隐神经射频热凝技术在膝关节疼痛治疗中的应用

发布时间：2018-05-26 05:57

本文选题：射频 + 疼痛　；参考：《北京中医药大学》2015年硕士论文

【摘要】：射频是交流变化频率超过10000次的高频电流,射频交变电流在工作电极尖端产生变化磁场,使得在磁场范围内的靶点组织的离子发生震荡,通过运动摩擦生热,使目标组织或者神经发生蛋白变性凝固,造成毁损。射频热凝技术被大量的用来治疗疼痛性疾病。射频能在C形臂或CT指引下,配合特殊电极用于椎间盘内病变组织的射频热凝治疗,使得病变椎间盘被毁损,从而解除突出的椎间盘对于脊神经的压迫,缓解患者的腰腿疼痛。射频热凝技术也被用来高选择性的毁损痛觉神经纤维的传导支,阻断疼痛信号向上位的神经进行传导,从而破坏疼痛传导通路,达到控制疼痛的目的。膝关节骨性关节炎是老年人常见的一种退行性关节疾病。以软骨退化变性、关节边缘形成骨刺、滑膜肥厚为主要病理变化,以膝关节疼痛、功能障碍和畸形为主要临床表现。骨关节炎的患病率随着年龄的增大而升高,由于膝关节疼痛,严重影响了患者的关节功能,引起心理困扰,造成生活质量下降。膝关节骨性关节炎的疼痛治疗需要结合病人自身情况,如年龄、性别、体重、病变部位及程度等选择合适的治疗方案。对于常规口服药治疗效果不理想,或长期使用药物产生胃肠道等副作用,导致患者不能耐受的早中期膝关节骨性关节炎患者,以及不宜接受截骨术和膝关节置换等手术治疗的患者；另外,还有膝关节骨性关节炎中晚期患者合并症多,不能耐受较大手术的的患者。射频技术为患者提供了有效的治疗手段,避免了长期服用药物的副作用,也减轻了其对常规膝关节手术的心理负担和经济负担。目前,针对膝关节骨性关节炎的射频治疗,根据部位可分为：膝关节腔内的射频治疗和针对隐神经的射频治疗。在关节镜下对膝关节骨性关节炎的射频治疗主要是通过等离子射频汽化棒进行的,是低温消融,通过100KHz的强射频电场,使等离子体薄层中的自由带电粒子获得足够动能,打断分子键,使靶组织细胞以分子为单位解体,在低温下形成切割和消融效果。等离子射频汽化棒可以在关节镜的帮助下清理多种病变组织,包括：滑膜、软骨等。等离子射频汽化采用双极技术,电流不直接流经组织,创面损伤小,深层组织仍保持健康状态。膝关节骨性关节炎时,膝关节周围的滑囊发炎、骨质增生等引起膝周疼痛。同时,发炎的滑囊及增生的骨赘会刺激局部炎性渗出,粘连,造成隐神经髌下支机械性卡压或炎性损害,从而引起膝关节周围疼痛加剧。另外,隐神经髌下支由缝匠肌和股薄肌之间浅出,分布于膝关节内下方及髌腱的前方,在下行途中,可能与膝内、前、下部的深筋膜粘连,其外包裹大量的纤维组织,此处皮下脂肪层薄,缓冲力欠佳,易受劳损或外伤,而导致局部渗出粘连,造成神经机械性卡压或炎性损害。这种疼痛比较顽固,局部临床表现为股骨内侧髁、胫骨内侧髁、内侧关节囊处有压痛,皮肤针刺样疼痛或痛觉减退,还可表现为酸痛或胀痛。单纯玻璃酸钠膝关节内注射的效果不理想。在玻璃酸钠关节内注射的基础上,有效地针对隐神经进行治疗,能缓解隐神经卡压等引起的疼痛。隐神经阻滞能解除膝关节疼痛,主要通过使用激素类药物消除炎症并软化纤维组织,解除对隐神经的压迫来改善症状,减轻疼痛。由于射频技术的不断推广,近年来,很多研究人员在临床上对隐神经射频治疗膝关节周围疼痛做了新的尝试,并且都取得了满意的疗效针对隐神经的射频治疗,通过高选择性的毁损痛觉神经纤维的传导支,阻断疼痛信号向上位神经传导,而破坏痛觉传导通路,达到控制疼痛的目的。作用于隐神经的射频手术模式：包括射频定位的电刺激 (Stimulation)、标准射频损毁模式(SL:Standard Lesioning).脉冲射频损毁模式(PL:Puse lesioning)。目前第一种方法主要是用于治疗前后的测试和确定射频针的位置。针对隐神经的射频治疗一般采用标准射频损毁模式和脉冲射频损毁模式。标准射频损毁模式临床常采用的设定参数为温度70～90℃,工作时间80-120 s,工作频率10 Hz,每周期工作时间是100 ms,是连续工作,无间歇期,温度上升模式为线性上升。脉冲射频损毁模式临床常采用的参数设定为：温度42℃,时间120 s,工作频率为2 Hz,每周期工作时间为20s,时间间歇是480 ms,温度上升模式为阶梯式上升。本研究隐神经射频采用的标准射频参数为：温度75℃,工作时间90s,工作频率10 Hz。隐神经射频仅针对感觉神经,干扰疼痛信号由隐神经向中枢神经系统的传输。在射频治疗隐神经时,通过射频定位模式,保证了对感觉神经的选择无误。其次,可以借助超声引导,有效提高神经定位的准确性。还可以通过诊断性测试,确定是否为隐神经的确切定位。另外,标准射频损毁模式的温度设定在75-C以下；而脉冲射频损毁模式的温度设定在42℃,一般都不会毁损运动神经纤维。因而,隐神经射频治疗是比较安全的治疗手段。隐神经射频治疗,定位确切,创伤小,并发症少,安全性高,可重复,避免了长期服用药物的副作用,减轻了患者对常规膝关节手术的心理负担和经济负担。WOMAC骨关节炎指数(Western Ontario and McMaster Universities Osteoarthritis Index西安大略和麦克马斯特大学关节炎指数)是美国风湿性关节炎临床研究组创建的测量工具。该测量工具也用于评估髋或膝关节骨关节炎。由受试者如实填写,只对病变膝关节评分,从躯体功能、僵硬、疼痛程度三方面以0-100毫米评分。SF-36是美国波士顿健康研究所研制的简明健康调查问卷,主要用于普通人群的生存质量测定、临床试验效果评价和卫生政策评估。SF-36从生理机能、生理职能、躯体疼痛、一般健康状况、精力、社会功能、情感职能以及精神健康共8个方面,通过36个具体问题,全面概括了受试者的生存质量,可以全面地评价被调查者的身体和精神两方面的健康状况。本研究采用WOMAC疼痛、僵硬和功能三方面评分,以及SF-36生理机能、精力两个方面评分,评价隐神经射频治疗后膝关节功能、患者生存质量改善情况,具有全面、准确的特点。本研究共分为两个部分：第一部分玻璃酸钠关节内注射复合隐神经射频治疗缓解膝关节疼痛目的：观察玻璃酸钠关节内注射复合隐神经射频治疗膝关节疼痛的有效性。方法：将60例膝关节骨性关节炎患者随机分成实验组(C组,n=30)和对照组(H组,n=30),实验组给予玻璃酸钠复合隐神经射频治疗缓解膝关节疼痛；对照组给予玻璃酸钠膝关节内注射,但是不给予有效地射频治疗,评价治疗前,治疗后5分钟,1周,2周和4周时的WOMAC评分和SF-36生活质量评分(PF和VT),并记录治疗中和治疗后的并发症。结果：实验组和对照组在WOMAC疼痛改善,晨僵,身体功能和SF-36生活质量评分(PF和VT)的平均改变有差异,P0.05,两组差异存在统计学意义。结论：玻璃酸钠关节内注射复合隐神经射频治疗膝关节疼痛的疗效优于单纯玻璃酸钠关节内注射治疗膝关节疼痛的疗效。第二部分玻璃酸钠关节内注射分别联合隐神经射频及隐神经阻滞治疗膝关节疼痛的疗效对比目的：观察玻璃酸钠关节内注射分别联合隐神经射频与隐神经阻滞治疗膝关节疼痛的疗效对比。方法：将50例膝关节疼痛患者,随机分成玻璃酸钠关节内注射联合隐神经射频组(C组,n=25)和玻璃酸钠关节内注射联合隐神经阻滞组(H组,n=25),C组给予玻璃酸钠关节内注射联合隐神经射频；H组给予玻璃酸钠关节内注射联合隐神经阻滞,评价治疗前,治疗后1周和4周时的WOMAC评分和SF-36生活质量评分与基础值的差值,同时记录治疗中和治疗后的并发症及不良反应。结果：实验组和对照组在WOMAC疼痛改善,晨僵,身体功能和SF-36生活质量评分(PF和VT)的平均改变有差异,P0.05,两组差异存在统计学意义。结论：玻璃酸钠关节内注射联合隐神经射频治疗膝关节疼痛的疗效优于玻璃酸钠关节内注射复合隐神经阻滞治疗的疗效。
