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利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛

2020-07-28 罗雨 徐敏 王存祖 国际神经病学神经外科学杂志

三叉神经痛(trigeminal neuralgia,TN)是临床常见的颅神经疾病,病因尚未明确,治疗方法众多,疗效也不尽相同,其中药物难治性和术后复发的病例属于顽固性三叉神经痛,是目前治疗的难点。

三叉神经痛(trigeminal neuralgia,TN)是临床常见的颅神经疾病,病因尚未明确,治疗方法众多,疗效也不尽相同,其中药物难治性和术后复发的病例属于顽固性三叉神经痛,是目前治疗的难点。

目前认为TN的病因包括原发性和继发性,公认的原发性病因以微血管压迫(microvascular compression,MVC)为主。TN有多种治疗方法,首选药物治疗,包括全身用药和局部用药,全身用药治疗初期疗效显著,但很难治愈TN,且需长期服药,副作用较大;局部用药具有创伤小、疗效肯定、便于推广等优势,但存在面部麻木等并发症,以及疼痛易复发的弊端。所以当药物治疗疗效不佳或出现患者难以耐受药物副作用时,推荐采用外科治疗。

TN的外科治疗主要有对三叉神经无损伤的微血管减压术(microvascular decompression,MVD)及有损伤的经皮穿刺三叉神经半月神经节射频热凝术、经皮穿刺三叉神经半月神经节球囊压迫术、三叉神经感觉支切断术等三叉神经毁损术,以及伽马刀和中医疗法。然而,上述治疗方法对顽固性三叉神经痛患者往往疗效不佳。研究发现,通过补充TN患者体内所缺失的镁离子,可有效的缓解疼痛,因此,对于顽固性三叉神经痛患者,可尝试静脉滴注利多卡因和硫酸镁。我院自2015年2月起,对顽固性三叉神经痛患者采用利多卡因联合硫酸镁静脉滴注治疗,取得了显著疗效。本研究将重点介绍利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛的方法、可能的作用机制、临床疗效等方面。

1.对象和方法

1.1研究对象

所有病例均来源于2015年2月至2017年5月在苏北人民医院治疗的顽固性三叉神经痛,共15例,其中男性5例,女性10例。平均年龄59.5(43~91)岁。平均病程7.1(0.25~20)年。11例为单支分布区疼痛,第一支1例,第二支9例,第三支1例,4例为二支分布区疼痛,第一支+第二支2例,第一支+第三支1例,第二支+第三支1例。5例为药物治疗无效,9例为MVD术后复发,1例为三叉神经毁损术后复发。

入选标准:①依据TN的诊断标准,已确诊为TN,经过正规药物治疗,疼痛无缓解或缓解不佳;②MVD或者毁损术后复发;③患者入院心电图提示心功能正常,能耐受利多卡因的副作用。

排除标准:①不符合TN诊断的患者,如疼痛部位和性质与TN相近的其他脑神经疼和疼痛性疾病者;②心电图提示有明显心律失常者;③精神疾病患者,如抑郁、神经官能综合征、癔症者;④患有桥小脑角区(cerebellopontineangle,CPA)肿瘤者。

1.2方法

15例患者给予利多卡因联合硫酸镁静脉滴注治疗,具体操作为2%利多卡因注射液5ml(0.1g)+25%硫酸镁注射液5ml(1.25g)添加到100ml0.9%氯化钠注射液中,静脉滴注,1h内滴完,每周一次,根据患者疼痛缓解情况,治疗1~3次。静脉滴注过程中,持续心电监测,注意呼吸急促、膝反射异常等利多卡因和硫酸镁相关不良反应。指定与本研究无关护理人员,采用疼痛数字评价量表(Numerical Rating Scale,NRS)对患者治疗前后的疼痛进行单盲评估,NRS值为0~10分,0分为无痛,1~3分为轻度疼痛,4~6分为中度疼痛,7~9分为重度疼痛(不能入睡或者睡眠中痛醒),10分为难以忍受的剧痛。分别评估治疗前、治疗后1周、2周、4周、2月、4月、末次随访NRS,平均随访时间19.7(8~35)月。

1.3疗效评定标准

疼痛消失即为治愈;疼痛减轻75%以上即为显效;疼痛减轻50%~75%为有效;疼痛减轻50%以下为无效。疼痛减轻50%及以上者所占总样本量的百分比为总有效率。

1.4统计学分析

使用SPSS17.0统计软件进行统计学分析。NRS值用均数±标准差(x±s)表示,比较治疗后各组与治疗前评估点NRS值采用方差分析;比较治疗后各组与治疗前评估点有效率采用χ2检验。P<0.05有统计学意义。

2.结果

2.1静脉滴注次数

患者接受利多卡因联合硫酸镁第一次滴注1周后,进行NRS评分,如果疼痛无明显缓解,滴注第二次,以此类推。本组15例患者中,滴注1次6例,滴注2次9例。

2.2静脉滴注治疗前后疼痛变化

治疗前NRS评分为(8.9±0.7)分,治疗后1周(6.1±1.9)分,2周(2.6±1.3)分,4周(2.1±1.7)分,2月(2.2±1.6)分,4月(2.1±1.7)分,末次随访(2.1±1.8)分。与治疗前相比,治疗后的NRS评分明显降低,差异有统计学意义(P<0.05)。治疗后4周NRS评分降至最低,之后NRS评分在较低水平上下轻微波动。在静滴疼痛缓解后,15例患者的疼痛缓解到自身能耐受的程度,均未服用任何药物来辅助镇痛,能够耐受轻微疼痛正常生活。

2.3静脉滴注治疗后疗效分析

利多卡因联合硫酸镁静脉滴注治疗后1周、2周、4周、2月、4月、末次随访的总有效率分别为7%、100%、100%、100%、100%、93%,分别与治疗前比较,除治疗后1周外,差异均有统计学意义(P<0.05)。见表1。


2.4不良反应情况

15例患者在治疗过程中,无心率减慢、血压下降,无明显气短、膝反射异常等利多卡因和硫酸镁相关不良反应。

2.5典型病例

第一例:患者,男性,71岁,右侧三叉神经第三支分布区疼痛4年,采取卡马西平0.2gbid,规范治疗无效,MRI提示右侧三叉神经感觉根入脑干处(Root Entry Zone,REZ)有血管压迫(图1)。


治疗前NRS为7.8分,予以利多卡因联合硫酸镁静滴1次,治疗后2周疼痛明显缓解直至消失,目前已随访28月,未见疼痛复发。

第二例:患者,男性,65岁,右侧三叉神经第二支分布区4年,采取卡马西平0.2gbid,规范治疗无效,MRI提示右侧三叉神经REZ区有血管压迫(图2),行微血管减压术,术后22天疼痛复发。治疗前NRS为8.6分,予以利多卡因联合硫酸镁静滴2次,治疗后2周疼痛明显缓解直至消失,目前已随访35月,未见疼痛复发。


原始出处:

罗雨,徐敏,王存祖,陈品,于波,施学强,易盼.利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛[J].国际神经病学神经外科学杂志,2019,46(03):301-304.

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    2020-08-13 青山颖钰

    学习了

    0

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    2020-07-30 贵阳
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