的存在和禁忌症的缺乏。
  2. 获得患者亲属的书面知情同意。

4. 治疗程序

  1. 患者位置: 确保患者处于侧向脱位位置, 侧面朝上接受治疗, 下肢弯曲, 使背部尽可能伸展。
  2. 消毒: 用2% 的诺碘对计划中的针状穿刺部位 (直径约30厘米) 的皮肤进行消毒, 两次。然后, 用手术毛巾覆盖病人的背部。
  3. 在侧向透视指导下麻醉针道: 麻醉皮肤和整个针道与5-8 毫升的0.5% 利多卡因 (2% 利多卡因稀释在0.9% 生理盐水), 没有血管收缩。在局部麻醉下, 针逐渐向椎体表面推进。将针尖放置在最佳注射区域。
    请注意:皮肤上的穿刺点距离多侧线约7-8 厘米, 具体取决于身体形状。图 1a显示了针道。图 1b显示最佳注射区域, 在腰椎 x 线的侧视图中, 注射面积约为椎体分界线的三分之一。
  4. 用造影剂确认针头位置的准确性: 在确保针尖在腰椎 x 线侧视图的最佳区域后, 注入 0.5 ml 造影剂, 以进一步评估针尖的正确位置。
    请注意:目标是保持造影剂主要局限于最佳区域, 然后沿腰大肌扩散。沿腰肌纤维的对比度分布是前筋膜后面成功注射的标志 (图 2)。
  5. 注射灭活剂, 5% 苯酚: 吸入后, 为确保无穿刺事故, 将2毫升5% 的苯酚水溶液注入最佳区域 (调整针尖方向, 确保1毫升苯酚扩散到头部方向, 然后1毫升。酚的脚的方向)。然后, 从皮肤上取出针头, 用纱布压缩和覆盖穿刺部位, 以实现止血。
    请注意:步骤4.3 至4.5 分别在 l3 和 l4 执行。
  6. 交感神经中断的疗效评估: 定义为在完成步骤4.5 后5分钟内皮肤温度至少上升2°c。如果未能实现令人满意的中断, 请对另一个最佳区域或 l5 进行补充注射, 双方的总苯酚体积不超过10毫升。如果需要, 以相同的方式执行另一侧。使用红外测温仪测量皮肤温度, 并计算胫骨、足底和背足温度升高的平均值。

5. 术后护理

  1. 鼓励患者在手术结束后喝水和活动。第二天检查病人是否有任何不适, 特别是在腰部、腹股沟和大腿, 并改善症状和任何原发疾病的迹象。测量皮肤温度, 如步骤4.6 中所述。与患者进行相应的随访。

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Representative Results

针尖应处于最佳区域, 如图 1所示。在选择性 cls 中, 对比度被注射在腰大肌的前筋膜后面, 针对的是灰色的拉米通道。图 2显示了选择性 cls (a) 和传统 cls (b) 中对比度分布的比较。

预期的临床效果是血管扩张 (用于治疗雷诺氏综合征、生活网状、血栓闭塞性血管炎、缺血性糖尿病足和红斑痛;图 3)、汗液减少 (用于治疗多汗症) 和止痛 (用于治疗红斑狼疮和幻肢疼痛)。

Figure 1
图 1: 穿刺针与周围器官组织的关系.(a) 针道水平的轴向木材 ct 扫描图。白线表示针道。需要注意的是, 针尖接近, 但不突破, 前筋膜的腰肌 (红弧)。a = 腹主动脉, v = 下腔静脉。(b) 腰椎 x 线的侧视。绿色区域说明了最佳区域, 位于腰椎血管 (通常位于椎体的中间水平), 在腰肌的前筋膜后面, 远离椎体后面的腰神经根。这是一个安全的位置, 最接近灰色的拉米通信。a = 腰椎动脉, v = 腰椎静脉。请点击这里查看此图的较大版本.