[Abstract]:Radio frequency is a high frequency current with alternating frequency of more than 10000 times. The radio frequency alternating current produces a changing magnetic field at the tip of the working electrode, making the ion of the target tissue in the range of the magnetic field oscillates. The target tissue or neurogenic protein is solidified by the movement friction and causes damage. The radiofrequency thermocoagulation technology is used in a large amount. To treat pain disease. Radiofrequency can be used with a C arm or CT, combined with a special electrode for radiofrequency thermocoagulation in the diseased tissue of the intervertebral disc, causing diseased intervertebral discs to be damaged, thus relieving the compression of the spinal nerve and alleviating the pain of the lumbago and legs. The conduction branch of the nerve fibers, which blocks the pain signal conduction to the upper nerve, destroys the pain conduction path and controls the pain. Osteoarthritis of the knee is a common degenerative joint disease of the elderly. The degeneration of cartilage, the edge of the joint, the main pathological changes of the synovial hypertrophy, and the knee closure. Pain, dysfunction and malformation are the main clinical manifestations. The incidence of osteoarthritis increases with age. Due to knee pain, it seriously affects the joint function of the patients, causes psychological distress and causes a decline in quality of life. The treatment of knee osteoarthritis needs to be combined with the patient's own condition, such as age and sex, It is not ideal for the treatment of conventional oral medicine, or the long-term use of the side effects of the gastrointestinal tract, which leads to the patients' intolerance of the patients with early and middle knee osteoarthritis, and the patients who are not suitable for osteotomy and knee replacement. There are more patients with middle and advanced osteoarthritis of the knee joint, which can not tolerate large surgery. Radiofrequency technology provides effective treatment for patients, avoids the side effects of long-term medication, and reduces the psychological burden and financial burden on conventional knee surgery. Radiofrequency therapy is divided into radiofrequency therapy in the knee joint and radiofrequency therapy for the saphenous nerve. Radiofrequency therapy for osteoarthritis of the knee under arthroscopy is mainly carried out by plasma radiofrequency vaporization rod, which is cryogenic ablation, and the free charged particles in the plasma thin layer are made through a strong radiofrequency electric field of 100KHz. To get enough kinetic energy to break the molecular keys to disintegrate the cells of the target tissue and disintegrate the molecules in a unit and to form a cutting and ablation effect at low temperatures. The plasma radiofrequency vaporization rod can clean up a variety of pathological tissues under the help of the arthroscope, including the synovium, cartilage, etc. plasma radiofrequency vaporization uses bipolar technique, the current does not flow directly through the tissue, and the wound is wound. The injury is small and the deep tissue remains healthy. During the osteoarthritis of the knee, the inflammation of the sac around the knee, the hyperosteogeny, and so on, causes the pain of the knee. At the same time, the inflammatory cysts and proliferating osteophyte will stimulate the local inflammatory exudation, adhesion, and cause the mechanical entrapment or inflammatory damage of the inferior patellar branch, causing the pain around the knee joint. In addition, the Subpatellar branch of the saphenous nerve is shallow between the sartorius and the gracilis muscle, distributed in the lower knee and front of the patellar tendon. In the downlink, it is possible to adhere to the deep fascia in the knee, front and lower part of the knee, and encapsulate a large number of fibrous tissue. The subcutaneous fat layer is thin, the buffer force is poor, and it is vulnerable to strain or trauma, which leads to partial exudation. Adhesion, causing neuromechanical compression or inflammatory damage. This pain is relatively stubborn. Local clinical manifestations are the medial condyle of the femur, the medial tibia, the inner condyle of the tibia, the pain of the