Kupweteka kwa postoperative neuropathic ndi vuto lofala, ngakhale wodwalayo ali bwino kwambiri.Mofanana ndi mitundu ina ya ululu wopweteka wa mitsempha, ululu wa neuropathic pambuyo pa opaleshoni ndizovuta kuchiza ndipo nthawi zambiri zimadalira adjuvant analgesics, monga antidepressants ndi anticonvulsants, ndi mitsempha yoletsa mitsempha.Ndinapanga chithandizo chogwiritsira ntchito malonda a hyaluronic acid (Restylane ndi Juvéderm), omwe amapereka chithandizo chokhalitsa, chachikulu popanda zotsatirapo.
Hyaluronic acid yolumikizidwa ndi mtanda idagwiritsidwa ntchito kwa nthawi yoyamba kuchiza ululu wa neuropathic pa Msonkhano Wapachaka wa 2015 wa American Academy of Pain Medicine ku National Harbor, Maryland.1 Pakuwunika kwa tchati cha 34-mwezi, odwala 15 opweteka a neuropathic (akazi a 7, amuna a 8) ndi ma syndromes opweteka a 22 anaphunzira.Avereji ya zaka za odwala anali zaka 51 ndipo nthawi yayitali ya ululu inali miyezi 66.Pafupipafupi zowawa zowawa za analog scale (VAS) musanayambe chithandizo chinali mfundo za 7.5 (pa 10).Pambuyo pa chithandizo, VAS inatsikira ku mfundo za 10 (pa 1.5), ndipo nthawi ya chikhululukiro inali miyezi 7.7.
Kuyambira pamene ndinayambitsa ntchito yanga yapachiyambi, ndachitira odwala 75 omwe ali ndi matenda ofanana ndi ululu (ie, post-herpetic neuralgia, carpal tunnel ndi tarsal tunnel syndrome, Bell's paralytic tinnitus, mutu, etc.).Chifukwa cha njira zomwe zingatheke pogwira ntchito, ndinasankha mankhwalawa kukhala okhudzana ndi neural matrix analgesia (XL-NMA).2 Ndimapereka lipoti la wodwala yemwe ali ndi ululu wosalekeza wa khosi ndi manja pambuyo pa opaleshoni ya msana.
Hyaluronic acid (HA) ndi proteoglycan, mzere wa anionic polysaccharide 3 wopangidwa ndi mayunitsi obwereza a glucuronic acid ndi N-acetylglucosamine.Zimapezeka mwachibadwa mu matrix a extracellular (ECM) (56%) a khungu, 4 minofu yolumikizana, minofu ya epithelial ndi mitsempha ya mitsempha.4,5 Mu minofu yathanzi, kulemera kwake kwa maselo ndi 5 mpaka 10 miliyoni daltons (Da)4.
Cross-linked HA ndi zodzikongoletsera zamalonda zovomerezedwa ndi FDA.Amagulitsidwa pansi pa mtundu wa Juvéderm6 (wopangidwa ndi Allergan, HA okhutira 22-26 mg/mL, molecular weight 2.5 miliyoni daltons)6 ndi Restylane7 (yopangidwa ndi Galderma), ndipo HA zili 20 mg/ Milliliters, molekyulu yolemera ndi 1 miliyoni Daltons.8 Ngakhale mawonekedwe achilengedwe osagwirizana ndi HA ndi madzi ndipo amapangidwa mkati mwa tsiku limodzi, ma molekyulu a HA amaphatikiza unyolo wake wa polima ndikupanga viscoelastic hydrogel, motero moyo wake wautumiki (Miyezi 6 mpaka 12) komanso mphamvu yoyamwa chinyezi. imatha kuyamwa madzi kuwirikiza 1,000 kulemera kwake.5
Mnyamata wina wazaka 60 anabwera ku ofesi yathu mu April 2016. Atalandira C3-C4 ndi C4-C5 posterior khomo lachiberekero decompression, posterior fusion, local autotransplantation ndi posterior segmental internal fixation, khosi linapitirira Ndipo kupweteka kwa dzanja limodzi.Zomangira zabwino pa C3, C4, ndi C5.Kuvulala kwa khosi kunachitika mu April 2015, pamene adagwa chagada kuntchito pamene adagunda khosi lake ndi mutu wake ndikumva khosi lake likugunda.
Pambuyo pa opaleshoniyo, ululu wake ndi dzanzi zinakula kwambiri, ndipo panali kupweteka kosalekeza kotentha kumbuyo kwa manja ndi khosi (Chithunzi 1).Pakupindika kwa khosi lake, kugwedezeka kwakukulu kwa magetsi kunkatuluka m’khosi ndi msana mpaka kumapazi ake kumtunda ndi kumunsi.Mukagona mbali yakumanja, dzanzi la manja ndilovuta kwambiri.