Figure 2
图 2: 选择性 cls (a) 与常规 cls (b) 在 x 射线视图中扩散造影剂的比较.(a) 选择性 cls。造影剂被注射在腰肌的前筋膜后面。横向视图显示造影剂在针尖周围和后面扩散。前后 (ap) 的观点表明, 造影剂沿腰肌纤维之间的空间向外和向下扩散, 形成细条, 勾勒出肌肉纤维的轮廓。(b) 常规 cls。造影剂注射在腰肌的前筋膜前。侧视图显示, 对比度集中在针尖前的松散组织中。ap 观点显示, 造影剂沿椎体集中, 在 x 线视图中与椎体重叠, 且不向外扩散。请点击这里查看此图的较大版本.

Figure 3
图 3: 在红血球患者右侧选择 cls 后进行临床观察.患者的血管扩张, 皮肤温度升高, 右肢体皮肤红润干燥。相比之下, 皮肤又湿又冷, 左侧有轻微的紫罗兰色, 未经治疗。请点击这里查看此图的较大版本.

Figure 4
图 4: 交感神经干和灰色拉米通讯的解剖插图.(a) 解剖上, 腰肌附着在椎体和腰椎间盘 (ld) 的外侧。在此图中, 大部分的前筋膜的腰肌被删除, 暴露了腰肌。腰椎交感神经干, 位于前筋膜前, 毗邻腹主动脉 (右腰椎交感神经干接近下腔静脉, 未显示)。扩大的腰椎交感神经节 (sg) 也是可见的。(b) 随着腰肌从椎体外部取出, 腰肌的腰部血管和灰色的拉米共传物被暴露在腰肌的深层。从交感神经节开始, 经前筋膜延伸, 沿椎体外侧缘向后延伸, 环绕腰椎血管, 最后加入腰椎神经根。请点击这里查看此图的较大版本.

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Discussion

在这里, 我们将 cls 归类为常规或选择性 cls, 主要区别是针对交感神经主干与灰色的 rami 通信 (在前筋膜的前面注射苯酚与前筋膜后面的腰主要肌肉)。我们在年轻的女性网状子宫肌细胞患者、7、9例红血球和晚期动脉硬化闭塞症和高危合症患者中实施了选择性 cls,我们已经确认了它持久、有益的效果和安全性。

输尿管损伤是最常见的 cls 并发症。报告的案件超过 10, 有1213141516、171819 起。在一份报告中, 报告的发病率为 1.24 (241名 ct 引导的 cls 中有3个纤维化输尿管狭窄)16, 提交人的结论是, 即使手术在技术上令人满意, 输尿管的损伤也可能随之发生。虽然比较少见, 但这种并发症很严重, 对患者造成了很大的伤害。在选择性 cls 中, 前筋膜可以为输尿管、腹主动脉和下腔静脉等重要器官提供自然的保护屏障。在我们医院, 输尿管损伤从未发生过超过 300 cls 的手术。

胸腔交感神经切除术中已认识到交感神经干功能不全的风险 , 视频辅助胸腔镜手术202122报告了选择感神经切开术 ( 锁骨切开术 ).木材交感神经的解剖分布不同于胸胸神经, 这使得选择性 cls 的实施成为可能 (参见图 4和下面的解释)。

腰椎交感神经主干位于腰肌的前筋膜前部, 这个位置是相对固定的 (图 1,图 4)。然而, 腰椎交感神经节有很大的变化, 他们的相对位置对椎体和数量 (2-6 在一般人群中, 最常见的 4, 最多 8) 之间的不同个体。即使在同一个体内, 神经节的分布也不一定是对称的。在某些情况下, 神经节位于椎体旁边, 而在另一些情况下, 他们位于旁边的腰椎间盘。灰白的神经节起源于交感神经节, 它们从发源的椎体的相对位置也有很大的变化。从那里, 交流到腰神经根的椎体的相对位置往往是一致的, 因为腰椎神经根的位置是固定的。这使得有可能在没有开放手术的情况下针对灰色的拉米通信。