medial articular capsule, the needling pain of the skin or the hypoalgesia, and the pain or sore pain. The effect of intralamna injection of sodium hyaluronate is not ideal. On the basis of intrapele injection, effective treatment of the saphenous nerve can relieve the pain caused by the pressure of the hidden nerve. The saphenous nerve block can relieve the pain of the knee joint. It is mainly through the use of hormone drugs to eliminate inflammation and soften the fibrous tissue, relieve the pressure of the hidden nerve to improve the symptoms and relieve the pain. In recent years, many researchers have made a new attempt to treat the pain around the knee by radiofrequency therapy, and have achieved a satisfactory therapeutic effect on the radiofrequency therapy of the saphenous nerve. Through high selective damage to the conduction branch of the painful nerve fibers, it blocks the conduction of the pain signal to the upper nerve, and destroys the pain conduction pathway. To control the pain, the radiofrequency operation mode of the saphenous nerve: radio frequency stimulation (Stimulation), standard radio frequency damage model (SL:Standard Lesioning). Pulse radio frequency damage model (PL:Puse lesioning). The first method is mainly used to test and determine the location of the radiofrequency needle before and after treatment. The radiofrequency radiofrequency therapy for saphenous nerve generally adopts the standard radio frequency damage model and pulse radio frequency damage model. The standard radiofrequency damage mode is often used as the setting parameters of 70~90 C, working time 80-120 s, working frequency 10 Hz, working time of 100 ms per cycle, continuous work, no interval, and temperature rising mode linear rise. The parameters of the radiofrequency ablation model are: temperature 42 C, time 120 s, working frequency 2 Hz, working time of 20s, time interval of 480 MS, and rising mode of temperature rise. The standard radiofrequency parameters used in this study are: temperature 75, working time 90s, working frequency 10 Hz. hidden God Radiofrequency is only for the sensory nerve, which interferes with the transmission of the pain signal from the saphenous nerve to the central nervous system. In the radiofrequency treatment of the saphenous nerve, the selection of the sensory nerve is ensured by the radiofrequency positioning mode. Secondly, the accuracy of the neural location can be improved effectively by the ultrasound guidance. It can also be determined by diagnostic test to determine whether or not. For the exact location of the saphenous nerve. In addition, the temperature of the standard radiofrequency damage model is set below 75-C; and the temperature of the pulse radio frequency damage mode is set at 42 degrees C, and generally does not damage the motor nerve fibers. Therefore, radiofrequency therapy is a safer treatment. High safety, repeatable, avoiding side effects of long-term use of drugs, alleviating the psychological burden and economic burden of patients on conventional knee surgery.WOMAC Osteoarthritis Index (Western Ontario and McMaster Universities Osteoarthritis Index Xi'an and McMaster University arthritis index) is American rheumatoid arthritis The measurement tool created by the clinical research group is also used to assess the osteoarthritis of the hip or knee. The subjects were filled out, and only 0-100 millimeters of.SF-36, the three aspects of the somatic function, stiffness and pain, were the concise health questionnaire developed by the Boston Health Research Institute in the United States. The quality of life of the general population, the clinical trial effect evaluation and the health policy evaluation.SF-36 from the physiological function, the physiological function, the physical pain, the