Pambuyo poyesa mayeso a computed tomography (CT) myelography ndi radiography (CR), zilonda zam'mimba za chiberekero zinapezeka pa C5-C6 ndi C6-C7, zomwe zimathandizira kupweteka kosalekeza m'manja komanso nthawi zina kusinthasintha kwa khosi Kupweteka (ie, yachiwiri ya neuropathic ndi kupweteka kwa msana ndi C6-C7 pachimake radiculopathy).
Zotupa zapadera zimakhudza mizu ya mitsempha yambiri komanso zigawo za msana zomwe zili kutsogolo, kuphatikizapo:
Dokotala wochita opaleshoni ya msana anavomera, koma anaona kuti palibe chimene akanapereka kwa opareshoni ina.
Chakumapeto kwa Epulo 2016, dzanja lamanja la wodwalayo lidalandira chithandizo cha Restylane (0.15 mL).Jekeseniyo amapangidwa poyika doko lokhala ndi singano ya 20, kenako ndikuyika 27 gauge microcannula (DermaSculpt) ndi nsonga yosamveka.Kuyerekeza, dzanja lamanzere ankachitira osakaniza 2% koyera lidocaine (2 mL) ndi 0,25% koyera bupivacaine (4 mL).Mlingo pa tsamba lililonse ndi 1.0 mpaka 1.5 mL.(Kuti mudziwe malangizo a pang'onopang'ono pa ndondomekoyi, onani m'mbali.) 9
Ndi kusintha kwina, njira ya jekeseni imakhala yofanana ndi mitsempha yamtundu wamtundu wa mitsempha yapakati (MN), mitsempha ya ulnar (UN), ndi mitsempha yapamwamba (SRN) pamlingo wa anatomical.Bokosi la snuff - gawo la katatu la dzanja lopangidwa pakati pa chala chachikulu ndi chapakati.Maola makumi awiri ndi anai pambuyo pa opaleshoniyo, wodwalayo anapeza dzanzi mosalekeza m'manja mwa chala chachinayi ndi chachisanu cha dzanja lamanja koma palibe ululu.Ambiri dzanzi choyamba, chachiwiri ndi chachitatu chala mbisoweka, koma panalibe ululu mu zala.Zotsatira zowawa, 4 mpaka 5).Kumva kutentha kumbuyo kwa dzanja kwatha.Ponseponse, adamva kusintha kwa 75%.
Pa miyezi 4, wodwalayo anaona kuti ululu dzanja lake lamanja akadali bwino ndi 75% kuti 85%, ndi dzanzi mbali za zala 1 ndi 2 anali wolekerera.Palibe zoyipa kapena zotsatirapo.Zindikirani: mpumulo uliwonse wochokera ku anesthesia wamba ku dzanja lamanzere unathetsedwa 1 sabata pambuyo pa opaleshoni, ndipo ululu wake unabwerera ku mlingo woyambira wa dzanja limenelo.Chochititsa chidwi n’chakuti wodwalayo anaona kuti ngakhale kuti ululu woyaka ndi dzanzi pamwamba pa dzanja lamanzere pambuyo pa jekeseni wa mankhwala oletsa ululu wa m’deralo unatha, m’malo mwake munali dzanzi losasangalatsa komanso lokwiyitsa.
Monga tanenera kale, wodwalayo adanena kuti atalandira XL-NMA, ululu wa neuropathic m'dzanja lamanja unakula kwambiri.Wodwalayo adayenderanso kumapeto kwa August 2016, pamene adanena kuti kusinthako kunayamba kuchepa kumapeto kwa July 2016. Anapempha kuti apititse patsogolo chithandizo cha XL-NMA pa dzanja lamanja, komanso chithandizo cha XL-NMA cha dzanja lamanzere ndi khomo lachiberekero. -brachial dera-awiri, proximal phewa, C4 dera ndi C5-C6 mlingo.
Wodwalayo adayenderanso pakati pa mwezi wa October 2016. Iye adanena kuti atatha kuchitapo kanthu mu August 2016, ululu wake woyaka moto m'madera onse opweteka unathandizidwa ndikumasulidwa kwathunthu.Zodandaula zake zazikulu ndi zopweteka / zowawa kwambiri pamwamba pa chikhatho ndi kumbuyo kwa dzanja (zomva zowawa zosiyana-zina zimakhala zakuthwa ndipo zina zimakhala zosasunthika, malingana ndi mitsempha ya mitsempha yomwe ikukhudzidwa) ndi zomangika kuzungulira dzanja.Kulimbanaku kunali chifukwa cha kuwonongeka kwa mitsempha ya mitsempha ya msana wake wa khomo lachiberekero, zomwe zimaphatikizapo ulusi womwe umapanga mitsempha yonse ya 3 (SRN, MN, ndi UN) m'manja.