最佳注射区域 (图 1) 还成功地避免了椎体上的腰椎动脉和静脉, 降低了手术和术后出血的风险。更重要的是, 附着在椎体外侧的腰肌成为腰神经根的天然保护屏障, 保护腰肌后面的腰神经根, 并确保不发生重大神经损伤。

除了轻度短暂的全胃部神经痛外, 没有其他并发症发生, 在选择 cls 治疗的所有病例中, 只有不到20% 发生并发症, 并且在我们的医院中, 所有这些并发症都在几天内自发地得到解决。文献中报告的发生率、强度和持续时间变化很大, 从轻微到显著, 从轻微到显著, 持续天数到第2232425年不等, 从轻微到显著不等, 从轻微到持续的天数, 26,27,28。肩周神经起源于腰椎神经丛的 lenl2 段, 然后沿着腰肌向下和向前传递, 并在大约 l3 水平的腰肌的前筋膜传递。在 l微小的感觉后注射少量药物, 理论上可以降低心外神经损伤的机会和程度。

昆茨的纤维被指责为胸腔内交感神经切除术手术失败29。目前还没有关于昆茨在木材交感神经中的纤维的报道。为确保 cls 中令人满意和持续的交感神经中断, 建议在最佳区域 (图 1b) 向头部和足部方向注入2毫升的苯酚。此外, 如果交感神经中断不令人满意, 建议将补充酚注射到另一个最佳区域或 l5, 这是首选注射更高的剂量在同一区域。在这方面, 使灰色拉米通信者失活的可能性可能会大大增加, 可以实现更高的安全性。

灰色拉米通信是非髓鞘神经, 与髓鞘神经相比, 它们更容易受到苯酚的感染。根据我们的经验, 5% 苯酚的2毫升通常对每个注射部位都足够。我们在较早的情况下使用了4毫升注射, 并逐渐将用量降低到2毫升。

总之, 我们描述了选择性 cls 的程序, 它的目标是灰色的拉米通信, 而不是交感神经的躯干, 我们强调前筋膜的前筋膜作为一个保护屏障, 当执行选择性 cls。精确的针道、对比剂扩散的准确评价以及小剂量苯酚的多次注射都是确保选择性 cls 成功的关键。

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Disclosures

作者没有什么可透露的。

Acknowledgments

这项工作由北京大学第三医院归国学者科研基金会 (g批号: 77434-01, long zhang) 和北京高等教育青年精英教师项目 (批准书: yetp0072, 王文辉) 资助。

Materials

Name Company Catalog Number Comments
10 cm 9# puncture needle Peking University Third Hospital Not Applicable 7# for children
5% Phenol diluted in aqueous solution Peking University Third Hospital Not Applicable 10 mL
Aseptic puncture kit Peking University Third Hospital Not Applicable 6 pieces of surgical towel, gauze, cotton balls, blood vessel forceps, etc.
Infrared frontal thermometer  OMRON health care (China) Co.,Ltd. MC-720
Iodophors skin disinfectants  Shanghai Likang Disinfectant Hi-Tech Co., Ltd. 20180404
Sterile surgical gloves Beijing Ruijing Latex products Co., Ltd.  2018070352

DOWNLOAD MATERIALS LIST

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医学 第143期 化学腰椎交感神经切除术 并发症 灰色拉米通信 微创 胸腔切开术 交感神经主干
选择性化学腰椎交感神经切除术中灰色拉米关节的靶向性
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Wang, W. H., Zhang, L., Dong, G. X., More

Wang, W. H., Zhang, L., Dong, G. X., Zhao, J., Li, X. Targeting Gray Rami Communicantes in Selective Chemical Lumbar Sympathectomy. J. Vis. Exp. (143), e58894, doi:10.3791/58894 (2019).

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