general health condition, the energy, the social function, the emotional function and the mental health. Through 36 specific problems, the quality of life of the subjects can be fully summarized, and the.SF-36 can be comprehensively evaluated. The two aspects of physical and mental health of the investigators. The study adopted the score of WOMAC pain, stiffness and function in three aspects, as well as the score of the physiological function of SF-36 and energy in two aspects. It evaluated the knee joint function after the radiofrequency therapy of the hidden nerve, and the improvement of the quality of life of the patients. This study was divided into two parts: The first part of sodium hyaluronate injection combined with saphenous nerve radiofrequency therapy to relieve the pain of knee joint: To observe the effectiveness of radiofrequency treatment for knee joint pain by intraarticular injection of sodium hyaluronate. Methods: 60 patients with osteoarthritis of the knee joint were randomly divided into experimental group (group C, n=30) and control group (group H, n=30), and the experimental group was given. Radiofrequency therapy with sodium hyaluronate combined with saphenous nerve was used to relieve knee pain. The control group was given intraarticular injection of sodium hyaluronate, but no effective radiofrequency therapy was given. The WOMAC score and SF-36 quality of life score (PF and VT) were evaluated at 5, 1, 2 and 4 weeks before treatment, and the complications after treatment and treatment were recorded. Results: in the experimental group and the control group, the WOMAC pain improvement, the morning stiffness, the body function and the SF-36 quality of life score (PF and VT) were different, P0.05, the two groups were statistically significant. Conclusion: the effect of sodium hyaluronate intraarticular injection of compound saphenous nerve for the pain of knee joint is better than that of sodium hyaluronate intra-articular injection. Curative effect of knee joint pain. Comparison of the curative effect of second part sodium hyaluronate combined with saphenous nerve block and radiofrequency and saphenous nerve block in the treatment of knee pain. Objective: To observe the curative effect of intraarticular injection of sodium hyaluronate combined with saphenous nerve block and saphenous nerve block in the treatment of knee pain. Method: 50 cases of knee joint pain were treated with sodium hyaluronate. The pain patients were randomly divided into sodium hyaluronate intra-articular injection combined with saphenous nerve radio frequency group (group C, n=25) and sodium hyaluronate joint injection combined with hidden nerve block group (group H, n=25). Group C was given intra-articular injection of sodium hyaluronate combined with saphenous nerve radiofrequency, and group H was given intra-articular injection of sodium hyaluronate combined with saphenous nerve block, before the treatment, 1 weeks after the treatment. The difference between the WOMAC score and the SF-36 quality of life score and the base value at the 4 week, and the complications and adverse reactions after treatment and treatment were recorded. Results: there were differences in the improvement of WOMAC pain, morning stiffness, physical function and SF-36 quality of life score (PF and VT) in the experimental group and the control group, and the differences in the P0.05 and the two groups were statistically significant. Conclusion: the curative effect of sodium hyaluronate combined with intra-articular injection of saphenous nerve in the treatment of knee pain is better than that of intra-articular injection of sodium hyaluronate.
【学位授予单位】：北京中医药大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R684

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