Wodwalayo adawona kuwonjezeka kwa 50% kwa chiberekero cha chiberekero (ROM), ndi kuchepetsa 50% kupweteka kwa chiberekero ndi mkono ku C5-C6 ndi C4 pafupi ndi mapewa.Anati XL-NMA kuwonjezereka kwa mayiko awiri a MN ndi SRN-the UN ndi khosi-brachial dera linakhalabe bwino popanda chithandizo.
Gulu 1 limapereka chidule cha njira yopangira zinthu zambiri.Iwo amawerengedwa molingana ndi kuyandikana kwawo kwa nthawi yotsutsana ndi anti-nociception-kuchokera ku zotsatira zachindunji m'mphindi zoyambirira za 10 pambuyo pa jekeseni ku chithandizo chokhalitsa komanso chokhalitsa chomwe chimawonedwa nthawi zina chaka kapena kuposerapo.
CL-HA imagwira ntchito ngati chotchinga choteteza thupi, kupanga chipinda, kuchepetsa kutsegulira kwa zochitika zokhazokha mu C fiber ndi Remak bundle afferents, komanso ephapse yosadziwika ya nociceptive.10 Chifukwa cha chikhalidwe cha polyanionic cha CL-HA, mamolekyu ake akuluakulu (500 MDA mpaka 100 GDa) akhoza kusokoneza mphamvu zomwe zingatheke chifukwa cha kukula kwa ndalama zake zoipa ndikuletsa kufalitsa kulikonse.Kuwongolera kolakwika kwa LMW/HMW kumabweretsa kutupa kwa TNFα-stimulated gene 6 protein regulation area.Izi zimakhazikika ndikubwezeretsanso chitetezo cha mthupi cha neural crosstalk pamlingo wa extracellular neural matrix, ndipo makamaka zimalepheretsa zinthu zomwe amakhulupirira kuti zimayambitsa kupweteka kosalekeza.11-14
Kwenikweni, pambuyo pa kuvulala kapena kuvulala kwa extracellular neural matrix (ECNM), padzakhala gawo loyamba lachiwopsezo cha kutupa kwachipatala, limodzi ndi kutupa kwa minofu ndi kuyambitsa kwa Aδ ndi C fiber nociceptors.Komabe, matendawa akayamba kudwala, kutupa kwa minofu ndi chitetezo chamthupi chamthupi kumakhala kosalekeza koma kocheperako.Kuchulukitsitsa kudzachitika kudzera mu kulowanso ndi kubwereza kobwerezabwereza, potero kusunga ndi kusunga pro-yotupa, pre-pain state, ndikuletsa kulowa mu gawo la machiritso ndi kuchira (Table 2).Chifukwa cha kusagwirizana kwa LMW/HMW-HA, ikhoza kukhala yokhazikika, yomwe ingakhale zotsatira za CD44/CD168 (RHAMM) gene aberrations.
Panthawiyi, jekeseni wa CL-HA akhoza kukonza zolakwika za LMW/HMW-HA ndikuyambitsa kusokonezeka kwa kayendedwe ka magazi, kulola kuti interleukin (IL) -1β ndi TNFα ipangitse TSG-6 kuti iwononge kutupa, mwa kulamulira ndi kutsika-kuwongolera LMW- HA ndi CD44.Izi zimalola kupita patsogolo kwabwino kwa gawo la ECNM lodana ndi kutupa ndi kutulutsa ululu, chifukwa CD44 ndi RHAMM (CD168) tsopano akutha kuyanjana ndi HMW-HA molondola.Kuti mumvetse njirayi, onani Table 2, yomwe ikuwonetsera cytokine cascade ndi neuroimmunology yokhudzana ndi kuvulala kwa ECNM.
Mwachidule, CL-HA ikhoza kuonedwa ngati chimphona chachikulu cha Dalton cha HA.Chifukwa chake, yathandizira mobwerezabwereza ndikusunga magwiridwe antchito amthupi a HMW-HA ndikuchiritsa mamolekyulu a biology, kuphatikiza:
Pokambirana za nkhaniyi ndi anzanga, nthawi zambiri ndinkafunsidwa kuti, "Koma zotsatira zake zimasintha bwanji chithandizo cham'mbali kutali ndi khosi?"Pankhaniyi, zilonda zodziwika za aliyense CR ndi CT myelography Kuzindikira pa mlingo wa zigawo za msana C5-C6 ndi C6-C7 (C6 ndi C7 mitsempha mizu, motero).Zotupazi zimawononga mizu ya mitsempha ndi gawo lakunja la msana, choncho ndi gawo lapafupi la gwero lodziwika bwino la mitsempha yozungulira mitsempha ndi msana (ie, C5, C6, C7, C8, T1).Ndipo, ndithudi, iwo adzathandizira ululu woyaka nthawi zonse kumbuyo kwa manja.Komabe, kuti timvetsetse bwino izi, lingaliro la zomwe zikubwera liyenera kuganiziridwa.16
Afferent neuralgia ndi yophweka, "...Ngakhale kuti kuchepa kapena kusakhudzidwa ndi zowawa zakunja (hypoalgesia kapena analgesia) ku gawo la thupi, ululu wopweteka kwambiri mu gawo lakutali la kuvulala."16 Zitha Kuyambitsidwa ndi kuwonongeka kulikonse kwa dongosolo lamanjenje, pakati ndi zotumphukira, kuphatikiza ubongo, msana, ndi minyewa yotumphukira.Mitsempha yotchedwa afferent nerve imaganiziridwa kuti ndi chifukwa cha kutayika kwa chidziwitso kuchokera kumphepete kupita ku ubongo.Mwachindunji, pali kusokonezeka kwa chidziwitso chodziwika bwino chomwe chimafika ku cortex kupyolera mu thirakiti la spinothalamic.Dera la mtolowu limaphatikizapo kutumiza zowawa kapena kulowetsa kwa nociceptive komwe kumakhazikika ku thalamus.Ngakhale kuti ndondomeko yeniyeniyo idakali yosamvetsetseka bwino, chitsanzocho ndi choyenera kwambiri pazomwe zikuchitika (ie, mizu ya mitsempha iyi ndi zigawo za msana sizimasiyana kwambiri ndi mitsempha ya radial).
Choncho, kugwiritsa ntchito ku ululu woyaka kumbuyo kwa dzanja la wodwalayo, molingana ndi njira 3 mu Table 1, kuvulala kuyenera kuchitika kuti ayambe kuyambitsa zowonongeka, zowonongeka zowonongeka kwa cytokine cascade (Table 2).Izi zidzachokera ku kuwonongeka kwa thupi ku mizu ya mitsempha yomwe yakhudzidwa ndi zigawo za msana.Komabe, popeza ECNM ndi gawo lopitilira komanso lofalikira la neuroimmune lomwe limazungulira mawonekedwe onse a neural (ie, ndi lonse), ma neurons okhudzidwa omwe akhudzidwa ndi C6 ndi C7 mitsempha ya mitsempha ndi zigawo za msana zimapitilira ndipo kukhudzana kwa miyendo ndi kukhudzana kwa neuroimmune pa. kumbuyo kwa manja onse awiri.
Chifukwa chake, kuwonongeka komwe kuli patali kumakhala chifukwa cha zotsatira zachilendo za ECNM yapatali patali.15 Izi zidzachititsa kuti CD44, CD168 (RHAMM) izindikire HATΔ, ndi kumasula IL-1β, IL-6 ndi TNFα yotupa cytokines, yomwe imayambitsa ndi kusunga ma distal C fibers ndi Aδ nociceptors pamene kuli koyenera (tebulo 2, #3) .Ndi kuwonongeka kwa ECNM kuzungulira distal SRN, XL-NMA tsopano itha kugwiritsidwa ntchito bwino kuti alowererepo kuti akwaniritse kuwongolera kolakwika kwa CL-HA LMW/HMW-HA ndi ICAM-1 (CD54) malamulo otupa (Table 2, # 3- #5 kuzungulira).
Komabe, ndizosangalatsa kupeza mpumulo wokhazikika kuzizindikiro zowopsa komanso zouma khosi kudzera mumankhwala otetezeka komanso osasokoneza pang'ono.Njirayi nthawi zambiri imakhala yosavuta kuchita, ndipo chinthu chovuta kwambiri chingakhale kuzindikira minyewa yomverera, ma neural network, ndi gawo lapansi lomwe limayenera kubayidwa mozungulira chandamale.Komabe, ndi kukhazikika kwaukadaulo kutengera mawonetseredwe odziwika bwino azachipatala, izi sizovuta.
Nthawi yotumiza: Aug-12-2021